Text-book of Forensic Medicine and Toxicology

INTRODUCTION

Medical Jurisprudence, Forensic Medicine, or Legal Medicine are terms for that science which teaches the application of the knowledge of all branches of medical and surgical science and art to the solution of every question connected with the conservation of the species and the administration of Justice. We find traces of this science in the Jewish law; among the Egyptians, according to Plutarch; and even among the Romans as early as the times of Numa Pompilius. Among German writers the term State Medicine includes both Medical Jurisprudence and Medical Police, Public Health, or Sanitary Science.

The special knowledge requisite to the Medical Jurist differs in many ways from that requisite for the art of healing the sick. The majority of medical students and practitioners may consider a simple exercise of common sense in the application of their general professional knowledge to the elucidation of problems of medico-legal import all that is requisite, and that no special training is necessary for the purpose. They may hope that it may never fall to their lot to be called upon to act in the capacity of medical jurists. It may occur, however, to any medical practitioner at any time of his professional career that his services be requisitioned by law for the purpose of elucidating problems of such a nature as will demand from him thought and judgment quite apart from those he exercises in the ordinary course of his medical and surgical practice. From such a requisition he has no escape; he cannot shift his responsibility to another, and it behoves him, therefore, to acquire a knowledge of Forensic Medicine, in order to guide him, when so called upon, to give such evidence as will enable a judge and jury to arrive at a just conclusion. The relations of all medical practitioners to the State are twofold—first, as healers of disease, and secondly, both as guardians of the innocent against unfounded criminal charges and aids towards the detection and punishment of crime.

CHAPTER I LEGAL CRIMINAL PROCEDURE — ENGLAND AND IRELAND — SCOTLAND — Citation of Witnesses—Subpœna — FEES ALLOWED TO MEDICAL WITNESSES

The Coroner‘s Court.—The office of coroner is mentioned in a charter in 925. Coroners were formerly chosen for life by the freeholders of the district, but their election is now in the hands of the County Councils. Their duties were first clearly pointed out by the Act 4 Edw. I. c. 2, 1275 (De officio coronatoris).

At the present time the duties of the coroner are chiefly to hold inquiry into the cause of death when there is any reason to doubt that death resulted from natural causes.

When death results from natural causes, and under ordinary conditions, the medical attendant is bound, under a penalty of forty shillings, to certify as to the cause. The registrar of deaths accepts such a certificate when accompanied by oral testimony given by a person who was present at the time of death, and issues a certificate accordingly, authorising the interment of the deceased.

Should conditions obtain to prevent the medical attendant from forming an opinion as to the cause of death, or which would lead him to infer that death did not take place from natural causes, he should notify the matter to the coroner. Such would be necessary if death were directly or indirectly due to accident, or if death occurred within a reasonable time after an accident, although due to some other cause, or if an accident happened to deceased during the course of a chronic illness, the accident, however, not being in itself necessarily fatal.

It would be necessary also to notify the coroner if the death took place under circumstances which, to the medical attendant, appeared suspicious, such as might arise from culpable neglect or cruelty on the part of persons in charge of the deceased. The same would apply to cases in which the cause of death was unknown. A great responsibility rests on the medical practitioner, in that he is compelled under a penalty to certify as to the cause of death; while if he do so without due consideration, or carelessly, he renders himself liable to censure or legal proceedings.

It may happen that in certain cases—for example, where an accident befell the deceased during the course of a lingering illness, and which in itself had no causal relations to the death—the doctor may be prone to certify the death as from the illness alone, taking no note of the accident; and pressure may be brought to bear upon him by the relations of the deceased to so certify and save them the trouble and publicity of an inquest. It should be remembered, however, that although the certificate be accepted by the registrar, and interment take place, the coroner, if informed of the matter, may order the body to be exhumed for the purposes of inquest.

There are coroners who, on receipt of information of death from uncertain causes, may elect, on evidence obtained apart from the medical practitioner, to notify the registrar authorising the interment without holding an inquest. The law, however, states that, “except upon holding an inquest, no order, warrant, or other document for the burial of the body shall be given by the coroner” (50 and 51 Vict.).

The Coroners Act (50 and 51 Vict.) provides that, when a coroner is informed that the dead body is lying within his jurisdiction, and there is reasonable cause to suspect that such person has died a violent or unnatural death, or a sudden death, of which the cause is unknown, or died in prison, he shall summon a jury of not less than twelve, or more than twenty-three, men to inquire touching the death of such person aforesaid.

If the deceased were attended at his death, or during his last illness, by a legally qualified medical practitioner, the coroner may summon such practitioner as a witness. If the deceased were not so attended in his last illness, the coroner may summon any legally qualified medical practitioner in actual practice, in or near the place where the death happened, to give evidence as to the cause of death. In either case the coroner may require the medical witness to make a post-mortem examination of the body, with or without analysis of the contents of the stomach or intestines.

Should a statement on oath be made by any one before the coroner, that in his belief the death of the deceased was caused partly or entirely by the improper or negligent treatment of a medical practitioner, such medical practitioner shall not make or assist at the post-mortem examination.

If a majority of the jury are not satisfied with the medical evidence, they may require the coroner, in writing, to summon another legally qualified practitioner, named by them, to make a post-mortem examination, with or without analysis of the contents of the stomach and intestines, and give evidence as to the cause of death. A medical practitioner who fails to obey the summons of a coroner, issued in pursuance of the Coroners Act, is liable to a penalty not exceeding five pounds, unless he shows good and sufficient cause for not having so done. When evidence has been given before a coroner or magistrate, and the case is afterwards sent for trial, copies of the medical report and depositions are given to the judge and counsel, so that evidence given at the trial is compared in detail with that given before the coroner or magistrate. In view of this, it is imperative on the part of medical witnesses to carefully consider their evidence before giving it.

The object of a coroner‘s inquest is to ascertain whether the death of the person, over whose body the inquest is held, was due to natural causes or not.

The proceedings are not directed against any one, they do not constitute a trial, and hearsay evidence is admissible. The coroner and jury alone have the right to interrogate the witnesses. Counsel may be present in the interest of persons concerned with the inquest who may desire such assistance, but counsel may not cross-examine any witnesses, and may only question them by permission of and subject to the decision of the coroner.

Witnesses are examined on oath, their evidence is taken down, and should the case be transferred to a superior court, they are bound under a penalty to appear and give evidence. The coroner may adjourn an inquest for the purpose of obtaining further evidence, if he should deem it necessary.

Should the verdict of the jury charge a person with murder, the coroner issues a warrant for the arrest of the person, unless the person be already in custody. In the case of manslaughter the coroner may accept bail. According to the Act 4 Edw. I. c. 2, the coroner and jurors must view the body, this being absolutely necessary to give jurisdiction to him, and he has the power, within a convenient time after the death, to order a dead body to be disinterred for this purpose.

Order of Summons from the Coroner to a
Legally Qualified Medical Practitioner

• “London.
• To wit—To ____________________ Esq., Surgeon.
• “Sir—By virtue of this my Order as one of HisMajesty‘s
• Coroners for the County of London you are hereby required
• to be and appear before me and the jury on
• ______ day, the ______ day of ______ at ______ o‘clock in the
• ______ noon, at ______ in the Parish of ______, then and there
• to give evidence on His Majesty‘s behalf touching the death of
• ____________, and to make or assist in making a post-mortem
• examination of the Viscera of the Head, Chest, and Abdomen of
• the body of the said ____________ with ______ an analysis and
• report thereon at the said Inquest. And herein fail not at your peril.
• Dated the ______ day of ____________ 19.”
• (Signature of Coroner.)

Prosecution.—There was no Public Prosecutor in England until some years ago, when an Act was passed authorising the appointment of such an official, who should undertake the duty of prosecuting in certain and specific cases of public importance, and in districts where the appointment might be agreed upon. In ordinary circumstances it has usually been left to the person against whom a crime has been committed to prosecute the offender.

Magistrates‘ Court.—In the Magistrates‘ Court of Petty Sessions, the proceedings are for the purpose of investigating as to the culpability or non-culpability of a person accused of some criminal act, or criminal negligence.

In this Court the accused person must be present, as the inquiry is relative to his guilt or innocence. Witnesses in this Court may be examined and cross-examined by counsel. A magisterial investigation cannot take place if no arrest have been made. The magistrate may deal summarily with cases of simple assault and such-like of minor import, but when the case is of a more serious nature, and in suspected manslaughter or murder, the accused person is committed to a superior Court for trial, such as the Court of Quarter Sessions, the Assize Court or, in London, the Central Criminal Court, all witnesses, medical or lay, being bound over to appear and give evidence. The summons to the Assizes is called a subpœna, and all witnesses receiving the same, when accompanied with reasonable travelling expenses, are bound to obey it.

Assizes.—The Assizes comprise two Courts, the Crown Court and the Civil Court. A separate judge presides over each. In the former only cases of a criminal nature are tried; in the latter suits are tried between two parties. Medical practitioners may be called upon to give evidence in either Court, according to the nature of the case in which they are directly concerned.

Prior to a case being investigated by a judge and petty jury, it has to come before the grand jury. This jury decides whether the case is a proper one to proceed to trial.

The grand jury hear the evidence of such witnesses as they think fit, apart from counsel. Should the grand jury consider the case one for trial, they return a “true bill,” and it goes before the judge and petty jury; if not, they “cut the bill,” and the accused is discharged.

Medical witnesses may be called upon, when under subpœna, to give evidence before the grand jury.

The Crown Court of Assize consists of a judge and a sworn jury of twelve men, called the petty jury. The latter hear the evidence of witnesses, and are guided by the summing up of the judge. They deliver a verdict after consideration of the evidence by which the accused person is found guilty or not guilty. The judge, after receiving the verdict, allots such punishment as he considers just. In certain cases the prisoner when convicted may appeal to the Court of Criminal Appeal.

In the Assize Courts only barristers can plead; in the Magistrates‘ Courts of Petty Sessions, solicitors or barristers may plead.

In the Courts of Assize the witnesses are subject to the following routine of examination. First, Examination-in-chief: this the witness undergoes at the hands of the barrister who is pleading on behalf of the party by whom the witness is called. In this examination such questions are put to the witness as may elicit answers conveying to the judge and jury a clear account of all the witness knows with regard to the case. After the examination-in-chief, the counsel of the opposite side subjects the witness to cross-examination, in such a way as to shake the evidence given by the witness during his examination in chief in points which would weigh against the prospects of his client. It is during cross-examination that a medical witness may be subjected to questions which suggest answers capable of a different interpretation from those he had previously given. After cross-examination, the counsel for the party upon whose side the witness appears subjects the latter to re-examination, if he consider it necessary, during which he endeavours to clear up any doubtful points in the evidence given by the witness during cross-examination, with the purpose of eliciting an explanation of their meaning.

The judge and members of the jury may put such questions to the witness as they may consider necessary.

The same method of procedure applies to the higher Courts.

In Scotland public prosecutors are appointed by the Crown. The chief public prosecutor is the Lord-Advocate; next in rank come the Deputy-Advocates and Procurator-Fiscal. The Lord-Advocate and Deputies take charge of cases in the High Courts of Justiciary, the Procurator-Fiscal in the lower Courts.

The duties of the public prosecutor are to bring all accused persons to a bar of justice; and in addition he acts as the coroner does in England. Any person who is supposed to know anything about the case is interrogated by the Procurator-Fiscal, or is precognosced. The examination is made on oath; the written evidence constitutes the precognitions. Counsel for the accused or for the Crown may precognosce witnesses.

The preliminary examination of the accused takes place before the Sheriff or Justice, and he may commit the person for trial or liberate him, according to the evidence.

The precognitions, in cases of committal, are forwarded to the Crown Counsel in Edinburgh, who may stop the proceedings, or send the accused before the High Court, Circuit Court of Justiciary, or Sheriff, with or without a jury. The Justiciary Courts correspond to the Courts of Assize in England. Should the case be so transferred for trial, the witnesses are summoned by writ. A penalty of £5 may be imposed for disobedience to such writ, or imprisonment pending expression of regret before the Court, and tendering bail for appearance.

Common witnesses and medical witnesses to fact are not allowed in Court except when giving evidence. Expert witnesses may be allowed to remain in Court by mutual consent of counsel. When one expert witness is giving evidence, other experts are required to leave the Court, and no expert witness who may have been present during the examination of common witnesses is allowed to give evidence as to facts.

The verdicts of “Guilty” or “Not guilty” are similar to those given in England, but in addition a verdict of “Not proven” may be given, and all are final. In the case of the last two the accused cannot be tried again.

In Scotland the verdict of a bare majority of the jury holds good, whereas in England the decision must be unanimous. In the case of a suspicious death, or a dead body being discovered, the Procurator-Fiscal, acting as a coroner does in England, but without a jury, may direct a medical man to examine the body and send in a report; but all reports must be certified on soul and conscience, without which they are of no value. Should the medical examiner be satisfied without making an internal examination, he may certify to the Procurator-Fiscal on the result of his external examination.

Should the Procurator-Fiscal consider it requisite to have a complete examination, he issues a warrant to that effect to the medical practitioner who has seen the case, and usually associates with him the most skilled practitioner available in the neighbourhood. The warrant consists of a petition by the Procurator-Fiscal, addressed to the local judge, setting forth the grounds of his application, and craving warrant to the inspectors named to make the necessary examination. This is signed by the Procurator-Fiscal, and countersigned by the Sheriff or local judge, if granted. The receivers of this warrant are empowered to take full custody of the body, and they should be careful to carry the warrant with them, or they may be refused admission pending its production, which may result in great waste of time, and end in a miscarriage of justice. The Procurator-Fiscal may supply to the medical inspectors portions of the precognitions likely to bear on the medical part of the inquiry. Medical men ought to be on their guard against performing dissections in cases evidently judicial without previously warning the proper law authorities, or without a warrant; for instances have occurred where, owing to the want of proper support, obstructions were thrown in the way which might have proved fatal to the value of the investigation; and, besides, the premature disclosure of the results of the inspection might frustrate other important steps of the precognition.

The medical men so engaged will, as a rule, find it to their interest to exclude all visitors, whether lay or professional, from the room during the dissection. The regulations issued by the Crown Office, Edinburgh, direct that no one should be allowed to be present at the examination out of mere curiosity, and recommend that any one not engaged in the inspection, but who is in attendance to give information, or for any other purpose, and who may afterwards become a witness, should remain in an adjoining room. The medical inspection often furnishes good tests of the value of other evidence in the case; therefore, it is desirable that the general witnesses should not have an opportunity of knowing what is observed in the dissection of the body. The notes of a case should be made at the time of inspection or immediately afterwards. In the case of post-mortem examinations it is better that while one inspector conducts the practical details of the examination, the other should take notes of its successive steps, indicating all the points inquired into, with the observations made, the appearances presented, negative as well as positive, stating simple facts alone, without either generalisations or opinions. These notes should be looked over by both inspectors before the body is sewn up, so that omissions in the notes, or in the inspection itself, may be then supplied.

In England, except upon a subpœna, a medical man is not bound to attend as a witness at a trial, and then it should be served a reasonable time before the trial, in order that he may make proper arrangements for the carrying on of his business during his absence. In civil cases his reasonable expenses should be tendered to him at the time the subpœna is served, or within a reasonable time of the trial; and he may refuse to give evidence unless his charges are paid, provided his objection be stated before he has been sworn. A witness may be summoned from any part of the United Kingdom.

The question has been raised, whether a scientific witness was bound to attend when subpœnaed. The law on the point is enveloped in some obscurity; the better course is therefore to attend.

No tender of fees is necessary in criminal cases, “except in the case of witnesses living in one distinct part of the United Kingdom being required to attend subpœnas directing their attendance in another, who are not liable to punishment for disobedience of the process, unless at the time of service a reasonable and sufficient sum of money, to defray their expenses in coming, attending, and returning, have been tendered to them.” When summoned to two cases, the one civil, the other criminal, the witness must attend the criminal; or when both cases are the same, the one to which he first received the subpœna—notifying, however, to the counsel engaged on the other case his unavoidable absence, and giving the reasons which prevent his attendance.

In Scotland, witnesses are summoned by a writ or citation, which must be delivered at the residence of the witness a reasonable time before the trial. Delivery to a member of the family, or a servant not within the house, will not do. If access cannot be gained, the copy is fastened to the most patent door of the house. If the witness do not appear, and it be clearly shown that he was duly cited, a warrant for his apprehension may be issued, and he becomes liable to be incarcerated till he finds “caution” for his due attendance at the trial. His non-attendance may also, unless good excuse be forthcoming, render him liable to a fine, or unlaw, of a hundred merks Scots—about £5.

Form of Subpœna in England.—Where a medical witness has given evidence in a case in which the accused person has been committed for trial to a superior Court, he is summoned to give evidence at such Court in the following terms:

In Scotland the following is the form of summons to appear before the High Court of Justiciary, and at an inquiry into a fatal accident:

Coroner‘s Court.—The Coroners Act states that fees for medical witnesses attending an inquest shall be, for attending to give evidence at an inquest whereat no post-mortem examination has been made by the witness, one guinea. For making a post-mortem examination and attending to give evidence, two guineas. No fee can be obtained for making a post-mortem examination by a medical practitioner, unless it be made by order of the coroner. Extra fees are not provided for when the inquest is adjourned. For an inquest held over the body of a person who has died in a lunatic asylum, public hospital, infirmary, workhouse infirmary, or other medical institution, whether endowed or supported by voluntary contributions, the medical officer of such institution shall not be entitled to a fee. Should the dead body of a person be taken to such an institution, the medical officer, if summoned to give evidence, is entitled to the usual fee. Such fees are paid at the termination of the inquest.

Magistrates‘ Court.—If the witness reside within two miles of the Court, the fee is ten shillings and sixpence; beyond two miles, one guinea.

Courts of Quarter Sessions, and Central Criminal Court of London.—One guinea per day, and two shillings a night away from home, with threepence per mile each way travelling expenses.

Assize Court.—One guinea per day, with two shillings a night away from home, and a reasonable and sufficient amount for travelling expenses. If there be no railway, threepence a mile each way. Sundays are not included.

Court of Probate and Divorce.—One guinea per day within five miles of the General Post Office. If beyond, two or three guineas a day, with expenses out of pocket for coming and returning.

Court of Appeal.—One guinea a day if resident in London; two or three guineas, with travelling expenses, if from a distance.

County Court.—From fifteen shillings as an ordinary witness, with one guinea per day expenses if from home, to one to three guineas for qualifying as an expert witness. With attendance at Court one to two guineas and expenses one to three guineas per day.

In Civil Cases.—An arrangement is usually made with the solicitor for a fee; this should be made before accepting the subpœna. A written undertaking for payment, and properly stamped, should be obtained from the solicitor before giving evidence; in default of this, the witness should appeal to the judge from the witness-box before being sworn. After taking the oath a witness is bound to give evidence, and the solicitor may refer him to his client for the fee, which may lead to disappointment.

IN SCOTLAND

The fee for attendance at High Courts of Justiciary or the Sheriff Criminal Court is one guinea per day, if the Court be held in the town in which the medical witness lives. For a post-mortem examination and report, two guineas. For an analysis of blood or other stains on clothing, two to four guineas, depending upon the amount of work done.

If the witness come from a distance, he is allowed two guineas per day, both for the actual attendance at Court and also for each day occupied in travelling to and fro, with a guinea a day for travelling expenses.

CHAPTER II MEDICAL EVIDENCE GENERALLY — 1. DOCUMENTARY — 2. ORAL OR PAROL — 3. EXPERIMENTAL — Identity — Examination of a Person said to have been Assaulted — Identity of the Dead

On the subject of evidence it is necessary to say a few words, for it must be remembered that that which may be held to be evidence in logic may not be so in law. Nothing in law is intuitive—nothing is self-evident; everything must go through the process of proof by testimony.

Legal evidence is therefore composed of testimony, but all testimony is not necessarily evidence in law. Thus, if a witness declare that he saw a certain act committed, his testimony may be accepted as evidence; but if he state that his knowledge of a fact is obtained from another person, such information, although it contain an absolutely true description of what actually occurred, will not be received. In this case his testimony is simply hearsay, and as such is not admissible, except in the case of dying declarations, and in one or two other instances which do not, however, concern us.

Medical evidence may be divided under the following heads: (1) Documentary; (2) Oral or Parol; (3) Experimental.

Under this head are included Medical Certificates, Written Opinions, Medical Reports, and Dying Declarations.

Medical Certificates.—Certificates generally refer to death, to vaccination, to notification of infectious and industrial diseases, and in districts which have adopted it, the notification of births; to the state of health of an individual, &c. For those which have respect to the health or to the illness of an individual there is no particular legal form, as a certificate is merely a simple statement of a fact. The only essential condition is that it contains the exact truth, and any departure from this will entail heavy penalties. A statement signed by a registered medical practitioner, distinctly describing the condition of A or B, is all that is necessary as far as the law in England is concerned. In Scotland the law is somewhat different, for “A certificate of bad health by a physician or surgeon must bear to be on soul and conscience.” ... “In cases of homicide, and other crimes against the person, medical certificates produced respecting the nature of the injuries must be verified on oath by the medical persons who granted them” (Dictionary Scot. Law). In Scotland, the omission of the words “on soul and conscience” invalidates a certificate.

Certificates of death, of vaccination, of notification of infectious diseases, tuberculosis, industrial diseases, and births, and of insanity can be procured already printed in the forms prescribed by the law.

Certificates of the Cause of Death.—A medical practitioner who has been in attendance during the last illness of a person is legally bound to give a certificate stating, “to the best of his knowledge and belief, the cause of death.” If he be unaware of the cause of death, or have reason to believe that death was not due to natural causes, or the result of violence, he may refuse the certificate. In such a case it is customary and desirable for the medical man to notify the Coroner of the circumstance as soon as possible. If he have no reasonable cause to prevent him supplying the certificate, he is liable to a penalty not exceeding forty shillings. In England and Ireland it is given to a relative of the deceased or legally authorised person, who must deliver it to the Registrar. In Scotland the doctor sends it to the Registrar direct. Not more than one certificate should be given. No fee is chargeable. The information on the certificate should be as clear, complete, and accurate as possible.

Notification of Births.—When the authorities of any district have adopted the Notification of Births Act of 1907, it is the duty of any person who has been in attendance on the mother at the time, or within six hours after the birth, to give notice of the birth in writing to the Medical Officer of Health of the district in which the child is born. The necessary certificate must be filled in and posted to the Medical Officer of Health within thirty-six hours of the time of birth. The certificate applies to any child dead or alive born after the twenty-eighth week of pregnancy. Should the relatives of, or other attendant upon the mother, fail to notify the birth, it is the duty of the medical attendant to do so, failing which he may be fined not exceeding twenty shillings.

Notification of Infectious Diseases.—By the Act of Parliament 1889, every medical practitioner attending on or called in to visit the patient, shall forthwith, on becoming aware that the patient is suffering from an infectious disease to which the Act applies, send to the Medical Officer of Health of the district a certificate stating the name of the patient, the situation of the building, and the infectious disease from which in the opinion of such medical practitioner the patient is suffering.

The notifiable diseases are: smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlatina or scarlet fever, typhus, typhoid, enteric, relapsing, continued and puerperal fever.

By consent of the Local Government Board the Health Authorities may add other diseases as occasion may require for a time or permanently. Of these due notice is given to medical men. Tuberculosis and ophthalmia neonatorum are now notifiable. The fee for the certificate in private practice is 2s. 6d., if in a public institution, 1s. Failure to certify renders the medical man liable to a penalty of 40s.

Notification of Tuberculosis.—As mentioned previously, tuberculosis is now a disease notification of which is compulsory. Special forms are provided for the purpose.

Notification of Industrial Diseases.—Under the Factory and Workshop Act, 1901, every case of lead, phosphorus, arsenical, or mercurial poisoning, or anthrax, if contracted in a factory or workshop must be notified by the practitioner in attendance on the case. The certificate must be sent to the Chief Inspector of Factories at the Home Office, London. The fee for notification is 2s. 6d. Other diseases may be added to the list by special order of the Home Office.

Written Opinions.—These generally refer to civil questions.

The Medical Report.—A Report is a document given in obedience to a demand by the public authorities in Scotland, and has reference chiefly to criminal cases. Medical Reports are sworn to as true by those who draw them up. According to Alison, it is not a sufficient objection that a Medical Report was made up at an interval after the occurrence of the circumstances to which it refers. The same high authority also states that should the writer of a Medical Report die before the trial, his Report may be used in evidence,—this may be doubted.

The necessity for simplicity in the arrangement and in the wording of their Reports cannot be too strongly urged on medical men. “A medical witness will do well to remember, also, that copies of his Report and depositions, either before a coroner or a magistrate, are usually placed in the hands of counsel as well as of the Court; and that his evidence, as it is given at the trial, is compared word for word with that which has already been put on record.” All hearsay statements and irrelevant matter should not be inserted in a Report; and the reporter should be particularly careful not to add any comments to his simple narration of facts. The use of superlatives is also very objectionable, as it partakes somewhat of exaggeration. All technical words or phrases should be as much as possible avoided; and where they are absolutely necessary, they should be briefly explained.

As a case in point, showing the necessity for care in the use of words, is the following from a published Paper by the late Sir R. Christison: “Some years ago, on an important trial in the High Court of Justiciary for assault, the public prosecutor attempted to prove that the person assailed had been wounded to the effusion of blood; which is held in law to be an aggravation of guilt in such cases. When the principal medical witness was examined as to the injuries inflicted, he was asked whether any blood had been effused; and he replied that a good deal must have been effused. But he meant that there was effusion of blood under the skin, constituting the contusion he had described; while the counsel and the Court at first received his answer as implying that there had been considerable loss of blood from a wound. The latter view was on the point of passing to the jury as a fact, when one of the judges detected the equivoque, and set the matter to rights.”[1]

In Scotland a medical practitioner may be called upon by the authorities to grant reports as to dead bodies, without performing a post-mortem examination.

In the first case, where a death has occurred unaccompanied by any suspicious circumstances, or where the evidence of suicide or death from accidental injury is apparent from a simple examination of the body, a certificate “on soul and conscience,” stating the probable cause of death, is considered sufficient by the authorities, and a post-mortem is dispensed with. It is not necessary that the deceased be seen by the medical practitioner before death, “yet, from the suddenness of the death, the age of the deceased, and the symptoms spoken to by the friends, he may still be enabled, satisfactorily to himself, to certify the cause of death.” In England, such a case would be the subject of a coroner‘s inquest.

In the second case, he may be summoned by a constable to inspect a body found on the public road, or in any other unusual situation. In this case he is called not only to certify the fact, but also the probable cause of death. He may, under these circumstances, give a report of the external examination of the body, at the same time suggesting the necessity for further and more careful examination by dissection, &c., and this is considered the proper course for him to take. In England, in this case also, an inquest would be necessary. In all cases medical men will consult their own interests in giving these Reports.

A Medical Report consists of two parts—the Minute of the Examination, and the Reasoned Opinion on the first portion of the Report. In the case where the Report is made by two or more persons appointed for the purpose, the latter portion is written in the plural, and signed by each of the parties certifying.

The following is an outline of a Medical Report, which may be more or less modified to suit the requirements of the case:

Dying Declarations.—The principle on which these are accepted is founded, partly on the awful situation of the dying person, and partly on the absence of interested motives in one on the brink of eternity, and which is supposed to obviate the necessity of a cross-examination. The law presumes that any one cognisant of impending death will tell the truth, and such declarations are equal to evidence on oath. The greatest care must be taken by the medical man who is called in to see a person supposed to be dying, with regard to any declaration he or she may wish to make. He must be satisfied as to the mental condition of the person. The medical attendant should simply take the statement as it is made, writing it down on the spot, or as soon after as possible. The identical words used should be committed to paper, and no suggestions or interpretations of his own should be made. Leading questions should never be put, nor any attempt made to induce the patient to make any statement. When we consider the condition of the patient, the possibility of delirium induced by the severity of the injury, together with the dread of death, it is, to say the least, injudicious to introduce the suspected party into the room for the purpose of identification, though this procedure has been suggested by some writers. In every case, however, it is advisable for the medical attendant, as soon as he sees that the case must end fatally, to acquaint the patient in the presence of others of the fact, when any statements made may then be taken. It is preferable that such statements be made before a magistrate if time will allow. It should also be borne in mind by those receiving dying declarations, that in England “it must be shown that the deceased, at the time he made the statement, was under the impression that death was impending; not merely that he had received an injury from which death must ensue, but that, as the popular phrase goes, ‘he then believed he was on the point of death’” (R. v. Forester). In one case (R. v. Fagent, 7 C. & P. 238) it was held that a declaration was inadmissible, because the person making it asked some one near her whether he thought she would “rise again”; and it was held that this showed such a hope of recovery as rendered the previous declaration inadmissible. The declaration should be signed by the person making it, and witnessed by some one present at the time.

In the case of Reg. v. Whitmarsh (Central Criminal Court, Sept. 19, 20, 21, 1896), 62 J.P. 680. Upon an indictment for the murder of a woman, who died as the result of the prisoner having used certain instruments or other means upon her with the intent to procure her miscarriage, it was shown that an inspector of police had seen her at Charing Cross Hospital. He asked her questions, and from her answers he wrote down a statement. The woman signed it. On July 7 the woman appeared to be in a dying condition, and was aware of it. She said she feared she must die, and asked to see her mother and a clergyman. The doctor told her that he had given up all hope, and that she might not live to see her mother. A magistrate saw her shortly afterwards, and read over to her the statement she made on June 29, and he affixed to it the following note, “This statement was read over to Alice Bayley by me, and is referred to in her dying declaration,” and signed. Held (Darling, J.), that though this statement might be admissible, it had better not be admitted in evidence. On the same day the woman had also made a statement to the magistrate, of which he had taken note, but before it was finished she became exhausted. The magistrate then took the statement of June 29, repeated portions of it to her in his own words, wrote these down, and asked her if it was correct. He then read the whole statement to her and she signed it. The statement commenced, “Having the fear of death before me, and being without hope of recovery”—concluding with the words, “And the statement I made on the 29th of June, and have now heard read over, is true.”

Justice Darling held this statement was admissible as a dying declaration.

In the case of Rex v. Smith, 65 J.P. 426 (Bruce, J., Central Criminal Court). A magistrate and a doctor visited a dying woman for the purpose of taking her statement. In reply to a question put to her by one of them, she said, “I am aware that I am seriously ill.” The magistrate asked her questions and the doctor wrote down the answers. At the trial the statement was objected to as inadmissible as a dying declaration on two grounds: Firstly, that the statement consists only of answers to questions put to her by the magistrate, and so comes within the ruling of Cave, J., in Reg. v. Mitchell, 17 Cox C.C. 503, that “a declaration should be taken down in the exact words which the person who makes it uses, in order that it may be possible from those words to arrive precisely at what the person meant. When a statement is not the ipsissima verba of the person making it, but is composed of a mixture of questions and answers, there are several objections open to its reception in evidence.... In the first place, the questions may be leading questions, and in the condition of a person making a dying declaration there is always very great danger of leading questions being answered without their force and effect being fully comprehended.”

Secondly, the prosecution had not shown that at the time the woman made the statement she was in expectation of immediate death.

The judge held (1) That the prosecution had not proved that in her own opinion the woman was beyond all hope of recovery, and that therefore the statement was inadmissible; (2) That such a statement—the magistrate asking her questions and the doctor taking down only her answers in writing—was not admissible as a dying declaration.

In the case of Rex v. Holloway, 65 J.P. 712 (Wills, J., Central Criminal Court). The prisoner threw a burning lamp at his stepson and set fire to his stepdaughter, who succumbed to the burns she received. A deposition of the deceased girl was taken down by a magistrate. At the time it was taken it was intended that it should be in accordance with the provisions of the 1867 Act. The accused was present and had full opportunity of cross-examining the witness. The deposition was read over to the girl, and she assented to it, but could not sign it because of the injuries to her hands. The magistrate who took the deposition signed it. It was held that the deposition had been taken in accordance with the provisions of the Indictable Offences Act, 1848, sec. 17, and was admissible though it had not been signed by the girl.

The validity of a dying declaration has been called in question when made by a person who has suffered a severe concussion of the brain, and then recovered his sensibility. It is well known that under such circumstances the recollection of what took place before or after the injury is in many cases very imperfect, and the injured party may thus draw unintentionally upon his imagination for his facts. In Scotland, “the written deposition of a person who is dead is admissible, whether the person were the party injured or not, if he would have been a competent witness. It is not necessary that the deceased believe himself to be dying when he emits the deposition, for his consciousness of approaching death may be inferred from the nature of the wound, or the state of illness or other circumstances of the case. Such depositions are generally taken by a magistrate, but a declaration deliberately made, though without an oath, and taken down ‘by a creditable person,’ is admissible” (Macdonald, Scottish Criminal Law, p. 512).

A medical man may be called as a common witness, or as an expert witness. In the first case, he has only to state, as any other witness might do, the facts that have fallen under his observation; in the second, he has to interpret the facts he has himself observed, or to give his opinion on facts noticed by others. In stating his opinion, a medical witness must be prepared to back up his opinion by such reasons as may be satisfactory to the understanding of his hearers, “and this is the principal qualification of a medical witness, that he make himself intelligible to ordinary comprehensions.” No man is bound to give any testimony by which he may render himself liable to any criminal prosecution. (See the ruling of Bailie, J., in the case of Mr. George Patmore, tried for the murder of John Scott in a duel.)

At the trial, the witness is first examined by the party who calls him: this is the examination-in-chief. He is then cross-examined by the opposite party; and, lastly, re-examined by the former party, when he is offered the privilege of explaining any discrepancies between his examination-in-chief and cross-examination, but he must not introduce any new matter, for by so doing he renders himself liable to be cross-examined on it.

The Use of Notes.—All notes should contain a plain statement of the facts, and, to render them admissible as evidence, they must be taken at the time, and duly attested. From the notes prepared as before mentioned a witness may refresh his memory, but they are not accepted in its place. A witness may not read his notes as evidence, nor may he refresh his memory by documents not his own and not produced, but he may refresh his memory by looking at a document received from the accused at the time of the offence, and kept by him (Geo. Wilson, jun., Aberdeen, May 1, 1861; 4 Irv. 42).

The Use of Books.—No witness is allowed to quote from books, or to quote the opinion of other medical men on the subject, but he may refer to facts. Sir Henry Littlejohn, in his papers on Medical Jurisprudence,[2] gives some useful hints on this subject. It appears that a medical witness, in an unguarded moment, stated that his opinion was corroborated by a distinguished member of the medical profession not engaged on the trial. The judge informed the witness that it was most irregular to have other medical men present at the dissection than those mentioned in the warrant, and that, if the witness did not feel qualified for conducting such dissections, he had better resign the post of medical inspector.

In England, at the request of both parties, the medical and scientific witnesses may be excluded from the Court, but as a general rule they are allowed to be in Court, and hear the whole of the evidence of the case. In Scotland they are always excluded, although, by mutual consent, “experts” may remain to hear the general evidence on which they are to express their opinions, but when an expert is giving his opinion the others must leave the Court. In the latter country also, a medical witness who has been in Court cannot be examined on the facts of the case, but only on matters of opinion. A medical man is, however, sometimes allowed, on a special motion, to remain, although he is to be examined as to facts, and withdrawn when other witnesses are to be examined as to facts to which he is to speak. (See case of E. W. Pritchard, H.C. 1865; 5 Irv. 88.)

In giving evidence the witness should—(1) Speak loudly and distinctly. (2) Answer questions categorically—Yes or no. (3) Never use superlatives. (4) Give answers irrespective of results of trial. (5) Express no opinion as to guilt of prisoner; state facts only. (6) Avoid using technical terms. (7) Avoid long discussions, especially theoretical arguments.

When a quotation is made from a book by the examining counsel, the medical witness, before replying to a question based on it, should see that the quotation has been fairly and fully given, due regard being paid to the context. Neglect of this precaution may lead him into considerable difficulty.

A medical witness should remember that he is not retained for a party, but in the cause of justice. He must, therefore, be candid in his manner and simple in his language. Mr. Haslam remarks that, however dexterous a witness may show himself in fencing with the advocate, he should be aware that his evidence ought to impress the judge, and be convincing to the jury. Their belief must be the test by which his scientific opinion is to be established. That which may be deemed by the medical evidence clear and unequivocal, may not impress the judge, nor carry conviction to the jury.

The advice given by Sir W. Blizard may not be out of place here: “Be the plainest man in the world in a Court of Justice; never harbour a thought that if you do not appear positive, you must appear little and mean for ever after; many old practitioners have erred in this respect. Give your evidence in as concise, plain, and yet clear manner as possible; be intelligent, candid, open, and just, never aiming at appearing unnecessarily scientific. State all the sources by which you have gained your information. If you can, make your evidence a self-evident truth: thus, though the Court may at the time have too good or too mean an opinion of your judgment, yet they must deem you an honest man. Never, then, be dogmatic, or set yourself up for judge and jury; take no side whatever, be impartial, and you will be honest. In Courts of Judicature you will frequently hear the counsellors complain when a surgeon gives his opinion with any of the least kind of doubt, that he does not speak clearly; but if he is loud and positive, if he is technical and dogmatic, then he is allowed to be clear and right. I am sorry to have to observe that this is too frequently the case.”

Liability of Medical Men to reveal Professional Secrets.—The question has arisen how far a medical man is bound to reveal the secrets confided to him in his professional capacity as medical attendant. This question was raised by Mr. Cæsar Hawkins in the trial of the Duchess of Kingston (11 Harg. St. Tri. 243), before the House of Peers, and decided by Lord Mansfield thus: “Mr. Hawkins will understand that it is your (the other Peers) judgment and opinion that a surgeon has no privilege, where it is a material question in a civil or criminal course to know whether parties were married or whether a child was born, to say that his introduction to the parties was in the course of his profession, and in that way he came to the knowledge of it. I take it for granted, that if Mr. Hawkins understands that, it is a satisfaction to him and a clear justification to all the world. If a surgeon was voluntarily to reveal these secrets, to be sure he would be guilty of a breach of honour, and of great indiscretion; but, to give that information in a Court of Justice, which, by the law of the land, he is bound to do, will never be imputed to him as any indiscretion whatever.” However objectionable it may be to the medical witness, and be considered by him a breach of professional confidence, to reveal in a Court of Law secrets known but to himself and patient, and regarded as sacred, he has no privilege but to reveal them if demanded as evidence, unless the evidence be such as might incriminate himself. This is not the ruling in most Continental countries, where the medical man claims the same privileges of secrecy as the priest in confessional.

Under this head will be treated Identity and the examination of the Living and the Dead, Real and Apparent Death, Cause of Death, Exhumations, and Autopsies.

Examination of the Living.—With regard to the identification of the living, the presence of a medical man is seldom required, but there are many occasions when his opinion may be sought. Thus, under the Factory Acts, he may have to examine children about whose age doubts may have arisen. The Table on p. 33, giving the periods at which the teeth appear, will assist him. A medical man may also be requested to give an opinion as to the mental soundness or unsoundness of an individual. He may also be consulted in cases where questions have arisen as to the existence and character of certain marks on the body—of deformities, either congenital or produced subsequent to birth, or of doubtful sex. The marks which most frequently give rise to differences of opinion are nævi materni, scars, and tattoo marks. In cases of doubtful sex, the male organs may resemble the female, the female the male, or they may be blended together in about equal proportions.

In all cases where an examination of a living person is required, the consent of the person must be obtained, the nature of the examination explained, and that any facts recorded will be used as evidence if required. If the person refuse to be examined then it must not be carried out.

Cicatrices.—The following questions may be put to the medical expert—(1) Do scars ever disappear? (2) Can the age of a scar be definitely stated?

In reply to the first and second questions, I shall quote the words of the late Professor Casper: “Consequently the scars occasioned by actual loss of substance, or by a wound healed by granulation, never disappear, and are always to be seen upon the body; but the scars of leech bites, or lancet wounds, or of cupping instruments, may disappear after a lapse of time that cannot be more distinctly specified, and may therefore cease to be visible upon the body. It is extremely difficult, or impossible, to give any certain or positive opinion as to the age of a scar.”

All cicatrices should be examined with oblique light and the aid of a lens. In the early stages a cicatrix is of a red colour, changes to brown, and later to white, and the surface glistens. In the intermediate stages one could not give any positive evidence of the age of a cicatrix. The probability is that a red cicatrix is a recent one, a white cicatrix is not recent.

I have seen well-defined cicatrices upon the back of a Russian, after incisions made by the blades of a cupping instrument fourteen years previously, and in an Englishman after twenty-five years (R. J. M. Buchanan).

Devergie states that where the brand of a galley-slave has vanished, it may be recalled by slapping its usual position with the palm of the hand. The scar remains white, while the skin round it is reddened. A change of temperature to the part will sometimes cause the reappearance of a vanished scar. Washing may also help to reproduce scars. Cicatrices produced in childhood may grow with the ordinary growth of the individual. The shape of a cicatrix will depend upon the character of the wound which produced it; on the nature of the healing process; on the elasticity or tension of the skin; on the convexity of the part; and on the looseness of the subcutaneous cellular tissue. An incised wound healing by the “first intention” will most probably leave a white linear cicatrix; on the other hand, a wound healing by granulation will leave a more or less irregular scar. The position of a wound on the body also modifies the subsequent cicatrix; thus a linear cicatrix is produced when the wound is in the long diameter of the limb, a more or less oval one when across the limb. The retraction of the skin in the latter case tends to draw the skin at right angles to the line of incision, thus approximating the extremities of the cut, increasing it in breadth and lessening it in length. Owing to one or more of the above-mentioned conditions the typical cicatrix of an incised wound is elliptical, tending, however, in some cases to assume a circular form. Linear cicatrices are found chiefly between the fingers and toes, and where the cutaneous surfaces are concave. In gunshot wounds the resulting cicatrix is depressed and disc-shaped, and more or less adherent in the centre to the subcutaneous tissues, and if the weapon be fired close to the surface of the body, grains of unburnt powder may be seen in the surrounding skin. Cicatrices from burns are, as a rule, large, irregular, and superficial, and frequently give rise to deformity. A scar left by caustics is circumscribed, deep and depressed in the centre. Cicatrices in the groins are probably venereal; those in the neck and under the jaw, strumous. Scars from operation incisions are much less evident now than when wounds were more likely to suppurate and heal by granulation. It is remarkable, after an incision made with aseptic precautions and healing by first intent, as time progresses the cicatrix becomes less and less noticeable, but they can be detected by methods described above. Fine punctures and stitch cicatrices may eventually leave little or no trace.

Dupuytren and Delpech state that the tissue formed in a cicatrix is never converted into true skin—the rete mucosum when once destroyed never being re-formed. It contains no sebaceous glands, sweat glands, or hair follicles, and is but slightly vascular. This may account for the white colour of ordinary cicatrices, but even to this rule exceptions may be taken, and dark brown patches of pigment have been known to mark the situation of old lacerated wounds. It must be remembered also that in irregular wounds and in incised wounds which may heal with an uneven joint, that portions of skin may become embedded or grow into the scar tissue and give rise to difficulty in forming an opinion. I have seen a well-defined dark coloration of the skin continue for three months after the application of a mustard plaster, followed at the time by desquamation.

Tattoo Marks.—With regard to tattoo marks, the question of their disappearance gave rise to considerable discussion in the celebrated Tichborne case. On this subject the experiments of Hutin, Tardieu, and Casper appear to point to the fact “that tattoo marks may become perfectly effaced during life,” but that after death the colouring matter with which the marks were made may be found in the lymphatic glands. This is especially the case when vermilion is used. The most permanent marks are made with Indian ink, powdered charcoal, gunpowder, washing blue or ink, and vermilion. These are given in the order of their permanency. Hutin found that in 506 men who had been formerly tattooed, the marks had disappeared from 47 of the number. Not only does permanency depend upon the colouring matter used, but also upon the depth to which it has penetrated. If superficial, it may gradually become effaced. If the material be carried down to the papillæ, it will remain permanent, and can only be removed in such a way as to leave a scar. But besides the spontaneous disappearance of tattoo marks from the lapse of time, these marks may be artificially removed, and in such a manner as to prevent the possibility of a definite opinion being given as to their primary character. The presence of a scar in the situation of a well-known tattoo mark is suspicious. Thus, the Claimant had a scar on a part where it was sworn that Arthur Orton had been tattooed. The application of strong acetic acid, potash, hydrochloric acid and glycerole of papain appears to be the means adopted for the removal of tattoo marks. Efforts are made to remove superficial tattoo marks by removing the particles with needles. Tattoo marks according to their position and design are useful evidence of identification.

Birth Marks.—The presence and characters of birth marks should be noted for purposes of identification. Their removal may be possible, but, except in such as are small and superficial, the process used for removal leaves traces behind in the form of cicatrices or irregularities of surface, which may generally be detected in oblique light and with the aid of a good lens. Large moles or nævi may he excised, but a cicatrix will remain, which will differ in shape from the original mark.

Congenital Deformities.—These offer no difficulty and are in many cases permanent, such as intra-uterine amputations, constrictions, abnormality of limbs, &c. Such conditions as hare-lip, cleft-palate, herniæ;, &c., may be altered by surgical procedure, but leave permanent records of this. Peculiarities in twins are interesting as to their being of the “mirror image” or “identical” type.

Anthropometry.—This is principally used for the identity of habitual criminals. The Bertillon method is based upon certain measurements of the body, the principal of which are (1) the length of the head, (2) width of head, (3) length of body, (4) length of trunk while sitting, (5) distance between tips of mid-fingers with arms outstretched, (6) length of left forearm, left middle finger, and left foot, (7) length and width of right ear, (8) colour of irides. These measurements place the person in one or other class, according to the special system of classification.

Fig. 1.—First line (from left to right), plain impressions of whorl (thumb), arch (second finger), radial loop (forefinger).

Second line, rolled impressions of whorl (thumb), ulnar loop (fourth finger).

Finger Prints.—These are largely used as a means of identification in criminal cases, either by prints left upon articles, or by prints definitely made by the police authorities as a record for identification purposes.

On articles, the finger prints may be rendered more visible by dusting with some finely powdered material of dark colour which will adhere to the impression, which may then be photographed and enlarged.

For purposes of record, the impressions are taken directly upon a suitable surface of the bulbs of the fingers and thumbs after having coated them with printer‘s ink. The impressions thus made show individual peculiarities in the distribution and arrangement of the ridges of the skin; and the chances of the markings of two individuals being alike is about one in sixty-four millions. By means of the pattern of these ridges, prints may be classified under the headings of arches, whorls, and loops, with certain recognised modifications of these. (See Figs. 1 and 2.)

Fig. 2.—First line (from left to right), plain impressions of whorl (forefinger), ulnar loop (thumb), arch (second finger).

Second line, rolled impressions of whorl (thumb), ulnar loop (third finger).

Eyes and Veins.—The angle of the eyes to the middle line of the face is an aid to identity; this will show whether the equator of the eye is on a plane at a right angle to the middle line, or above or below it. Tamassia lays much stress upon the arrangement of the veins on the back of the hands, which is an individual characteristic and one which is not easily altered or likely to be. By compressing the arms with a ligature the veins are made to stand out in relief and the backs of the hands are photographed.

Other Peculiarities.—The identity of the accused may be further proved by the absence or malformation of the teeth corresponding with a bite on the party assaulted, or the impression of the teeth on soft articles like cheese. Peculiarities of dentistry may be useful in identification. Or it may be proved that the wound inflicted could only have been made by a left-handed person, or in a manner peculiar to those engaged in the slaughtering of animals—e.g. is the cut from within outwards, as employed by butchers? The correspondence in the size and peculiarities of the foot of the prisoner and the footprints found in the vicinity of the crime is important as evidence. There is considerable difference of opinion as to the size of a footprint on the ground, Mascar of Belgium asserting that it is smaller than the foot that made it, Caussè, on the contrary, that it is usually larger. It should be borne in mind that the size of the footprint varies in running, walking, and standing, being smallest in running and largest when the individual is standing, which may account for the difference of opinion of the two observers just mentioned. This fact should always be borne in mind when an examination is required to be made of the footprints in the neighbourhood of the crime. A mark in the footprint showing that the sole of the boot had been patched, or in the case of the naked foot that there was some deformity of the toes, would of necessity be important. The mark of the naked foot smeared with blood has, in several cases, led to the identification of the culprit. Photographs may be used as a means of identification. Casts of footprints may be taken by smearing the print carefully with oil, and pouring in liquid plaster of Paris, or by dusting it over with powdered paraffin wax, and then melting it by holding a hot iron over the print; this may be repeated until a sufficiently thick cast is obtained. Hot solution of gelatine in water, mixed with oxide of zinc and glycerine to the requisite consistence, may be used for the purpose.

Dyeing of Hair.—As a means of disguise the hair may be dyed, or the colour may be changed from dark to light. For darkening the hair, preparations containing permanganate of potash, or the acetate of lead, bismuth, or nitrate of silver, are most frequently employed. Sticks of nitrate of silver or lunar caustic are used for darkening eyebrows and moustachios. A wash containing sulphide of potassium is used before the application of the lead solution. This removes the grease, and helps the rapid formation of the black sulphide of lead. Preparations of henna are fashionable for the production of shades of copper to rich brown. To detect fraud, some of the suspected hair should be steeped in dilute nitric acid, the acid driven off by gentle heat, and the nitrate dissolved in distilled water, and then sulphuretted hydrogen passed through the solution, the result being the formation of the black sulphide of lead. If silver be present, the addition of hydrochloric acid will throw down the insoluble chloride of silver. If careful examination be made of dyed hair, it will be found that the dye is irregularly taken by the hair; the hair loses lustre, and I have not unfrequently seen the hair close to the scalp white, or at least several shades lighter than the rest. The scalp may also be seen more or less discoloured, especially when nitrate of silver is used and applied by the individual himself.

For lightening the natural colour, solutions of chlorine, of peroxide of hydrogen, nitric and nitro-hydrochloric acids, of varying strengths, are used. It must be remembered that the action of chlorine is by no means uniform. The hair retains the odour of chlorine for some time, even after repeated washing, and is hard, stiff, and brittle. Devergie states that he has not succeeded in producing a perfect whitening of the hair in less than from twelve to twenty hours. It must be borne in mind that, under certain circumstances, dark hair may become suddenly white. I have seen large patches of grey hair over the head, the result of repeated attacks of neuralgia.

In the examination of persons whose hair is alleged to have been dyed, it is necessary to compare the dyed hair with that from other parts of the body, e.g. the pubes, or axilla, to wait and watch for irregularities of colour as the hair grows, new growth being free from dye, and if necessary to shave the part and compare the new growth with other hair, also to examine carefully the skin in the position where the dye has been applied. In one case which I noted, a man had been in the habit of touching the moustachios and eyebrows with lunar caustic, having previously damped it with his tongue; in time it produced argyria which coloured the whole of his face, the body generally, but most noticeable on the face.

Fig. 3.—Photo-micrograph of transverse section
of normal hair follicle, × 250.
(R. J. M. Buchanan.)

Carefully examine the bruises, wounds, &c., to see if they could have been inflicted as described. Ask no questions that may suggest an answer. Examine all weapons said to have been used, and hand them over to the police. In all cases where danger to life is imminent, send for the Authorities, and take dying declarations, as these may become evidence of vast importance, and, if properly taken, are as valid as if given on oath.

Much of what has been said under the heading of identity of the living is applicable in examinations to establish identity of the dead. The latter requires certain special details of examination owing to the peculiar circumstances which may be present demanding them. The material subject to examination may be incomplete, and difficulties arise, so that it is essential to record every minute detail which may be of value as evidence.

The purposes of examination under this heading are mainly related to the questions of stature, age, sex, and special peculiarities of the body.

It will be useful here to emphasize the importance of making a detailed examination of the body. The examination, particularly the external inspection, should be made in daylight.

If the body be seen where first discovered, note should be taken of the exact position and attitude, of any signs of a struggle, of footprints to or from the body; of bottles, medicines, vomit, or excreta near the body, and which should be collected and retained. The expression and colour of the face, the condition of the hands, the condition of the dress as to tears and stains, the heat, amount of rigidity or putrefaction, the presence of wounds and vital reaction in them.

If the body has been removed from the place where found, make similar notes, remove the clothes, and compare any cuts if present in the clothes with those on the body. Record for identification—nævi, moles, tattoos, scars, hare-lip, cleft-palate, the mammæ, abnormalities of fingers, teeth, bones, limbs, joints, &c.

An examination of the mouth, for the presence or absence of false teeth, or of any peculiar formation of the jaw, may lead to the identification of the body. In the case of Dr. Parkman, the recognition by a dentist of the false teeth worn by the deceased led to identification of the remains, and also to the discovery of his murderer. The presence of an ununited fracture, as in the case of Livingstone, may lead to the identification of the body. In one case where a man was said to have died from a fracture of the ribs recently caused by a blow, it was found on examination that the bones were united by a firm callus, clearly showing that the skeleton produced could not be that of the man alleged to have been murdered.

Record the height and if possible the weight. Note the sex, the probable age, nutrition, and cleanliness or otherwise. Examine all wounds, bruises, and describe them carefully, and marks, e.g. strangulation or throttling. Examine the hands carefully and describe their peculiarities, also the colour of hair and eyes. Examine all the apertures of the body for foreign bodies, or abnormal conditions, and, in females, record carefully the condition of the external genitalia and the presence or absence of the hymen.

Although a more detailed account of the method of carrying out post-mortem examinations is given later on, it will not be out of place here to point out briefly the steps of examination. I would again emphasize the importance of making a thorough and complete internal examination, leaving no organ unexamined. If there be no call for special examination of the thorax or abdomen first, commence with the examination of the surface of the brain, then proceed downwards. Note the direction of any wounds and their depth. Examine all organs for morbid changes, and in females, the vagina and uterus. Examine the larynx and œsophagus. Remove injured bones and examine joints. Remove the spinal cord. Always remember to note the contents of the stomach and bladder in reference to the period at which death may have occurred. Weigh all organs. Always remember the probability of poisoning, and make your examination accordingly.

All fragments or injured parts of a body or its organs should be preserved, and photographs taken of them.

It is better for two medical men to conduct the examination together. Do not make the examination without an order from the coroner. A medical man who is alleged as implicated in the cause of death should not be present.

Identification of the dead may present special difficulties where mutilation of the body has taken place, or where the body has been severely burnt, or is disfigured as in cases of explosions or advanced putrefaction. In such cases, fragments of clothes, ornaments, and dental work may afford valuable evidence.

Occupation Marks.—As an aid to identification, it is important to remember that certain trades leave marks by which those engaged in them may be identified.

Thus, in shoemakers there may be more or less depression of the lower portion of the sternum, due to constant pressure of the last against the bone.

Tailors work sitting, with the legs crossed and the body bent forward. The body is thus cramped, and the abdomen drawn in, and the thorax projects over it, due to the manner of sitting. They frequently have a soft red tumour on the external malleolus. A like tumour, but not so large, may also be found on the external edge of the foot, and a corn on the little toe.

Photographers have their fingers blackened by nitrate of silver, pyrogallic acid and other developers, or stained yellow with bichromate of potash.

Seamstresses have the index finger of the left hand roughened by the constant pricking of the needle.

Copyists have on the little finger of the right hand, near its extremity, a corn, and at the end of the middle finger a hard groove made by the pen.

Violinists have corns on the tips of the fingers of the left hand, harpists on both hands.

In smokers of pipes the incisors and canines are more or less worn by the mouthpiece, but sometimes the groove is between the canines and bicuspids. In cigarette smokers, the forefinger and thumb are stained with tobacco juice, also between the index and middle fingers, on the dorsum.

In coachmen, corns may be formed between the thumb and index finger, and between the index and the second finger of the left hand, from the pressure of the reins, and between the thumb and index finger of the right hand, from the pressure of the whip.

In bricklayers, from the constant action of picking up bricks, the flattening of the tip of the thumb and index finger of the left hand is not uncommon.

Plasterers have corns on the external surfaces of the thumb and index finger, due to grasping the “hawk” on which the plaster is placed during their work.

Joiners and carpenters have callosities on the palm of the right hand from grasping their tools, and between the thumb and index finger of the right hand, also over the first interphalangeal joint of the right index finger. The right shoulder is lower than the left.

The finger-ends of turners and coppersmiths are also more or less flattened; in the latter, a deposit of the metal may take place.

To ascertain the time which may have elapsed since death.—This can scarcely be determined with precision, as so much depends upon the conditions under which the body may have been placed. The subject under consideration is, therefore, beset with difficulties, and its elucidation will require the greatest care on the part of the medical expert. A careful attention, however, to the subjects treated in the following pages will help to clear up many a doubtful point.

COOLING OF THE BODY

(1) External    circumstances.		Covered by bed-clothes, or otherwise
		unexposed, when cooling will be dry
		slower than in cold air quickly moving.
(2) Condition of the		Slow, if fat.
body itself.
		1. Wasting diseases. Quick.
		2. Suffocation. Slow.
(3) Kind of death.		3. Cholera, yellow fever,		Increase
		rheumatic fever, and		of heat
		cerebro-spinal meningitis.		after death.

The following circumstances must also be taken into consideration: (1) Age. (2) Air—(a) moving; and (b) at rest. (3) Moisture. (4) Warmth. (5) Nature of the supposed cause of death, as affecting cooling of the body, and promoting the rapid advance of putrefaction. (6) Presence or absence of the rigor mortis. Bodies may be preserved for months if exposed to intense cold.

The following Table, compiled from the experiments of Devergie, may be of use in aiding the expert to form his opinion, but it must be borne in mind that, from the great difficulties which surround the subject, the statements made are only approximately correct. The table is divided into four stages or periods, the last being that in which putrefaction commences:—

First.—From a few minutes to twenty hours after death—Animal heat more or less present, but seldom continuing longer than ten or twelve hours. Muscles contract on the application of galvanic stimuli, and in the earlier stage to blows.

Second.—From ten hours to three days—Body quite cold and rigor mortis well marked; muscles do not contract on the application of stimuli. The age, mode of death, and other collateral circumstances must, more or less, be taken into consideration before an opinion can be given.

Third.—From three to eight days—The body is quite cold, and cadaveric rigidity has passed off. The muscles no longer respond to any galvanic or mechanical stimulus. The stage is modified and somewhat shortened in summer.

Fourth.—From six to twelve days—Commencement of putrefaction. Putrefaction may, however, take place on the first or second day after death; so that, as before stated, care must be taken before any positive decision can be given.

Stature.—As a general rule the length of the body is equal to the distance between the tips of the middle fingers with the arms outstretched. If an arm be missing, the length of the remaining one multiplied by two, with the addition of 6 inches for each clavicle and 1½ inches for the width of the sternum, will give the approximate height. The femur is said to be equal to .275 of the body height. If the skeleton be entire, the addition of 1½ inches for the soft parts should be made.

Where only a limb or long bone or part of one be available, it is not possible to give anything more than an approximate opinion of the height.

Sex.—When mutilation, putrefaction, or charring has taken place, by which the genitalia have been demolished, it may be difficult to determine the sex. Evidence will be afforded by the distribution of the pubic hair, which in the male reaches as high as the umbilicus, but is horizontal with few exceptions in the female. Males have more hair on the body generally.

The presence of moustachios and beard and the length of the hair on the head will assist in sex determination.

The breasts if present will denote the sex, also the uterus, which withstands putrefaction and burning to a marked degree.

Remains of clothing and ornaments will indicate the sex of the wearer.

Lineæ albicantes on the abdomen, buttocks, and breasts indicate the female sex, and the probable occurrence of previous pregnancies. It must, however, be remembered that lineæ albicantes occur in males who have been stout or had the abdomen distended by disease.

The Skeleton in Relation to Identification.—When a complete skeleton is submitted for examination, the chief points to elucidate are the age and sex. These will be noted further on. It may happen that a single bone, separate bones, or only a part of one is obtainable, when there may be considerable difficulty in expressing a definite opinion. The questions to be answered are: Are they human or belonging to the lower animals? When the bones are entire the answer is not very difficult to settle; but when parts of bones have to be dealt with, one has to be very careful in forming conclusions, and the fragments may have to be submitted, to a skilled anatomist. One may not be able to express an opinion about bones of the lower animals, other than to state they are not human. The services of a skilled Comparative Osteologist may be necessary to decide the nature of the animal.

When fragments resembling bone have to be examined, the microscope will be necessary to determine their osseous structure. When several bones have to be examined it may be possible to build up part or the whole of a skeleton. Duplicate bones will indicate remains of more than one creature. All fragments and bones should be carefully described, measured, and photographed.

By the character of the bones one may be able to determine the sex to which they belong and the approximate age. As a general rule the bones of the female are smaller, lighter, and less marked by muscular and other attachments.

The thorax in the female is deeper than in the male, the sternum shorter and more convex, the ensiform cartilage thinner and ossified later in life. The cartilages of the ribs are larger and the ribs smaller than in the male. The ribs are more oblique and may show the results of long corset pressure. The body of the sternum is over twice the length of the manubrium in the male, less than this in the female.

The length of the twelfth rib in the male averages 103 mm., in the female 83.8 mm. The pelvis exhibits marked differences. The sacrum of the male is more curved than that of the female, which is straighter in the upper half and more curved in the lower. The male pelvis is more compact, deeper, rougher, and narrower. The pubic angle is smaller, the obturator foramen is oval, and the ischia incurved. The female pelvis is more open, shallower, wider, not so rough, a wider pubic angle, and shallower and broader symphysis, the ischia are everted, wider apart and flatter, and the obturator foramen triangular. The inlet of the female pelvis is greater in all its diameters.

The skull in the male is heavier and larger, the markings and ridges being more pronounced, the mastoid processes, occipital protuberance, zygomatic and superciliary ridges are more prominent, and the capacity greater than in the female.

In the female the jaw is less prominent and has a wider angle.

The lumbar curve is longer in the female, and the lumbo-sacral angle greater than in the male.

The angle made by the neck of the femur with the shaft is about a right angle in the female, more obtuse in the male. It must be remembered that these differences between the sexes are not present to the same degree before puberty, so that prior to it the examination offers little evidence as to sex.

When examining bones any injuries to their structure or other abnormalities should be noted. The skull must be carefully examined for fractures, especially the base, which may be easily overlooked. Injuries to vertebræ should be looked for. The presence of callus will indicate that fracture has occurred at a period before death long enough for its formation.

Age.—There are several data which enable one to form a fairly accurate opinion as to the age of a body, these are especially useful in earlier years and intra-uterine life.

The more general are the size, height, development, the presence or absence of signs of puberty, the state of dentition, the greyness of the hair; in the female the atrophic condition of the uterus after the menopause, and the character of the lower jaw.

In addition are the time of life at which centres of ossification appear and the union of epiphyses to the shafts of bones and bones with each other.

In intra-uterine life centres of ossification appear by the end of the sixth month in the os calcis, manubrium, and the bodies and laminas of the sacral vertebræ; by the seventh, in the first piece of the body of the sternum and the astragalus; by the eighth, in the second piece of the body of the sternum; at full term in the cuboid, third piece of the sternal body, first coccygeal vertebra, and the lower epiphysis of the femur.

All traces of the fontanelles have disappeared by the end of the fourth year. The angle of the jaw in infants and young children is obtuse; as dentition proceeds, the body becomes deeper and the angle alters so that towards adult life it approaches a right angle, the ramus is longer and the body has become well developed with a mental foramen midway between upper and lower borders. In the new-born, the mental foramen is low down as the body of the jaw is practically all alveolar. In old people the angle again becomes obtuse and the alveolus disappears as the teeth are shed, and the mental foramen is at the upper border.

Table of the Eruption
of the Teeth

Table showing the Periods at which Points
of Ossification appear after Birth

Periods of Union of Epiphyses with the Shafts of Bones,
and of Bones with each other

Table showing the Development of the Embryo
according to the Lunar Months

Table giving the Measurements, according to the Months,
of the Extremities of the Fœtus in
the Order of their Development

Table showing the Maximum and Minimum Dimensions of the Osseous
Nucleus of the Inferior Femoral Epiphysis from the Seventh
Month of Intra-Uterine Life to Two Years after Birth

CHAPTER III MODES OF DYING, SUDDEN DEATH, SIGNS OF DEATH — MODES OF DYING — SUDDEN DEATH — SIGNS OF DEATH — Real Death — Exceptions. — Cutaneous Hypostasis — External Conditions Which Modify Putrefaction — Internal Conditions Which Modify Putrefaction — THE PHENOMENA OF PUTRESCENCE IN THEIR CHRONOLOGICAL ORDER — 1. External — 2. Internal — Organs which Putrefy Early — Organs which Putrefy Late

Syncope—death beginning at the heart.
Asphyxia—death beginning at the lungs.
  Coma—death beginning at the brain.

Syncope.—From δνγκοπτω, I strike down. Sudden arrest of the action of the heart.

This condition may be brought about by

• 1. Deficiency of blood due to hæmorrhage—death by anæmia.
• 2. Effect of certain diseases and poisons, &c.—death by asthenia.

Causes—Heart Disease.—Aortic regurgitation, fatty degeneration, &c.

Hæmorrhages from wounds of blood-vessels or the heart, profuse hæmoptysis or hæmatemesis, uterine hæmorrhage, bursting of varicose veins, bursting of aneurysms.

Shock.—Emotion; blows on the head or epigastrium; sudden evacuation of fluids from the body, as in emptying an over-distended bladder, tapping a hydrocele, ascites, or a pleural effusion. Extensive injuries to the body (railway and machinery accidents). Drinking large quantities of cold water when heated.

Exhaustive diseases, chronic or infective.

Symptoms.—Pallor of the face and mucous membranes, dimness of vision, cold perspirations, sense of impending death, restlessness, air hunger and gasping for breath, nausea, and, maybe, vomiting, noises in the ears, passing delirium, quick, feeble, and fluttering pulse, or the latter may be imperceptible at the wrist, insensibility, convulsions.

In ordinary fainting attacks many of the above symptoms are absent; such as are present are temporary. In collapse, consciousness is retained.

Post-mortem Signs.—The cavities of the heart contain a normal quantity of blood in death by asthenia, but may be almost empty when death is due to anæmia. The blood in asthenic death is simply arrested in its course; blood is, therefore, found in the large veins and in the arteries. The brain and the lungs are not engorged with blood.

Asphyxia.—From ἀ priv. et δφνξιϛ, pulse. Apnœa is the better term—ἀ priv. et πνεω, I respire; but this word is now used by physiologists to denote a cessation of the respiratory movements due to artificially oxygenated blood. Blood in this condition fails to excite the respiratory centre in the medulla, and respiration ceases. To avoid confusion the term asphyxia had better be retained, especially as it is most commonly used and generally understood. Asphyxia, or death from defect in the quality of the blood, is brought about when any impediment is placed on the healthy action of the lungs. Experiment has shown that for a short time after respiration has ceased, the heart still continues to act, and that if the impediment to the proper aeration of the air by the lungs be removed, life may be prolonged. Taking therefore the primary meaning of the terms asphyxia and apnœa into consideration, it may be remarked that the latter precedes the former in point of time—asphyxia marking the period at which the action of the heart ceases, apnœa the cessation of the respiratory functions.

Causes of Asphyxia.—1. Mechanical obstruction to the air passages: foreign bodies, exudations, tumours, suffocation, strangulation, drowning, hanging, spasm of glottis from mechanical irritation, or irritant gases.

2. Interference with the action of the respiratory muscles: exhaustion of the muscles from cold; paralysis of muscles from injury to or disease of respiratory centre; poisons acting on the centre; continued pressure on walls of the chest; fixation of muscles from tetanus or strychnine poisoning.

3. Diseases of and injuries to the lungs: pleurisy with effusion, acute pneumonia, empyema, pneumothorax, pyopneumothorax, pulmonary apoplexy, embolism of pulmonary artery.

4. Inhalation of air deficient in oxygen.

Symptoms of Asphyxia.—Divided into three stages. First stage: deep, frequent, and laboured respiration; the extraordinary muscles of respiration are called into play. Second stage: the inspiratory muscles are less active than expiratory, convulsions of nearly all the muscles of the body occur. Third stage: paralysis of respiratory centres, dilated pupils, loss of consciousness, absence of reflexes. Gasping inspirations with prolonged intervals precede dissolution.

Post-mortem Signs.—Engorgement of the pulmonary artery, the right cavities of the heart, and vent cavæ; but on the left side of the heart the cavities, together with the aorta and pulmonary veins, are either empty or contain but little blood. It must be remembered, however, that cases of asphyxia do sometimes occur where the cavities on each side of the heart are empty, or nearly so. This is the case in the syncopal asphyxia of some writers. If also the obstruction to respiration be imperfect, the circulation may be continued for some time, congestion of one or more of the internal organs being the result. The blood is dark-coloured, contains much CO₂, and the hæmoglobin is almost completely reduced. The blood coagulates slowly.

Coma.—Insensibility ending in death. Causes.—Concussion of the brain, cerebral hæmorrhage, embolism, thrombosis, tumour, depressed fracture of skull, meningitis, and serous effusions; effects of poisons such as opium, alcohol, ptomaines, arsenic, barium, oxalic and carbolic acids; in certain diseases of kidneys and liver, uræmia, cholæmia, acetonæmia, profound anæmia, e.g. pernicious, and as a terminal stage to acute or chronic diseases.

Symptoms of Coma.—Coma is generally preceded by stupor, from which the patient may be roused to a certain extent, but only temporarily. The reflexes in this stage may be exaggerated, and the power of swallowing fluids may be retained. When coma is present there is complete abolition of consciousness, sweating, the patient is powerless, the breathing stertorous. The temperature may vary according to the cause; normal or subnormal generally, it may rise in lesions of the pons Varolii. The pulse is generally full and bounding, the pupils dilated or contracted and insensitive to light, the conjunctival reflex absent. Mucus collects in the air-passages and causes “the death rattle,” and the breathing becomes more and more embarrassed and irregular. The reflexes are lost, and the sphincters relaxed.

Post-mortem Appearances.—Causal lesions are found in the brain or other organs; there is usually hyperæmia of the brain and spinal cord and their membranes, unless there be profound anæmia preceding death. The condition of the heart and lungs is not constant; the general appearances resemble those in death from asphyxia.

Table giving the Diagnosis of Several
Forms of Insensibility

Injury to the Head—Concussion of the Brain.—The symptoms are very similar to those of shock, with unconsciousness, but it may be possible to rouse the person. The pupils are equal and dilated or contracted, and react sluggishly to light. The breathing is shallow and slow with sighing, the pulse feeble. The muscles are relaxed but not paralysed. Vomiting and involuntary micturition and defæcation may occur. The temperature is usually subnormal.

Cerebral Compression.—This, when due to injury, is usually associated with fracture of the skull and hæmorrhage. Insensibility is complete, the person cannot be roused. The pupils may be unequal, contracted or dilated, and may not react to light. The breathing is slow, stertorous, and may be irregular, or Cheyne-Stokes in type. The pulse is full and bounding, the cheeks are blown out during expiration. Paralysis, rigidity, or convulsions may be present on one side of the body. There may be retention of urine, with overflow incontinence.

In cases associated with severe fracture or hæmorrhage within the skull, the conjunctivæ may be chemosed, or there may be hæmorrhage from the nose or ear; and a flow of cerebro-spinal fluid may take place from the nose.

Alcohol.—In coma due to alcohol, there will be an alcoholic odour of the breath, alcohol in the stomach contents, and it can be detected in the urine. The odour of alcohol in the breath may be due to the administration of alcohol by an outsider at the onset of the symptoms which have ended in the coma. The pupils are equal, contracted, the conjunctival reflex present, and the pupil dilates on pinching the skin of the neck. The pulse is rapid, at first strong it becomes feeble, the respirations snoring. If the coma be not complete, muscular inco-ordination may be noticed. The person can usually be aroused by stimulation.

In pure alcoholic coma the presence of the special features of coma from other causes will be absent. It must be remembered, however, that alcoholic coma may be combined with other kinds, and the more serious form should be kept in mind. Where there is the slightest doubt in the diagnosis, one‘s procedure should be ruled by the possibility of the graver cause.

Opium or Narcotic Poisoning.—The skin is usually perspiring freely, moist and cold; the countenance placid, pale and ghastly, the lips livid. The eyes are heavy, and the pupils contracted to a pin-head and equal, the conjunctival reflex usually present. There is the odour of opium in the breath. The pulse is slow, and the respiration stertorous and slow. There is no paralysis, and the person can be momentarily roused by a sharp question or blow.

Apoplexy.—The person is with difficulty, if ever, temporarily aroused. The face is red and bloated. Respiration suspirious and stertorous, and there is often Cheyne-Stokes breathing. The pupils are dilated or irregular; in pontine hæmorrhage, contracted. The temperature may at first be subnormal but gradually rises.

There may be rigidity of the limbs, or hemiplegia. The pulse is full and bounding, often of high tension with hardened arteries.

Albuminuria may be present.

Uræmia.—This is less profound than in cerebral hæmorrhage; the patient may be temporarily aroused; the onset is usually gradual. There is albuminuria with casts; albuminuric retinitis may be present. The pupils may be contracted or dilated. The breath has a peculiar so-called “uræmic odour.” The pulse is generally slow, the tension high, and the heart enlarged. The respirations are slow and sighing, and may be Cheyne-Stokes in type. There is no paralysis. There may have been preceding convulsions, and the coma may alternate with these attacks.

Anasarca may be present.

Diabetic Coma.—This may come on suddenly, and may occur unexpectedly in a person in whom diabetes has not been discovered up to the time of coma. There is sighing respiration, “air hunger.” The odour of acetone in the breath is present, and sugar in the urine.

Epilepsy.—Unconsciousness is profound, and comes on immediately with rigidity, followed by convulsions, unilateral, limited to the side of the face, jaws, head and neck or arm, or generalised. Bloody froth exudes from the mouth, the tongue being bitten. The eyes are wide open, the pupils dilated and insensible to light. Micturition may occur. After the convulsive attack has passed off, post-epileptic coma may remain, though usually for a short time only.

Syncope.—This has been described under modes of dying (p. 38).

In all cases of coma when first seen examine the head for signs of injury, note the odour of the breath, observe the state of the pupils and their reactions, examine the limbs for paralysis, count the pulse and note its character, and the state of the arteries, note the size of the heart and auscultate it at each area. Count and note the character of the respirations, take the temperature, examine the urine, take note of the person‘s age, and inquire into the previous history.

Sudden death may proceed from natural or violent causes. From the former, death may occur unexpectedly and very rapidly, but as a rule the period of time occupied by the phenomena of “dying” is measurable, though inconstant. Should such period of time be immeasurable, death may be considered as instantaneous.

Apart from sudden death resulting from violence or poisoning, the common causes are as follows:—

1. Diseases of the heart: angina pectoris, valvular diseases with failure of compensation, especially aortic regurgitation, degeneration of the heart muscle, rupture of the heart, heart failure from diphtheria or toxic diseases.

2. Diseases of the blood-vessels: rupture of aneurysms or varicose veins, thrombosis, embolism.

3. Cerebral hæmorrhage, especially when in the region of the pons Varolii or cerebellum.

4. Lesions of the respiratory system: œdema or spasm of the glottis, membranous deposit or foreign bodies in the larynx or trachea, foreign bodies in the pharynx, tumours, whooping-cough, asthma, embolism of the pulmonary artery, air embolism, fat embolism, rupture of a vessel or aneurysm into the air-passages, as in phthisical cavities, pneumothorax, hæmothorax, pleuritic effusion, and in acute pneumonia.

5. Rupture of a gastric ulcer or ulcer of some other part of the alimentary tract.

6. Sudden hæmorrhage into the peritoneal cavity from ruptured uterus, ectopic gestation, &c.

7. Rupture of internal organs: distended bladder, spleen, pregnant uterus, or other abdominal viscus.

8. Hæmorrhage into the pancreas.

9. Conditions associated with the nervous system: mental emotions, epilepsy, uræmia, laryngismus stridulus in children.

10. Sudden death has occurred in Addison‘s disease, in diabetes, in cases of lymphatism or status lymphaticus in young people, during the early stage of chloroform anæsthesia, during simple vaginal examination in women, during the injection of fluids into the vagina or uterus. Bouvalat (Annales d‘Hygiène, 1892) relates a case in which, as the cannula of a syringe was being introduced into the os uteri of a woman with the object of criminal abortion, she fell back before any fluid was injected, and died in a few minutes.

A similar case came under my notice, in which death took place while the husband of the woman was attempting to introduce a solution of 20 minims of tincture of iodine, mixed with water to measure two drachms, into her uterus through a No. 3 catheter.

Real or Apparent Death

It will be unnecessary here to discuss any of the theories put forward with regard to cases of apparent death or prolonged trance, but simply to note in the order of their occurrence the phenomena which attend real death.

Under this heading it is important to draw a distinction between “Somatic death” and “Molecular death.” “Somatic death” is defined as “the cessation of the vital functions and of the general renewal of tissue consequent on that cessation”; “Molecular death” is the death of the tissues themselves.

The signs of death occur as follows:—

1. Entire and continuous cessation of the respiration and circulation; no sounds heard on auscultation. The absence of the heart sounds is the most important sign of death, for even in the severest forms of syncope the cardiac pulsations, as shown by M. Bouchet, can with care be heard.

Tests for cessation of respiration:—

(a) Auscultation. (b) Placing a cold hand-mirror or empty drinking-glass over the mouth or nostrils, or a light feather, and noting the presence or absence of bedewing or movement. (c) Placing a shallow vessel, such as a saucer, full of water on the chest or abdomen, and observing the presence or absence of rippling of the fluid (Winslow‘s test).

Tests for cessation of the circulation:—

(a) Auscultation.

(b) Manual exploration of the principal arteries for pulsation or thrill.

(c) Magnus‘s test, applying a ligature tightly round a finger, sufficient to stop the venous but not the arterial circulation, and noticing whether or not a bloodless ring forms at the seat of ligature, and a zone of livid redness on the distal side of the ligature, the part becoming first red, then purple.

(d) Applying pressure to the finger-nail, and noticing whether the colour disappears on pressure, and a pink tinge appears after relaxing the pressure.

(e) Applying heat, such as dropping melted sealing-wax on the skin, and noting whether or not redness or vesication ensues.

(f) Holding the hand, with the fingers abducted, against a strong fight, and observing whether or not the web of the fingers is translucent.

(g) Inserting a brightly polished needle into a fleshy part of the body, allowing it to remain for ten seconds or so in situ, and noticing whether it is tarnished or not on withdrawing it.

(h) Injecting hypodermically a solution of fluorescin (resorcin-phthalein and sodium bicarbonate, a gramme of each dissolved in 8 c.c. of water). No local discoloration of the skin takes place if the circulation has ceased, but if not, a yellowish-green coloration of the skin occurs round the seat of injection, and the substance may be detected in the blood at a part some distance from the seat of injection. By immersing some white silk threads in the blood drawn at a distance from the prick, then boiling them in distilled water, the latter will have a greenish colour if the fluorescin has been circulated (Icard‘s test).

These tests will detect whether the circulation has ceased or not, and so differentiate suspended animation from real death.

2. The lustre of the eye is lost immediately after death. It has, however, been stated that the iris will respond to the action of atropine and eserine for some hours after death, and that the action of the latter is always more marked than that of the former. The fundus as seen by ophthalmoscopic examination is altered, the normal redness changes to a yellowish-white, the vessels in the disc and just around it become empty, and the veins appear to contain bubbles of gas and the column of blood is broken up (Bouchet). A blackish round or oval stain has been described by M. Larcher on the sclerotic coat on the outer side, which he calls l‘imbibition cadavérique du fond de l‘œil. It is probably due to thinning of the sclerotic from evaporation, enabling the choroid to be seen through it. The spot precedes rigidity and is a forerunner of putrefaction.

3. The most powerful stimulus applied to the body does not cause any reaction. The muscles may, however, be made to contract shortly after death by the stimulus of a slight blow, or by galvanism.

4. The surface of the body becomes of an ashy-white colour.

5. The temperature of the body at the time of death is retained for some time. As a sign of death the fall of temperature must be progressively continuous. Cooling will depend on the medium in which the body is placed, and mere coldness of the body is not a sign of death.

6. Relaxation, primary flaccidity, more or less general, of the muscular system takes place.

“If the above signs are alone present, death must have taken place in from ten to twelve hours at the longest” (Casper). Exception: cadaveric spasm.

7. Want of elasticity in the eyeball: flaccidity of the iris. This condition invariably occurs in from twelve to eighteen hours after death.

8. Flattening of the muscles of those parts on which the body rests, due probably to loss of vital turgidity.

9. Hypostasis.—Suggillation, or post-mortem staining, is due to the gravitation of the blood to the most dependent parts of the body not subject to direct pressure. The hypostatic marks begin to form in from eight to twelve hours after death, and increase in size till putrefaction sets in. They alter their position with changes in the position of the body so long as the blood remains fluid, but when it has coagulated they remain permanent. Hypostasis may be mistaken for an ecchymosis or a bruise, and in the lungs for congestion, inflammation, &c. Errors may also occur with regard to the brain, stomach, kidneys, and intestines: in the last, the redness of inflammation is seen all over the parts, whereas the coloration of hypostasis is interrupted, and this is best shown by drawing out the convolutions. The heart is an exception to the rule, but it may contain clots varying in size and colour. These are post-mortem formations. The use of the word suggillation is objectionable, as it has been used in opposite senses by Continental and British authors—some writers restricting the term to ecchymosis proper, others using it as synonymous with cadaveric lividity or external hypostasis.

10. Cadaveric rigidity.—From the moment of death till the time when putrefaction sets in, the muscular structures of the body may be said to pass through three stages:—

Cadaveric rigidity, or rigor mortis, is a purely muscular phenomenon, and is not dependent on the nervous system, as it is not prevented, though it may be delayed, by division of the nerves, and is as well marked in paralysed as in non-paralysed limbs. Cadaveric rigidity, which occurs early in the heart, must not be mistaken for hypertrophy, or its absence for dilatation. In every case the rigor mortis precedes putrefaction, and consists in a shortening and thickening of certain muscles, chiefly the flexor and adductor muscles of the extremities, and also the elevators of the lower jaw.

This condition commences in the involuntary muscles, and in the heart may simulate hypertrophy of that organ, then passes into the voluntary muscles of the back of the neck and lower jaw, and then into the muscles of the face, front of the neck, chest, and upper extremities, and then into the trunk muscles, and last of all, into those of the lower extremities. In most cases it passes off in the same order, the body becoming quite flaccid, the rigor mortis never returning. These phenomena occur whilst the body is cooling. The muscle becoming rigid is dying, the rigid muscle is dead. The cause of the rigor mortis is held to be due to the coagulation of the myosin. The reaction is acid from the presence of sarcolactic acid, but becomes alkaline during putrefaction.

If fresh difibrinated blood be passed through the rigid muscle, it will become flaccid, and respond by contraction to electric stimulation.

Cadaveric rigidity generally supervenes from eight to twenty hours after death, and may continue from a few hours to four or nine days.

The sooner rigidity comes on after death the sooner will it pass away, and the later the onset the longer it will last. It is a general rule that whatever exhausts the muscular irritability before death causes the early appearance and the more rapid disappearance of rigor mortis.

Conditions which modify the onset and duration of rigor mortis:—

Death during alcoholic intoxication favours the duration of rigor mortis. After violent muscular exercise death is quickly followed by rigidity. Animals that have been hunted for some time before death stiffen very rapidly. When convulsions precede death, rigor mortis sets in early as a rule, but in certain cases, where death has been preceded by strong convulsions, rigidity may appear quickly, but last for some days, as in some cases of poisoning by strychnine.

Conditions which simulate rigor mortis:—

Cadaveric Spasm or Instantaneous Rigor.—“When this phenomenon occurs the last act of life is crystallised in death.” It is a prolongation of the last vital contraction of the muscles into the rigidity of death. Cadaveric rigidity of the muscles must be distinguished from muscular spasm occurring at the moment of death.

They may thus he distinguished: In cadaveric rigidity any object placed in the hand prior to the onset of rigor mortis can be readily removed, even if the precaution be taken of binding it in the hand prior to the accession of rigor mortis.

In the case of muscular spasm the object is found grasped in the hand, and can only be with difficulty removed.

The difficulty experienced in removing a pistol or other weapon from the hand may point to suicide; its easy removal to homicide, the weapon having been placed there after death.

No adequate explanation of this phenomenon has yet been made. It is not an unusually early onset of rigor mortis in the muscles affected, because they do not share in the initial relaxation that precedes it, or the weapon would fall from the hand, and the bodies would not retain the peculiar attitudes which have been described in different instances. Nothing can simulate cadaveric spasm and it cannot be produced in any way after death. Instantaneous rigor only occurs in cases in which there has been great mental tension and nerve excitation before death. It is a continuation of probably the very last voluntary act of life.

A body showing the signs of death before mentioned (Nos. 1 to 10) may be held to be that of a person who has been dead from two to three days at the longest (Casper).

Muscular states of the body between the period of somatic and molecular death:—

11. Putrefaction.—the last of the phenomena which follow death—is the resolution of the organised tissues of the body to the inorganic state. It is a gradual process, and is the result of the action of micro-organisms, aided by moisture, air, and warmth.

Putrefaction is the only absolute sign of death having taken place.

The conditions which modify putrefaction are as follows:—

External Conditions.—1. Micro-organisms; 2. Air; 3. Moisture; 4. Warmth.

Internal Conditions.—1. Age; 2. Sex; 3. Condition of the body—(a) Constitutional peculiarity; (b) State of the body. 4. Kind of death—(a) The result of disease; (b) The result of poisons.

1. Micro-organisms.—A fauna and flora of decomposition has been described in a paper by Hough on “The Fauna of Dead Bodies,” B. M. J., vol. ii. 1897, p. 1853, to which the reader is referred.

Many different forms of micro-organisms combine in the production of putrefaction, and the result of their action is inevitable, unless the body be guarded against their invasion by special means, or the tissues be rendered unfit for their use.

2. Air.—Exposure in the open air has a marked effect in promoting putrefaction; but garments fitting close to the body, and thus excluding air, have a contrary effect. Dry air, or air in motion, by assisting evaporation from the corpse, acts as a preservative. The composition of the soil in which the body is placed has also a more or less modifying effect. In light, porous soil, allowing of the free ingress of air, decomposition is more rapid than in close, compact soil, as clay; but in this we have to contend with another agent—moisture—which more or less counteracts the protective virtue of the closer earth.

3. Moisture.—Putrefaction cannot proceed without moisture. The body, however, contains sufficient water to enable this process to commence spontaneously. Organic substances artificially deprived of water do not putrefy. Cold and heat possess marked antiseptic properties—the former by freezing the fluids in the body, the latter by drying them up.

4. Warmth.—A temperature between 70° and 100° F. is found most favourable to decomposition. The effect of cold is shown by the fact that a body immersed in water during winter, at a temperature between 36° and 45° F., may be so well preserved as to present, ten or twelve days after death, well-marked signs of violence, which would in summer have been utterly obliterated in five or seven days. The preservative influence of cold water will, however, depend greatly on the depth at which the body has been submerged. Bodies so submerged, and then exposed to the air, putrefy with such rapidity that exposure for one day is said to work a greater change than three or four days longer retention of the body in the water. As an instance of the preservative power of cold, may be mentioned the mammoth found in Siberia embedded in a block of ice.

1. Age.—The bodies of young children, other things being equal, are said to putrefy rapidly. It should be remembered, however, that clothing possesses considerable power in retarding putrefaction, and that, in the hurry and anxiety to get rid of the infants, they are oftener exposed naked than clothed, which may, in some measure, account for their more rapid decomposition.

2. Sex.—Sex, it would appear, has little or no influence either to retard or hasten putrefaction; but it has been remarked that females dying during or soon after child-birth, irrespectively of the cause of death, putrefy rapidly.

3. Condition of the Body.

(a) Constitutional Peculiarity.—It is generally admitted that persons of the same age and sex, dying similar deaths, and subjected to like conditions as to exposure to the air and interment in the same soil, exhibit marked differences as regards the accession and rapidity of putrefaction. The explanation may be difficult, but the fact still remains.

(b) State of the Body.—Fat and flabby corpses putrefy more rapidly than the lean and emaciated. Hence old people, who are generally thin, keep fresh for a comparatively long time. Bodies, also, which are much mutilated rapidly decompose—decomposition setting in first at the parts injured. In examining wounds and bruises said to have been inflicted during life, it is well to remember that the tendency of putrefaction is to make them appear more severe.

4. Kind of Death.

(a) Effect of Disease.—Healthy persons dying suddenly, other things being equal, are said to decompose more slowly than those who have died from exhausting diseases, as in the case of typhoid, phthisis, and dropsy, following organic disease, or of those diseases attended with more or less putridity of the fluids.

(b) Effects of Poisons.—Putrefaction rapidly supervenes in those who have died suffocated by smoke, by carbonic oxide, and by sulphuretted hydrogen. Narcotic poisoning is stated to accelerate this condition; but in poisoning by phosphorus or alcohol, and in cases of death from sulphuric acid, the putrefactive changes are greatly retarded. Arsenic, chloride of zinc, and antimony are reputed to possess antiseptic properties. The manner in which death takes place from the action of the poison greatly hastens or retards putrefaction. Thus, in the case of poisoning by strychnine, it is found that when death has occurred rapidly, without much muscular exhaustion, putrefaction sets in slowly; but that, when the muscular irritability has been greatly exhausted by successive fits, the contrary is the result.

One to Three Days.—Greenish coloration of the abdominal walls. Odour of putrescence is gradually developed, and, concurrently with this, the eyeball becomes soft and yielding to pressure.

Three to Five Days.—The green colour, of a deeper shade, has now passed over the abdomen, extending also to the genital organs. Patches of this green coloration also make their appearance somewhat irregularly on other parts of the body, such as the neck, back, chest, and lower extremities. A dark reddish frothy fluid about this time wells up from the mouth.

Eight to Ten Days.—The patches of green colour have now coalesced, so that the whole body is discoloured. On some parts of the body the colour is of a reddish-green, due to the presence of decomposed blood in the cellular tissue. The abdomen is now distended with gases, the products of decomposition. In India this distension has been known to occur in less than six hours, the average period being a little over eighteen hours. Much depends upon the season of the year. The colour of the eyes has not disappeared, but the cornea have fallen in. Relaxation of the sphincter ani takes place, and the superficial veins appear like reddish-brown cords. The nails still remain firm.

Fourteen to Twenty Days.—The colour of the surface is now bright green, with here and there patches of a blood and brown colour. The epidermal layer of the skin is raised in bullæ of varying size, in some places the skin being more or less stripped off. The nails are detached, and can be easily removed. The hair can be pulled from the scalp with ease. The body is now greatly distended with gases, and the features cannot be recognised, owing to the swollen condition of the face. The body is generally covered with vermin. In determining the time at which death occurred, it will be necessary to take into consideration the season of the year, as it is found that an advanced stage of decomposition may be present in from eight to ten days, with the thermometer ranging between 68° and 77° F., which in winter, with a temperature of from 32° to 50° F., would require twenty to thirty days. “Bodies green from putridity, blown up and excoriated, at the expiry of one month, or from three to five months after death (cæt. par.), cannot with any certainty be distinguished from one another” (Casper).

Three to Six Months.—During the above period the stage of colliquative putrefaction has set in. The thoracic and abdominal cavities, due to the increased formation of gas, have burst. The bones of the cranium have more or less separated, allowing the brain to escape. The soft parts are more or less absorbed, and no recognition of the features is possible. The sex can only be positively made out by the presence of a uterus, or by the peculiar growth of hair on the pubes, which in woman only covers the pubes, but in man extends upwards to the navel.

Saponification.—Bodies exposed to the action of water, or buried in damp, moist soil, are apt to undergo certain changes, in the course of which they become saponified, and the formation of a substance known as adipocere is the result. Adipocere—adeps, lard, and cera, wax—is chiefly composed of margarate of ammonia, together with lime, oxide of iron, potash, certain fatty acids, and a yellow-coloured odorous matter. The melting-point is 126.5° F. Adipocere has a fatty, unctuous feel, is either pure white or of a pale yellowish colour, and with the odour of decayed cheese. It is highly resistant to putrefactive organisms, and is generally free from them. The formation of this substance “to any considerable extent is not likely to occur in less than three to four months in water, or six months in moist earth, though its commencement may take place at a much earlier period” (Casper). The above-quoted authority mentions a case in “which the remains of a fœtus were found imbedded in adipocere, and which fœtus was proved to have been buried in a garden exactly six months and three-quarters.” Taylor also records the case of a bankrupt who committed suicide by drowning, in which the muscles of the buttocks were found converted into adipocere in five weeks and four days at the longest.

Although the above statements may be accepted with regard to the formation of adipocere as far as European countries are concerned, they do not seem to be applicable to India, where the change appears to be more rapid. Dr. S. Coull Mackenzie, in his valuable book on Medico-Legal Experiences in Calcutta, records a case of a young man whose body, recovered after seven days‘ immersion in the river Hooghly, “was found to be in an advanced state of saponification,” and the fleshy portions of undigested food in the stomach were converted entirely into adipocere. “Lastly,” he writes, “in the hot, steamy, rainy months of September and October, in three of the cases above mentioned, saponification was found in bodies immersed in water, both externally and internally, in from two days to eight days ten hours. In the soft and porous soil of Lower Bengal during the rainy seasons, even in a wooden coffin, the change is very rapid—three or four days.”

To explain the formation of adipocere, it has been supposed to be due to the decomposition of the muscular structures of the body, by which hydrogen and nitrogen are evolved, these combining to form ammonia, and this, coming in contact with the fatty acids of the fat, forms a soap. The process of saponification takes place most rapidly in young fat persons; next, in those adults who abound in fat, and in those whose bodies have been exposed to the soil of water-closets; more rapidly in running than in stagnant water; and lastly, in those who have been buried in moist, damp soil, especially if the bodies have been piled one on the top of the other, the lowest being first saponified. The muscular tissue appears to be the first to undergo this change. In water the process is said to be completed in about five months, but in soil a period of two or three years appears necessary.

Mummification is of no medico-legal interest, as the causes which produce it are unknown, and no reliable data can be obtained as to the period of its accession, or the time required for its production.

1. The Trachea, including the Larynx.—The rapid change in the trachea must be borne in mind, in order to avoid the error of attributing death to suffocation or drowning. An examination of the trachea should never be omitted.

2. The Brain of Infants up to the First Year.

3. The Stomach.—The first traces of putrefaction are seen in from four to six days after death. All the coats of the stomach are softened, but there is no excoriation, as is the case when corrosive poisons are taken. Emphysematous separation of the mucous coat may be present, but must not be confounded with the excoriation just mentioned.

4. The Intestines.—Casper declares that he does not remember any case in the course of his experience where the intestines were “found earlier putrefied than the stomach.” In the course of putrefaction they become of a dark brown colour, bursting, and allowing an escape of their contents; and they ultimately become changed into a dark pultaceous mass.

5. The Spleen.—This organ in some cases putrefies before the stomach and intestines; but, as a rule, it resists decomposition longer.

6. The Omentum and Mesentery.

7. The Liver.—This organ is not unfrequently found firm and dense some weeks after death. It putrefies earlier in new-born children than in adults. The convex surface first shows signs of putrefaction. The gall-bladder also remains for some time recognisable.

8. The Adult Brain.—The brain of newly-born children, as mentioned before, soon putrefies. This is not the case in the adult brain. Putrefaction sets in not on the surface, but at the base of the brain. A wound of the brain causes it to putrefy more rapidly than if no injury be present.

9. The Heart.

10. The Lungs.—Contemporaneously with the appearance of decomposition in the heart, the lungs also begin to show signs of putrefaction, though this condition may take place earlier.

11. The Kidneys.—These organs are long in yielding to the putrefactive process.

12. The Bladder.—Nearly all the other organs of the body are in a state of decomposition before this viscus becomes materially affected.

13. The Gullet.—This long remains firm, even after the stomach and intestines fail to be recognised.

14. The Pancreas.—The body must be far advanced in putrefaction before this gland becomes affected.

15. The Diaphragm.—This may be distinguished after the lapse of four to six months.

16. The Blood-vessels.—The aorta may be recognised after the body has been interred for fourteen months.

17. The Uterus.—Of all the organs of the body, the uterus resists the putrefactive changes longer than any other organ.

Table showing some important Facts to be
noticed with regard To Putrefaction:

• 1. Earliest external indication of it.
• (1) In a Body exposed to Air.—Greenish coloration of the
• abdominal coverings.
• (2) In a Body immersed in Water.—Face, head, and ears,
• gradually extending from above downwards.
• 2. Earliest internal indication.—Found in the trachea, including
• the larynx.
• 3. Advanced putrefactive appearances to be expected in a body
• exposed to air, say from fourteen to twenty days at mean
• temperature, as regards—
• (1) Epidermis.—Raised here and there in blisters about
• the size of a walnut, in some places the size of a dinner
• plate, and quite stripped off.
• (2) True Skin.—Maggots cover the body, chiefly in the
• folds of the skin.
• (3) Cellular Tissue.—Blown up with gas.
• 4. Comparative time required to produce equal extent of putrefaction
• in a body—
• (1) In Air.—One week. One month.
• (2) In Water.—Two weeks. Two months.
• (3) In Earth.—Eight weeks. Eight months.

Does Lime hasten Putrefaction?—It is a very general opinion that it does. Careful experiment has, however, proved that lime neither retards nor hastens putrefaction, but that it prevents the escape of the gases produced during the process by absorbing them; it is, therefore, a good and safe deodoriser, and in this property its true value lies.

CHAPTER IV POST-MORTEM EXAMINATIONS AND EXHUMATIONS — I. Part of General Directions — II. Necessary Implements — III. External Aspect, and Examination of the Body — IV. Dissection, or Internal Examination of the Body — V. Examination in Cases of Wounds and Contusions — VI. Examination in Cases of Poisoning — VII. Examination in Cases of Suffocation — VIII. Examination in Cases of Burning — IX. Examination in Cases of Criminal Abortion — X. Examination in Cases of Infanticide — EXHUMATIONS

The following are some of the Instructions issued to Medical Inspectors by the Crown Office in Scotland, slightly modified:

13. When any portions of the body, or any substances found in or near it, are to be preserved for further examination, they ought never to be put out of the custody of the inspectors, or of a special law officer. They must be locked up in the absence of the person who keeps them. When they are to be transmitted to a distance, they should be labelled, and the labels signed by the inspectors; and after being properly secured and sealed, they should be delivered by the inspectors themselves, or the special law officer whose duty it is to see them delivered into the hands of the parties for whom they are intended.

14. Besides the ordinary instruments used in common dissections, the inspector should be provided with a foot-rule for measuring distances, and a glass measure graduated to drachms, for measuring the quantities of fluids, two or three stoneware jars of medium size, or when these cannot be had, a few clean bladders, for carrying away any parts of the body which it may be necessary to preserve for future examination, and in cases of possible poisoning, three or four bottles of eight, twelve, and sixteen ounces, with glass stoppers or clean corks, for preserving fluids to be analysed. The common square green glass pickle bottles are very suitable, and can generally be obtained. No bottle or jar should be used until it has been thoroughly washed under the supervision of one of the inspectors. In cases of infanticide a balance, having a flat scale-pan with a foot-rule painted on it, is of great use; on it the infant may be stretched, weighed, and measured at one operation. Paper, pens, ink, and sealing-wax should also be provided.

15. All distances, lengths, surfaces, and the like, whose extent may require to be described, ought to be accurately measured; and the same rule ought to be followed in ascertaining the volume of fluids. When large quantities of fluids are to be measured, any convenient vessel may be used, whose capacity is previously ascertained by the inspectors. Conjectural estimates and comparisons, however common, even in medico-legal inspections, are quite inadmissible.

16. The importance of the external examination, and the particulars to be chiefly attended to in performing it, will vary in different cases with the probable cause of death. It comprehends an examination—(1) Of the position of the body when found, as well as of all external injuries or marks presented by it. (2) Of the vicinity of the body, with a view to discover the objects on which it rested, or from or upon which it may have fallen, marks of a struggle, signs of the presence of a second party about the time of death or after it, weapons or other objects the property or not the property of the deceased, the remains of poisons, marks of vomiting; and where marks of blood are of importance, and doubts may arise as to their really being blood, the articles presenting them must be preserved for further examination. (3) Of the dress, its nature and condition, stains on it of mud, sand, and the like, of blood, of vomit, of acids, or other corrosive substances, marks of injuries, such as rents or incisions; where injuries have been inflicted on the body, care should be taken to compare the relative position of those on the body and those on the clothes; and where stains, apparently from poison, are seen, the stained parts are to be preserved for analysis. (4) Ligatures, their material and kind, as throwing light on the trade of the person who applied them; the possibility, or impossibility, of the deceased having applied them himself; their sufficiency for accomplishing their apparent purpose, &c.

17. The inspectors will commence the examination of the body itself by surveying the external surface and openings. Before cleaning it they will examine it on all sides, not neglecting the back, as is often done, and look for marks of mud, blood, ligatures, injuries, stains from acids, and the like; foreign bodies, or injuries within the natural openings of the body, viz. the mouth, nostrils, ears, anus, vagina, and urethra. If there are impressions of finger marks, they will consider which hand produced them. If there be any doubt about stains being blood, the skin presenting them must be preserved for analysis. If there be acid stains, or other probable remains of poison, or any foreign matter, the nature of which may require to be determined by analysis, these must also be preserved. The ordinary places for the impressions of ligatures are the neck, the wrists, the ankles, and the waist. The degree of warmth of the trunk and extremities, the presence or absence of cadaveric rigidity, and whether it exists equally in the upper or the lower extremities, should be noted in this stage of the proceedings; in other cases the progress of putrefaction, as indicated by the odour of the body, the looseness of the cuticle, the colour of the skin, and formation of dark vesicles on it, the evolution of air in the cellular tissue, the alteration of the features, the softness of the muscles, the shrivelling of the eyes, the looseness of the hair and nails.

18. In this part of the examination it will sometimes be necessary to observe the particulars by which the body may be identified. These are numerous. But the most important are the stature, the age and sex, the degree of plumpness, the size and form of the nose and mouth, the colour of the eyes and hair, the state of the teeth, warts, nævi, deformities, scars of old abscesses, ulcers, and wounds, and, if a woman, marks of her having had one or more children.

19. The body is next to be washed, if necessary, and the hair of the head shaved, or at least closely cut; and a thorough examination of the whole integuments is to be made. At this stage the inspectors will look particularly for the appearance of lividity, noting its chief seat and its relation to the posture in which the body was found—for impressions on the skin of objects on which it had rested—for marks of injuries, more especially contusions, taking care to ascertain their real nature by making incisions through the skin—for marks of disease, such as eruptions, ulcers, and the like—for marks of burning—for marks of concealed punctures in the nostrils, mouth, external openings of the ears, the eyes, the nape of the neck, the arm-pits, the anus, the vagina, and beneath the mammæ or scrotum; in infants, also in the fontanelles and the whole course of the spine. At this stage, wounds and other injuries should be carefully examined according to the directions given in Division V. (infra). Where the injury may have caused loss of blood, the presence or absence of pallor of the skin, lining membrane of the mouth, and the gums ought to be noted.

20. In commencing the dissection of the body, it must be laid down as an invariable rule that all the great cavities should be examined, and also every important organ in each, however distinctly the cause of death may seem to be indicated in one of them. It is right to examine the cavity of the spine, and at all events its upper portion, in any case where an unequivocal cause of death has not been discovered elsewhere.

21. In examining the organs situated in the several cavities of the body the inspectors must be guided in a great measure by their ordinary anatomical and pathological knowledge.

22. The inspectors should begin with that cavity over which there is a wound or other mark of injury. Or, if there be an injury on the extremities, the dissection ought to commence there. In the absence of any such guide, that cavity should be taken first where the circumstances of death, so far as they are ascertained, may lead the inspectors to expect unusual appearances. In other cases, the abdomen should be first opened but not dissected, and a general survey made of the parts exposed, without disturbing them materially, the position of the diaphragm being determined by examining it with the hand; then the thorax is immediately to be examined, unless there is good reason for doing otherwise. The reasons for this method of procedure are as follow: If the abdominal organs are removed, and the veins cut, the blood in the heart may drain away through the venæ cavæ, and error result. If, on the other hand, the thorax be first opened, the relation of the abdominal organs to each other cannot be clearly made, owing to the relaxation of the diaphragm, due to the severing of its thoracic connections. Again, if the thorax be first opened, the position of the diaphragm cannot be determined. The inspectors may begin with the head, which may be examined thoroughly in the first instance, afterwards the chest and belly, as above described; the spine being reserved till the conclusion. Wherever unusual appearances are discovered in the first cursory survey, the anatomical examination ought in general to be begun there.

23. In examining the several regions of the body it is to be observed that wherever a wound, or other obvious injury of the external parts, lies in the way of the ordinary incisions, that part must be avoided, so as to leave the external injury unaltered.

24. The most approved mode of opening the head in medico-legal cases is, after dividing the integuments from ear to ear, and reflecting the scalp over the forehead and occiput, to make the usual circular incision through the skull, about an inch above the orbits in front, and over the occipital protuberance behind, using the saw lightly and carefully after the outer table of the skull has been divided, so as to avoid injuring the membranes of the brain; and to raise the skull-cap from before backwards, taking care to detach the dura mater from the skull with the handle of the scalpel or a spatula where it adheres firmly. The chisel and mallet should never be used where there is any chance of finding a fracture of the skull; for how could it be distinguished from a fracture made with the mallet? Should the dura mater be firmly adherent to the skull-cap, the better practice is to divide it carefully, so as to remove both at the same time. Tearing the membrane and crushing the brain substance are thus avoided. In infants and young children this mode of procedure is most necessary, as in them the dura mater is, as a rule, adherent.

25. The ordinary mode of examining the membranes of the brain, and the brain itself, answers well in medico-legal dissections. Effusions of fluid within the skull should always be measured. After the brain is removed, the dura mater ought to be stripped from the base of the skull to facilitate the search for fractures there, which will, of course, indicate external violence. After the removal of the brain, the upper part of the spinal canal should be examined through the foramen magnum before any part of its course be laid open; and search should be particularly made for dislocation or other injury in the region of the atlas and dentata. In cases of fatal fractures of the head, the strength of the bones should be attended to. In cases of extravasation within the head, the state of the coats of the cerebral arteries should be examined.

26. The best mode of opening the spine is, after having finished the examination of the brain, to cut through the integuments from the occiput to the coccyx—to lay the vertebræ thoroughly bare on each side by cutting away the muscles—to make an incision with the saw on each side of the skull, from the postero-inferior angle of the parietal bones into the lateral edge of the occipital hole—to remove the triangular portion of the occipital bone thus detached, and then to cut the rings of the vertebræ on each side with the bone-nippers or spine-knife, beginning with the atlas. In these cases preference should be given to the saw, by which the operation is not only more easily accomplished, but there is no risk of confounding previous fracture with that made in dissecting. Where there is reason to think that the bones are injured, the laying open of the canal should stop at the distance of two or three vertebræ from the injury, and the injured bones, with two or three adjacent vertebræ on each side, should be removed entire before the examination is extended farther down the spine.

27. The organs of the throat may be examined, either by dividing the lower jaw-bone at the chin, cutting the soft parts close to the inner surface of each half of the bone backwards, and then turning the two segments outwards; or by freely reflecting the skin of the throat, separating the soft parts from the inside of the lower jaw, the knife being carried parallel with and close to the bone, drawing the tongue out below the chin, and then continuing the dissection backwards.

28. The best mode of examining the organs situated in the throat is, after detaching the soft parts from the lower jaw, as advised in Sect. 27, to dissect the soft palate from the bone, and proceeding backwards, to detach the whole soft parts from the base of the skull and vertebræ down to the sternum, leaving them connected with the organs in the chest. Besides the ordinary points to be attended to in this part of the examination, the presence of venereal or other ulcerations is a matter requiring attention in some cases.

29. It is necessary to examine the pharynx and gullet, the larynx, trachea, and its greater ramifications, the lungs, the heart, and the great vessels with particular care, because here are most frequently found the causes of sudden natural death. In examining the heart each auricle and each ventricle ought to be laid open by an independent incision of its parietes; and this should not intersect any of the valvular openings or the septum cordis.

30. For laying open the chest and abdomen, the most convenient method is to make an incision down the fore part of the neck, chest, and abdomen to the pubes; then cutting from the peritoneum upwards, to dissect back the integuments and muscles of the chest, and examine the abdomen, as in Sect. 22; next, divide the cartilages of the ribs, and, cutting upwards, close under them, to raise the cartilages along with the sternum. In separating the sternum from the clavicles, care must be taken not to wound the subjacent vessels; and this may be avoided by the dissector moving each shoulder so as to show the exact position of the sterno-clavicular joints, and then dividing both joints cautiously. In dividing the cartilages of the ribs, the saw is sometimes necessary. The cartilages should be cut as far from the sternum as possible, to give free space for the subsequent examination.

31. In inspecting the organs in the chest, a cursory examination should be first made by turning them over, ascertaining the nature and measuring the quantity of effused fluids, feeling for fractures of the ribs, tumours, or other diseases, and opening the pericardium to obtain a view of the heart. The most convenient course to pursue next is, without moving the heart from its place, to lay open its several cavities, in order to judge of the quantity and state of the blood in both sides of that organ. For this purpose the following incisions should be made: The first, beginning close to the base, is carried along the right border of the heart directly into the right ventricle towards the apex, care being taken not to cut the septum. This lays open the right ventricle. The second incision, opening up the right auricle, begins midway between the entrances of the venæ cavæ, ending just in front of the base. The third, for exposing the left auricle, commences at the left superior pulmonary vein, and ends just in front of the base, close to the coronary vein, care being taken not to wound it. The fourth, displaying the left ventricle, commences behind the base, and ends close to the apex. If the blood is in a fluid state, the quantity contained in the right auricle may be materially affected by the head being examined previously, as the blood may have escaped from the heart by the jugular veins. The whole of the organs in the chest—the lungs, heart, and gullet—together with the parts dissected downwards from the throat, should now be removed in one mass, in order to examine them in detail on a table. But previously two ligatures should be applied on the gullet, just above the cardiac orifice of the stomach, and the division made between them.

32. The organs in the abdomen ought to be turned over, like those of the chest, before any one of them is minutely examined, but before the thorax is opened, for the reasons given in Sect. 22. In the subsequent examination, that organ is to be first proceeded with in which there may appear to be disease.

33. In a post-mortem examination, the most approved mode of examining these injuries is, if they be situated over great cavities, to expose the successive structures in the manner of an ordinary dissection, observing carefully what injuries have been sustained by the parts successively exposed before they are divided. Wounds ought not to be probed, especially if situated over any of the great cavities. The depth of a wound is best ascertained by careful dissection and exposure of the parts involved; but after this is done, the thickness of the tissues penetrated may be measured by the probe.

34. The seat of the wounds must be described by actual measurement from known points, their figure and nature also carefully noted, and their direction ascertained with exactness.

35. Before altering by incisions the external appearances of injuries, which should never, if possible, be done, care must be taken to consider what weapon might have produced them, and if a particular weapon be suspected, it should be compared with them. The wounded parts should be cut out entire, and carefully preserved.

36. Apparent contusions must be examined by making incisions through them; and the inspectors will note whether there is a swelling or puckering of the skin; whether the substance of the true skin be black through a part or the whole of its thickness; whether there be extravasation below the skin or in the deeper textures, and whether the blood be fluid or coagulated, generally or partially; whether the soft parts below be lacerated, or subjacent bones injured; and whether there be blood in contact with the lacerated surfaces. By these means the question may be settled whether the contusions were inflicted before or after death.

37. In the cases of wounds, too, the signs of vital action must be attended to, especially the retraction of the edges, adhesion of blood to their surfaces, or the injection of blood into the cellular tissue around, or the presence of the signs or sequelæ of inflammation. Hypostasis must not be mistaken for vascular injection.

38. When large arteries or veins are found divided, care must be taken to corroborate the presumption thus arising by ascertaining, in the subsequent dissection, whether the great vessels, lungs, liver, and membranous viscera of the abdomen be unusually free of blood.

39. In the course of the dissection of wounds, a careful search must be made for foreign bodies in them. When firearms have occasioned them, the examination should not be ended before discovering the bullet, wadding, or other article, if any, lodged in the body; and whatever is found must be preserved. When the article discharged from firearms, or when any other weapon had passed through and through a part of the body, the two wounds must be carefully distinguished by their respective characters, especially as regards their comparative size, inversion or eversion, smoothness or laceration, of their edges, their roundness or angularity, and the comparative amount of bleeding from each. In gunshot injuries, the presence or absence of marks of gunpowder should be noted.

40. When wounds are situated over any of the great cavities, they ought not to be particularly examined until the cavity is laid open; and in laying open the cavity, the external incisions should be kept clear of the wounds.

41. When the discoloured state of a portion of the skin is such as to render it doubtful whether it is due to injury or to changes after death, an incision should be made to ascertain whether there is blood effused into the textures, constituting true ecchymosis, or merely gorging of the vessels of the skin, or discoloration from infiltration of the colouring matter of the blood, which takes place in depending parts of a dead body. The term suggillation should be avoided, as it has been used in opposite senses by Continental and British authors. The respective expressions, “discoloration from extravasated blood,” and “lividity after death,” are preferable.

42. In examining a body in a case of suspected poisoning, the inspectors should begin with the alimentary canal, first tying two ligatures round the gullet, above the cardiac orifice of the stomach, two round its pyloric end, and a third at the sigmoid flexure of the colon, then removing the stomach and entire intestines; next dissecting out the parts in the mouth, throat, neck, and chest in one mass; and, finally, dissecting the gullet, with the parts about the throat, from the other organs of the chest. The several portions of the alimentary canal may then be examined in succession.

43. Previous to commencing the dissection in cases of supposed poisoning, the inspectors should make such inquiries as may enable them to form an opinion as to the class of poison to which the death may be traceable, and thus to guide them as to the conclusions to be come to from the presence, or it may be the complete absence, of any marked appearance explaining the cause of death.

44. The medical inspectors may afford most important aid to the law officers in investigating the history of cases of supposed poisoning. For this purpose minute inquiry should be made into the symptoms during life their nature, their precise date, especially in relation to meals or the taking of any suspicious article, their progressive development, and the treatment pursued. It is impossible to be too cautious in collecting such information, and, in particular, great care must be taken to fix the precise date of the first invasion of the symptoms, and the hours of the previous meals. The same care is required in tracing the early history of the case, where the inspector happens to visit the individual before death; and if suspicions should not arise till his attendance has been going on for some time, he ought, subsequently to such suspicions, to review and correct the information gathered at first, especially as to dates. All facts thus obtained should be immediately committed to writing.

45. Besides inspecting the body and ascertaining the history of the case, the inspectors may afford valuable assistance to the law officers in searching for suspicious articles in the house of the deceased. These are—suspected articles of food, drink, or medicine; the vessels in which they have been prepared or afterwards contained; the family stores of the articles with which suspected food, &c., appears to have been made. All such articles must be secured, according to the rules in Sect. 13, for preserving their identity. In this examination the body-clothes, bed-clothes, floor, and hearth should not be neglected, as they may present traces of vomited matter, acids spurted out or spilled, and the like.

46. When a medical man is called to a case during life, where poisoning is suspected, he ought as soon as possible to follow the instructions laid down for securing articles in which poison may have been administered.

47. In the same circumstances, it is his duty to observe the conduct of any suspected individual, were it for no other reason than to prevent the remains of poisoned articles from being put out of the way, and to protect his patient against further attempts.

48. The whole organs of the abdomen must be surveyed, and particularly the stomach and whole tract of the intestines, the liver, spleen, and kidneys, the bladder; and in the female, the uterus and its appendages. The intestines should in general be split up throughout their whole length; and it should be remembered that the most frequent seat of natural disease of their mucous membrane is in the neighbourhood of the ileo-cæcal valve, and that, next to the stomach, the parts most generally presenting appearances in cases of poisoning are the duodenum, upper part of jejunum, lower part of ileum, and rectum.

49. In cases where the possibility of poisoning must be kept in view, and where matters may require to be procured for chemical analysis, it is essential to be sure that all instruments, vessels, and bladders used are scrupulously clean.

50. When any unusual odour is perceived, either in the blood in the course of making the dissection, or in the stomach when opened, it ought to be carefully observed, and if possible identified by all the medical men present. In this way alcohol, opium, prussic acid, oil of bitter almonds, and other odorous poisons may be recognised. The smell of the contents of the stomach ought always to be noted whenever it is opened, as the smell often alters rapidly.

51. The stomach and intestines should be taken out entire, and their contents emptied into separate bottles. If the stomach or part of the intestines present any remarkable appearance, examination may be reserved, if convenient, till a future opportunity; but in every circumstance it must be preserved and carried away, as it may itself be an important article for analysis. The throat and gullet may be examined at once, and preserved with their contents, which, if abundant, may be kept apart in a bottle. In addition to the alimentary canal and its various contents, portions of the solid organs of the body ought to be secured for analysis. The most important are the liver, spleen, and kidneys. A part of the liver, at least a fourth part, should be secured in every case of supposed poisoning; and in cases where the fatal illness has been of long duration, and therefore only traces of the poison may remain in the body, the whole of the liver, the spleen, and both kidneys should be secured. A portion of the blood, especially when the odour of any volatile poison is perceived, should be at once put into a bottle, closed by a good cork or stopper.

52. No person ought to undertake an analysis in a case of suspected poisoning unless he be either familiar with chemical researches, or have previously analysed with success a mixture of organic substances, containing a small proportion of the poison suspected.

53. All persons undertaking an analysis should bear in mind that the opinion of some other person practised in toxicological researches may be required; and they should therefore take care, when practicable, to use only a portion of the several articles preserved for analysis. The identity of the subjects for analysis must be secured by the rules in Sect. 13.

54. In cases of suspected drowning, the inspectors will observe particularly whether grass, mud, or other objects be clutched by the hands, or contained under the nails; whether the tongue be protruded or not between the teeth; state of the penis; whether any fluid, froth, or foreign substances be contained in the mouth, nostrils, trachea, or bronchial ramifications; whether the stomach contains much water; whether the blood in the great vessels be fluid. Careful pressure should be made upon the lungs; any fluid contained in them in thus forced into the bronchial tubes and trachea, and its nature observed. When water with particles of vegetable matter or mud is found within the body, these must be compared with what may exist in the water in which the body was discovered, and should be preserved for further scientific investigation, if requisite. Marks of injuries must be compared diligently with objects both in the water and on the banks near it, and especial attention given to the question—whether any observed injuries had been sustained by the body before or after death.

55. In cases of suspected death by hanging, strangling, or smothering, it is important to attend particularly to the state of the face as to lividity, compared with the rest of the body; the state of the conjunctiva of the eyes as to vascularity; of the tongue as to position; of the throat, chin, and lips as to marks of the nails, scratches, ruffling of the scarf-skin, or small contusions; the state of the blood as to colour and fluidity; the state of the heart as regards the amount of blood in its several cavities; the state of the trunk and branches of the vena cava in the abdomen as regards distension with blood; and the state of the lungs as regards congestion, rupture of any of the air cells, and small ecchymoses under the pleura, or the pericardium. The mark of a cord or other ligature round the neck must be attentively examined; and here it requires to be mentioned that the mark is often not distinct till seven or eight hours after death, and that it is seldom a dark livid mark, as is very commonly supposed, but a pale greenish-brown streak, presenting no ecchymosis, but the thinnest possible line of bright redness at each edge, where it is conterminous with the sound skin. Nevertheless, effusions of blood and lacerations should be also looked for under and around the mark, in the skin, cellular tissue, muscles, cartilages, and lining membrane of the larynx and trachea. Accessory injuries on other parts of the body, more especially on the chest, back, and arms, must also be looked for, as likewise the appearance of blood having flowed from the nostrils or ears, and the discharge of fæces, urine or semen. In cases where death may be due to the emanations from burning fuel or other poisonous vapours, a small phial should be filled with the fresh blood, and securely corked for further investigation, if requisite.

56. In supposed death by burning, the skin at the edge of the burns should be carefully examined for redness, or the appearance of vesicles containing fluids.

57. In suspected criminal abortion, when the woman survives, the chief points for inquiry are: The proofs of recent delivery, the ascertaining of facts tending to show that she has been subjected to manœuvres with instruments, and the occurrence of symptoms traceable to the action of any of the drugs reputed as capable of causing abortion.

When the woman has died, the points requiring special attention at the dissection are: The state of the womb, as regards its size and the condition of its lining membrane, in reference to the probable period of delivery; the condition of the intestinal canal, in reference to the action of irritant drugs; of the mucous membrane of the bladder, in reference to the action of cantharides; close inspection of the womb and vagina, in reference to mechanical injuries, especially punctured wounds; and any appearances that the death may have been caused by inflammation in the organs of the pelvis, or by bleeding from the wound.

58. In cases of suspected infanticide, certain specialities must be borne in mind. The cavity of the head should be laid open with a pair of scissors. In opening the abdomen, the navel should be avoided, so that the state of the vessels of the navel-string may be examined correctly. This is done by carrying two incisions from the ensiform cartilage to each of the anterior superior spines of the ilia, and by deflecting downwards the triangular flap thus formed.

59. The inquiry in cases of infanticide should be conducted with reference to the five following distinct questions: (1) The probable degree of maturity of the child? (2) How long it has been dead? (3) Whether it died before, during, or after delivery, and how long after? (4) Whether death arose from natural causes, neglect, or violence? and (5) Whether a suspected female be the mother of the child?

60. The points to be attended to for ascertaining the probable degree of maturity of the child are: The general appearance and development, the state of the skin, its secretions, and its appendages; the hair and nails; the presence or absence of the pupillary membrane; the length and weight of the whole body; whether the navel corresponds or not with the middle of the length of the body; the situation of the meconium in the intestines; the size of the testicles in the case of males, and in either sex the size of the point of ossification in the lower epiphysis of the thigh-bone. This is easily observed by making an incision across the front of the knee into the joint, pushing the end of the thigh-bone through the cut, slicing off the cartilaginous texture carefully until a coloured point is observed in the section, and then, by successive very fine slices, ascertaining the greatest diameter of the bony nucleus. This does not exist previous to the thirty-sixth week of gestation, and in a mature child is about one-fourth of an inch in diameter. Has the infant been washed? Absence or presence of vernix caseosa. Nature and character of the wrappings, if any, found on the child.

61. The points of chief importance in reference to the period which has elapsed after death are those specified in the last clause of Sect. 17—it being borne in mind that the bodies of infants are often concealed in ash-pits and dunghills, and that in these circumstances putrefaction is very rapid.

Plate.—Section through the epiphysis
of the lower end of the femur showing
ossification centre, in a full-term fœtus.

62. The circumstances which indicate whether the child died before, during, or after parturition, and how long after it, are the signs of its having undergone putrefaction within the womb; the marks on the crown, feet, buttocks, shoulders, &c., indicating presumptively the kind of labour, and whether it was likely to have proved fatal to the child; the state of the lungs, heart, and great vessels, showing whether or not it had breathed; the nature of the contents of the stomach and of the intestines; the presence of foreign matters in the windpipe; the state of the umbilical cord, or of the navel itself, if the cord be detached.

63. In order to examine properly the state of the lungs, heart, and great vessels, with a view to determine whether or not the child had breathed, the inspection should be made in the following order: Attend, first, to the situation of the lungs; how far they rise along the sides of the heart; to their colour and texture; whether they crepitate or not. Then secure a ligature round the great vessels at the root of the neck, and another round the vena cava above the diaphragm. Cut both sets of vessels beyond the ligatures, and remove the heart and lungs in one mass, which must be weighed and put into water, to ascertain whether the lungs, with the heart attached, sink or swim. In the next place, put a ligature round the pulmonary vessels, close to the lungs, and cut away the heart by an incision between it and the ligature. Lastly, ascertain the weight of the lungs; whether they sink or swim in water; whether blood issues freely or sparingly when they are cut into; whether any fragments swim in the instances where the entire lungs sink; and in every instance of buoyancy whether fragments of them continue to swim after being well squeezed in a cloth.

64. The general question to be considered in relation to the cause of death is, whether the appearances are such as to be traceable to the act of parturition, or whether they indicate some form of violent death. The directions given in Divisions V., VI., and VII. apply to infants as well as adults; but the following points are specially to be noticed in cases of supposed infanticide:

65. The circumstances noticed in Sects. 60, 61, 62, 63, 64, compared with the signs of recent delivery in the female, will lead to the decision of the question whether the suspected female be the mother of the child. These circumstances may be shortly recapitulated as being the signs of the degree of maturity of the child—the signs on the body of the kind of labour, the signs which indicate the date of its death, and the interval which elapsed both between its birth and death, and between its death and the inspection.

It becomes necessary sometimes to exhume the bodies of persons who have been buried. The cases which generally call for this always unpleasant proceeding are those where a suspicion of poisoning or violence has arisen some little time after the burial of the supposed victim. Or the necessity may arise to show that the body buried is that of a person whose death it is absolutely necessary to prove. In the case of Livingstone, though this can scarcely be called a case of exhumation, yet an examination some months after death of the arm of the corpse alleged to be that of Livingstone, proved the existence of a badly united fracture which the deceased was known to have had.

In conducting the exhumation, it is necessary that the medical experts should be present to see the body removed from the coffin, and also any person or persons who may be in a position to speak as to the identity of the corpse—as, for instance, those who dressed it and prepared it for burial. The person who made the coffin may also be of assistance to speak as to its identity. As soon as the medical men are armed with the proper authority, no time should be lost in order to get the body as fresh as possible, and at once prove or disprove the accusation of the crime, which, in the case of innocent persons, cannot be too quickly removed. The best time to take up the body, if in the summer, is early in the morning; and, in all cases, the examination, if possible, should be made during daylight. Everything necessary for making a medical inspection should be taken, and also a table on which to place the body. Rubber gloves should be worn. A pail containing a solution of some disinfectant, for the inspectors to wash their hands after the exhumation is finished, should be close at hand. And it is as well to expose the body for a short time to the air before beginning the inspection. There is seldom any risk to health in removing a single body, yet certain precautions are necessary; thus it is as well to stand on the windward side of the corpse. Vaults should not be entered as soon as they are opened, but time allowed for their ventilation. Carefully note the amount of preservation of the coffin, and, if broken, if any of the surrounding earth is in contact with the body. This precaution is necessary in cases of suspected mineral poisoning (as in arsenic, &c.), and it is as well also to save one or two pounds of the earth immediately above the coffin for analysis. The body may then be examined externally, any hair left on head or face preserved for identification; and then an inspection of all the cavities made, the contents of the stomach and bowels being placed in dry earthenware jars or glass bottles, corked and capped with thin indiarubber skin, and so tied and sealed that the string must be cut or the seals broken in order to open them. The ends of the string should be sealed in the presence of the authorities. In the examination, the instructions previously given should be carefully followed. All injured or diseased parts should be removed and preserved whenever this is practicable. Soft parts not intended for analysis may be preserved in a concentrated solution of salt.

Beyond what Period is it useless to Exhume a Corpse?—There is no scientific limit, for even the bones may show that violence has been used, or may point to the identity of a corpse, as in the case of Livingstone just mentioned. Pregnancy may be detected. The medical inspectors must proceed with the inspection unless they can positively say that the progress of decay is such as to render the examination nugatory in relation to its special objects. Casper mentions the case of a man whose body was three times exhumed for different purposes. In Scotland the law imposes a limit of twenty years, but in England the law is silent on the point; in France a limit of ten years from the date of the supposed crime; and in Germany, the limit is thirty years, if the offence is that punishable with death, the time varying from three to thirty years with the nature of the crime.

CHAPTER V ASSAULTS, HOMICIDE, AND WOUNDS — (1) Murder. (2) Culpable Homicide. — WOUNDS — INJURIES OF SPECIAL REGIONS — Injuries of the Head and Spine — Wounds of the Throat and Chest — Injuries of the Abdomen — FRACTURES OF BONES — Is the Wound Suicidal, Homicidal, or Accidental? — Duties of a Medical Man When Called to Examine a Wounded Person — PRETENDED ASSAULT — THE CAUSES OF DEATH FROM WOUNDS — 1. Direct — 2. Indirect — 3. Malum regimen — THE SEVERAL KINDS OF WOUNDS — 1. Incised Wounds — 2. Punctured Wounds — 3. Lacerated and Contused Wounds — 4. Gunshot Wounds

Assault.—Every act of attack upon the person of another is an assault in law, whether it injure or not; nor is it necessary that the act done take effect. Spitting on anyone is an assault. No provocation by word, whether written or spoken, can justify an assault, though it may mitigate the offence. If a medical man unnecessarily strip a female patient naked, under pretence that he cannot otherwise judge of her illness, it is an assault if he himself take off her clothes (R. v. Rosinski, 1 Mood C.C. 12). So, where a medical man had connection with a girl fourteen years of age, under the pretence that he was thereby treating her medically for the complaint for which he was attending her, she making no resistance solely from the bona fide belief that such was the case, this was held to be certainly an assault, and probably a rape (R. v. Case, 1 Den. 580; 19 L.J. [M.C.] 174). Such an act is now held to constitute a rape.

Battery.—This includes beating or wounding. A touch of the finger, however slight, is included under this term.

Homicide.—In Scotch law homicide is held to be committed only where a distinctly self-existent human life has been destroyed. Destruction of an unborn child, however short a time before delivery, may be criminal, but is not homicidal. In the same country criminal homicide is divided into two classes:

1. Murder is constituted in law by any wilful act causing the destruction of human life, whether plainly intended to kill, or displaying such utter and wicked recklessness as to imply a disposition depraved enough to be wholly regardless of the consequences. Murder may be the result of personal violence, poison, or by the committal of some other serious crime, as where anyone causes the death of a woman in the attempt to procure criminal abortion, rape, or by the exposure of an infant which results in its death. The use of weapons is not essential.

2. Culpable Homicide.—The name applied in law to cases where the death of a person is caused or materially accelerated by improper conduct of another, and where the guilt does not come up to the crime of murder:

Justifiable Homicide.—Self-defence; hanging a prisoner properly sentenced to death; killing another to prevent murder, if prevention can avail in no other way. In self-defence, the person killing must be in reasonable dread of death at the hand of his adversary.

In England there is—1. Murder; 2. Manslaughter; 3. Justifiable Homicide.

Murder, according to Lord Coke (3 Inst. 47), is constituted “where a person of sound memory and discretion unlawfully killeth any reasonable creature in being, and under the King‘s peace, with malice aforethought, either expressed or implied.”

In England the killing must be committed with malice aforethought. Malice may be expressed or implied.

In Scotland malice aforethought is not necessary (5 Irv. 525, and 40 S.J. 92, and 5 S.L.R. 20).

The law in both countries appears to differ more in terms than in practice. In England, if an injured party live for one year and a day, and then die, death is not attributed to the injury; but in Scotland, although no definite time is fixed, yet no case would I believe be entertained at any lengthened period after the commission of a homicidal act. The longest interval, according to Taylor, at which conviction has taken place from indirectly fatal consequences was nine months.

In the United States, as a rule, the crime of murder admits of two degrees: in the first, where the act is intentional or is the result of an attempt at burglary, rape, arson, or by poison; otherwise the crime falls under the second degree.

Legal Definition.—According to the statute (24 and 25 Vict. c. 100, sec. 18), the word “wound” includes incised, punctured, lacerated, contused, and gunshot wounds. But to constitute a wound within the meaning of the statute, the whole skin, not the mere cuticle, or upper skin, must be divided (R. v. M‘Laughlin, 8 C. & P. 635). But a division of the internal skin, e.g. within the cheek or lip, is sufficient to constitute a wound within the statute (R. v. Warman, 1 Den. C.C. 183). If the skin be broken, the nature of the instrument with which the injury is inflicted is immaterial, for the present statute extends to wounding, &c., “by any means whatsoever.” A wound from a kick with a boot is within the statute (R. v. Briggs, 1 Mood C.C. 318). Injuries, burns, and scalds—which, in accordance with the above definition of a wound, are not wounds—are provided for under the clause, “or cause any grievous bodily harm to any person.”

Casper defines “an injury” to be “every alteration of the structure or function of any part of the body produced by any external cause.” Taylor proposed the following as the best definition which can be given to the word “wound,” whether in a medical or legal sense, viz. that it is “a breach of continuity in the structures of the body, whether external or internal, suddenly occasioned by mechanical violence.” This would include dislocations, fractures, either simple or compound, injury to the skin or mucous membrane, and to internal organs. Burns and injuries due to the action of corrosives are excluded from the category of wounds.

Concerning Wounds in general.—Great care must be taken to ascertain the exact site and course of the injury on the body, as this precaution will greatly assist in answering the questions: Is the wound dangerous to life? Does it cause grievous bodily harm? Is it suicidal, that is, inflicted by the person on himself; or homicidal, inflicted by another? The solution of the question of the dangerous character of the wound is left to the professional knowledge of the witness, who may be required to state his reasons for considering the wound dangerous to life. His mere assertion will not be accepted. “The safest course,” says Elwell, “for the witness, in regard to all these questions, is to give a true and plain account of the wound, describing it minutely, and the probable consequences that may attend it.” In relation to their danger to life (apart from so-called “simple” wounds which are not usually extensive, heal easily, and cause little trouble in their course), wounds may be considered dangerous to life when they are so extensive, or on account of their position and relation to important structures when they would prove fatal without the intervention of surgical skill; and when the danger is imminent. A mortal wound is one which is rapidly followed by death. Wounds, however, which in themselves could not be regarded as dangerous to life, may become so by intercurrent complications, such as erysipelas or other infective process. As a general rule, only those wounds in which the danger to life is imminent should be stated as dangerous to life. Compound fracture of the bones of the cranium, injury to any large arterial trunk, or to any of the internal organs, may be considered as “dangerous to life”; but where the danger is more remote, as in the probable supervention of tetanus, erysipelas, &c., the medical opinion must be more guarded. But the medical witness should always bear in mind that death may follow the slightest injury. A case is recorded of death in forty-eight hours after extraction of a tooth. The contrary also holds good, for the most fearful injuries have been followed with recovery.

The following suggestions may help the practitioner in the formation of his opinion as to the probable danger of a wound:

1. The extent of the injury. 2. The character of the instrument used in the infliction of the wound. 3. The violence suffered by the parts. 4. The size and importance of the blood-vessels and nerves injured. 5. Is the wound healing or likely to heal well, and is the constitutional disturbance severe or slight? 6. Age of the sufferer. 7. Is there any constitutional taint likely to render even a slight wound more severe, or even dangerous to life? 8. Has the previous medical treatment been skilful or otherwise?

Should the injured party be found dead, a careful post-mortem examination will alone determine the probable part the injury bore in the production of the fatal result.

Points of Importance to be Noticed
in Examination of a Dead Body
found Wounded.

These may be either external, affecting the integuments; or internal, affecting the brain substance, &c. In the latter, as a rule, there are signs of external violence. An ecchymosed tumour of the scalp may impart a sensation of crepitation to the finger, and may thus be mistaken for a fracture of the skull. The tumour may also pulsate if any large vessel be near it, giving one the idea that the pulsations are due to the movements of the brain. A large wound without fracture points to a more or less oblique blow, a small wound to direct violence. A blow with a heavy blunt weapon may make a clean incised wound, and often in these cases the seat of the bruise does not correspond with the centre of the cut. Dr. Ogston mentions the case of a young lady on whom a cricket ball inflicted a wound across the forehead, immediately above, and of the length of, one of the eyebrows, which he could not distinguish from a wound by a cutting instrument. All injuries to the head are more or less severe and dangerous, and great care is required in forming a prognosis with regard to the ultimate effect of an injury to the head. Inflammation of the brain does not, as a rule, supervene for about a week after the accident, and patients should not be considered safe from danger till two or three weeks after. Be it remembered also that in some cases the inflammatory action may proceed insidiously for some months without giving any distinct evidence of its presence till close upon a fatal termination. Scalp wounds are dangerous, from erysipelas, &c. They should be examined as to their extent, form, depth, and position.

Concussion of the brain may arise from falls on the nates, or from blows on the head. The face becomes pale, the pupils contracted, the pulse weak and small, the extremities cold, the respiration scarcely perceptible, and the sphincters relaxed. The tendency to death is from syncope. Reaction may then occur: the pulse quickens; the skin is hot and dry; there is great confusion of thought, from which the patient ultimately recovers; vomiting is present in most cases. Concussion often passes into compression, due to hæmorrhage from the lacerated cerebral vessels. Concussion and compression differ in this: in the former, the effects are instantaneous; in the latter, a short time elapses before the symptoms make their appearance; and these become more and more marked, whereas in concussion they gradually pass off. It is often a difficult matter to distinguish the effects of compression from those common to drunkenness or narcotic poisoning. The odour of the breath and the history of the case will assist in forming an opinion. Concussion of the brain may prove fatal without either fracture of the skull, effusion of blood within the cranium, or any other change being observed on dissection, death being caused by the shock given to the whole nervous organ, which, being unrelieved, speedily lapses into annihilation of function.

The symptoms of compression—a full, strong, and often irregular or slow pulse; normal heat of surface; muscular relaxation; dilatation, contraction, or inequality of the pupils; stertorous breathing, and paralysis—are not unfrequently retarded, and this consideration should render the opinion very guarded. Bryant records a case (Surgery, vol. i. p. 216) in which a man was thrown out of a gig on to his head. After a short period of insensibility he walked for half an hour, and then gradually again became insensible, and ultimately died. A large clot was found over the left cerebral hemisphere, the blood evidently having flowed from the middle meningeal artery. The short period of insensibility probably arrested the flow of blood from the artery, which recurred on the sufferer walking. The structural form of the cranium may have much to do with the danger to be expected from blows—some skulls being thinner than others—and in a few rare instances the fontanelles may not have become ossified during life.

The possibility of an unhealthy condition—atheroma—of the arteries of the brain, or of disease of the heart, must be taken into consideration before venturing an opinion as to the tendency or ultimate cause of death.

It may be stated that the patient died of apoplexy. Apoplexy is a disease of old age, and seldom occurs in the young, although it is just possible it might occur. The arteries should, in every case, be examined for the presence or absence of disease. When violence is used, the effusion of blood is, as a general rule, on the surface of the brain; but two cases are given by Dr. Abercrombie of spontaneous bursting of a blood-vessel within the head, followed by effusion of blood upon the surface of the brain. “An external injury, coexisting with an extravasation of blood into the cerebral substance, does not necessarily imply cause and effect. The previous condition of the brain, or the outpouring of blood from diseased vessels, may, in fact, have been the cause of the accident” (Hewett). When, however, blood is found effused on the surface of the brain, especially between the dura mater and the skull, either beneath or opposite to an external wound, we may reasonably infer that the hæmorrhage is due to a direct blow. Hæmorrhage so severe as to produce dangerous pressure on the brain, as a rule, comes from a rupture of the middle meningeal artery.

Husband relates a case in the Edinburgh Infirmary in which there was a large clot over the left frontal lobes, accompanied with aphasia and right hemiplegia, with no rupture of the middle meningeal artery, or any signs of external injury. The man had just left the cells on a charge of drunkenness. The source of the hæmorrhage was not clearly made out, but it seemed to be due to the rupture of an artery in a pachy-meningitic patch. Blood may be found in the cavity of the arachnoid in the great majority of severe injuries to the head, and even in trifling cases where least expected. Rupture of the venous sinuses may take place without fracture of the skull. I have met with this in a fatality during a boxing match; a large effusion over the brain, and especially in the temperosphenoidal fossa, taking place from rupture of the left lateral sinus at the junction with the superior petrosal; there was also a vertical hæmorrhage into the pons. The effused blood may, after a time, become changed, and form a false membrane on the parietal arachnoid, seldom on the visceral surface. Blood cysts may even be formed, in the course of time, having all the appearances of a serous membrane. The blood may spread to parts remote from the seat of injury, and the extravasation does not always occur at the exact spot of the application of the blow, but often at a spot directly opposite. Two extravasations may be the result of one blow.

Fits of passion have been advanced as a cause of apoplexy, but this cause is rare. Fracture of the cranial bones may be due to counter-stroke—contre-coup—or to falls on the nates, &c. Fractures of the skull are divided into two groups (Körber): (1) those produced by bilateral compression of the skull; and (2) those resulting from violence applied to one side only. In both groups the line of fracture runs parallel with the axis of compression. Fissures of the base from bilateral compression of the skull are always transverse. Punctured wounds of the cranium are always dangerous, but the patient may survive many days. Dr. Bigelow, Professor of Surgery in Harvard University, U.S.A., relates a case in which an iron bar, weighing thirteen and a quarter pounds, three feet seven inches in length, and one inch thick, was driven through the head, followed by recovery, the patient only losing the use of the injured eye.

Contusion and laceration of the brain may occur from injuries to the head, either at the seat of injury or by contre-coup at some other part. The contused area may exhibit local extravasation of blood, or in the diffuse form, extravasations may be multiple and also on the surface. The symptoms are those of cerebral irritation, coma, or restlessness, paralysis, tonic or clonic spasms. In slight cases recovery may follow, in others some degree of loss of mentality and paralysis may remain.

There is great danger of inflammatory complications. I have met with a case of severe comminuted fracture of the skull with laceration of the brain, the latter substance appearing on the surface of the scalp, with loss of brain substance, in a boy who made a complete recovery without any loss of intelligence or power following the injury.

For the detection of brain substance on weapons the microscope is alone reliable, and then only the cellular portion of the brain is of any use.

Injuries to the spinal cord may cause immediate death; cases, however, occur of life being prolonged for some days, or even longer, after injury to the cord. The symptoms are progressive paraplegia and paralysis of the bladder and rectum, ending in death. Bedsores and septic infection of the bladder and kidneys are complications which add to the gravity of the condition. Spicula of bone in the cord, dislocation of the vertebræ, or extravasation of blood in the membranes of the cord, may be found after death. The presence of blood upon the spinal cord is not necessarily the result of violence, as hæmorrhage may take place spontaneously. The spine should be examined in all fatal cases of supposed injury. Concussion of the spinal cord is a fertile source of differences of opinion in railway cases. In no case should a hasty decision be given as to the probable future result to the patient from the injury.

Wounds of the face are not generally dangerous, unless they penetrate the brain. There is always the possibility of injury to the eye causing detachment of the retina, or inflammation leading to blindness. Punctured wounds in the neighbourhood of the orbit may become septic and lead to secondary meningitis.

Wounds of the throat are more or less dangerous, due to the possibility of severe hæmorrhage, emphysema, and bronchitis.

Wounds of the chest are dangerous, on account of the amount of the hæmorrhage which may take place, and the importance of the organs which may be injured. Death may result more from the mechanical action of the blood effused than from the depressing effect of the quantity evacuated. Penetrating wounds of the thorax injuring the lungs cause emphysema, pneumo-, pyo-, or hæmothorax, any of which may prove fatal; pleurisy and pneumonia may occur. A fracture of the ribs may give rise to injury of the lung substance or to inflammation of its coverings. Laceration of the lungs may take place without fracture of the ribs. The ventricles of the heart may be pierced, and yet life may be prolonged for one or two months, permitting of considerable locomotion during that period (Briand et Chaudé, Med. Leg., vol. i. p. 511). Wounds of the heart, however, are, as a rule, rapidly fatal. Rupture of valves may follow blows on the chest, and rupture of the heart may occur from crushes or violent blows. Rupture of the heart has taken place during violent exertion, and this is more likely to occur when the muscle is diseased. It is often difficult to make out the direction of the wound, as the lungs change their position during respiration.

Wounds of the abdomen, penetrating the intestines, although not necessarily fatal, may cause death from peritonitis, due to the escape of the intestinal fluids. Rupture of the intestine may follow blows or crushing; it is generally fatal from peritonitis unless early surgical treatment is carried out. Hernia may also follow wounds of the abdomen. Rupture of the liver is not of infrequent occurrence, and may occur without any external signs of the injury. The rupture is, as a rule, longitudinal, transverse lacerations being rare. It is often followed by pneumonia if not rapidly fatal. The cœliac plexus may be much damaged by a blow or kick on the stomach, especially if this organ be distended with food, and death may result without leaving any trace of the injury externally or internally. The bladder may be ruptured and death result from extravasated urine. Rupture of the bladder may occur from fracture of the pelvis without sign of external injury. Rupture of the kidney may be recovered from if slight, but when severe is fatal. Rupture of the spleen is usually fatal, and is more likely to occur when enlarged from any cause. Coagulable lymph, the effect of a wound of a serous membrane, may be thrown out in twelve hours or less.

Injuries to the abdomen may cause death by—

Wounds of the genital organs of the female may cause fatal hæmorrhage, which takes place from the plexus of veins which, in these parts, are devoid of valves. A kick from behind whilst the woman is stooping or kneeling may rupture the labial vessels and death supervene.

Blows and kicks upon the abdomen do not often injure the non-gravid uterus, but during gestation may produce abortion and hæmorrhage. If the pregnancy be advanced the uterus may be ruptured or the placenta separated. Penetrating wounds either through the abdominal wall, or per vaginam in the attempt to procure abortion, cause hæmorrhage and peritonitis with septic infection.

Unless they implicate some special structure, such as the brain and medulla, simple fractures are not considered dangerous to life. When compound, they may be complicated with hæmorrhage and infective processes.

Certain pathological conditions favour the spontaneous fracture of bones, or this occurrence with such slight violence as would not cause fracture in the normal may take place.

In old people bones are more liable to fracture from their brittle condition. Liability to easy fracture occurs in the insane, in nervous lesions as locomotor ataxia and general paralysis of the insane, when the bones are the seat of new growths, in fragillitas ossium, osteopsathyrosis; in the latter disease I have seen the femur fracture by the weight of the leg while resting the foot on a cushion. The liability to fracture depends upon the proportion of organic and inorganic constituents. In disease, the latter may be reduced and predispose to fracture; in the young, the bones are more liable to greenstick or incomplete fracture; and in the old, from excess of inorganic constituents causing brittleness.

A medical man may be required to express an opinion as to whether or not fractures are the result of direct violence, and especially when allegations have been made against attendants on the senile or insane.

The previous predisposing pathological conditions must always be taken into account, and also the amount, if any, of repair that has followed in relation to the time the alleged violence took place.

As the condition of a fracture of the bone of a limb may become a question of considerable importance in medico-legal investigations, the following brief account of the process of repair in fractures is given:

Although the blood clot completely disappears from the immediate neighbourhood of the fracture at an early period, yet layers of dark coagulum may often be found beneath the superficial fascia for four weeks or more after the accident (Erichsen).

It may be of importance to remember this in medico-legal inquiries. The presence or absence of the signs of vital reaction will help to distinguish fractures caused before or after death.

A fracture taking place immediately after death cannot be distinguished from one immediately before death, but if a few hours after death, the differences are easily recognised, blood is not effused round the ends of the bones unless a large vessel be torn.

In the examination of bones for fracture in the living it is the duty of the examiner to have an X-ray plate taken of the injured bone, especially if the seat of injury is in close vicinity to a joint.

Previous fractures are easily recognisable after death even when the bone does not show manifestations externally; on longitudinal section the seat of fracture is rendered evident.

An attempt is made to answer this question by a consideration of the wounds in reference to their position, nature, extent, and direction.

In reference to their position it has to be borne in mind that one person may wound any part of the body of another, but that to the suicide certain parts only are accessible, and they have a predilection for wounding themselves in favoured regions; the front of the body and vital parts are chosen by the suicide, while wounds on the back point to homicide. Suicidal wounds on the head are generally in front or lateral, and on the neck in front or to one side, in cutting the throat. Accidental head injuries are more often on the vertex, and when there may be no history of a fall on the occiput, wounds in this situation indicate homicide.

Suicides may choose unusual regions, such as cutting of a large vessel as the femoral artery in Scarpa‘s triangle, or by a limited incision, the carotid in the neck, the injury may be about the genitals, and the penis and scrotum have been amputated.

Accidental injuries may occur on any part of the body, but most commonly on exposed parts.

The nature and extent of the wounds does not afford much assistance; with the exception of contused wounds which are usually homicidal or accidental, any other form of wound, particularly incised or punctured wounds, may be suicidal or homicidal, and with regard to gunshot wounds, much depends upon their position and extent. As a rule, the suicide does not make several wounds, and the homicide may not only inflict several but of a greater severity than are necessary to carry out his purpose.

Suicides, especially when insane, may wound themselves severely and cause great injuries by leaping from buildings or similar high positions. In some cases suicides have inflicted several and varied wounds on their bodies.

The direction of suicidal wounds, when the person is right-handed, is generally from above downwards and inwards on the chest, and on the left side. An upward direction points rather to homicide.

Cut throat wounds, when suicidal and inflicted by the right hand, are generally oblique from left to right, beginning higher up than they end. They generally cross the thyroid cartilage, and the larger vessels may escape; if made below the thyroid cartilage they are generally smaller and horizontal. The skin is the last structure divided, and there may be several so-called “tentative cuts.” It has been held that when the large vessels are cut the suicide stops, but this is incorrect, as in some cases the wound has reached the spine and the vessels been quite severed. Suicides may try to decapitate themselves from behind, and failing this stab themselves. A homicidal cut throat wound, when made from the front with the right hand, commences on the right side and is carried to the left; they are often deep incisions to the vertebræ and the tissues “undercut” at the ends. A homicidal cut throat wound when made from behind the victim resembles a suicidal one. When wounds are present on the forearms, hands, and fingers, and if there are injuries on other parts of the body also, the inference would be that the hand wounds were received in guarding the throat or other efforts at defence from a homicidal attack.

Wounds produced by Firearms.—To distinguish between suicidal, homicidal, and accidental wounds is far from easy. If the weapon be held hard up or close to the body, as in suicide, the skin and hair would be scorched and blackened, as would probably the hand that held the weapon, but this has not occurred in every case. The grasping of the firearm by the hand in cadaveric spasm is certain evidence of suicide, as this cannot be simulated by an assailant placing the weapon in the hand after death. Full investigation should be made by noting the bullet track and surrounding objects which may have been grazed in its course, in order to form a probable estimate of the direction from whence it came. Bullet wounds in the back are usually homicidal.

The surgeon should at once visit the wounded party, and proceed to examine the injury, for if this be done before swelling occurs, he will be better able to form an opinion of its nature, extent, and severity. If the wound has been dressed, he should, if possible, obtain the attendance of the person who applied the dressings, and who would be able to describe their nature, and the dangers to be avoided in their removal, should that be deemed necessary. In no case should a surgeon remove the dressings applied by a professional brother without his presence and assistance. The condition of the injured party should be carefully noted, and a minute description of the wound written down at the time. The statements of the bystanders are also useful and should be noted. The procedure in the examination of the dead body has been previously described (p. 60).

An important question here arises. Have the wounds found on the body been produced during life or after death? The answer is beset with difficulties, and considerable caution will be necessary, but tables will be given under the different kinds of wounds to assist the diagnosis. Signs of vital reaction are important, as showing the ante-mortem infliction of the wound; but these may, to some extent, be removed by the action of water, as in cases where the body is found in a pond. Under these circumstances the evident signs of drowning—water in the stomach, &c.—will assist the diagnosis. The presence of putrefaction also greatly obscures the diagnosis. The presence of coagulated blood between the edges of the wound is not a trustworthy indication of the ante-mortem infliction of the wound, as experiment has shown that as long as the body remains warm coagulation may take place. Coagulation even in contused wounds, effected before death, may be retarded from various unknown causes—disease, e.g. scurvy; mode of death, e.g. asphyxia. The amount of hæmorrhage on or around the body is, other things being equal, a safe criterion as to the time when the wound was inflicted; if in considerable amount, arterial blood points to ante-mortem injury; the presence of venous points blood to post-mortem injury.

Care should be taken to record and photograph the body in position where found, and its relation to surrounding objects. Careful note should be made of the surroundings and the character and presence of any blood-stains, footprints, &c. The question may have to be considered as to whether the body is in the place it was when the wounds were inflicted. Blood in any quantity in one place, and the body found in another so seriously injured that locomotion would be impossible, point to the body having been removed.

Signs of a struggle, if any, should be recorded. If a weapon be found near to the body, its position should be noted, and if in the hand, the firmness of the grasp—cadaveric spasm—should be recorded. All clothing should be carefully examined, and the relation of cuts and body wounds noted. All blood-stains on the clothing should be examined and described.

Multiple bullet wounds denote homicide, but suicides have been known to inflict more than one wound. It is strong evidence of suicide if the gun or pistol has burst by the explosion, as suicides have a predilection for overloading the weapon employed.

How may wounds, alleged to have been the result of an assault, be shown to have been self-inflicted? This has to be done by considering:

(1) The character of the wounds: in these cases they are generally slight, and may consist in a series of small, superficial wounds.

(2) The parts of the body where they are, and those from which they are absent. They are never found on vital parts, but always where there is little danger of doing harm. They are present on parts accessible to the individual. The hands are seldom wounded, and if they be, not severely.

(3) The clothing may not be cut, and if it be, the cuts may not go right through, and if they do, they may not coincide with the position of the wounds. The person should be clothed in order to determine this. Blood-stains on the cuts in the clothing may be erratic in distribution, some being on the inner layer only, some on the outer, and rarely soaking through all, pointing to the probability of its having been artificially applied.

Such self-inflicted wounds are usually produced for the purpose of bringing a fictitious charge of assault, feigning self-defence or provocation on the part of the assailant when accused; and in order to divert suspicion, as in the case of a person who alleges he has received the injuries by an assailant who was committing robbery while he himself is guilty of it.

Wounds may prove fatal from results which are (1) directly due to injury—hæmorrhage, shock, or mechanical injury to some vital organ, e.g. the heart or lung; or (2) indirectly from complications which may supervene such as infective processes—erysipelas, tetanus, septic infections, gangrene,—exhaustion, or the effects of surgical operations; or (3) malum regimen (a) on the part of the patient, (b) on the part of the medical attendant.

Hæmorrhage.—Hæmorrhage may be profuse and cause rapid death if a large blood-vessel, more especially an artery, has been injured. The hæmorrhage may take place internally, in which case it need not necessarily be profuse; it will depend upon the position; a small hæmorrhage into the pericardium or in the brain may prove rapidly fatal.

Shock.—Death from shock is generally associated with severe injury, either a single one, or from several smaller injuries, any of which alone would not be expected to prove fatal. Death may occur from shock when the visible injury may be slight, as in blows over the heart and abdomen, the latter causing fatal syncope from dilatation of the splanchnic vessels. Repeated lesser injuries as in flogging may cause death through shock; and fatal psychical shock may be caused by mental excitement, as, for instance, in an encounter when no physical injuries have been received.

Mechanical Injury to Viscera.—This causes rapid death, more especially when the viscus injured, as the heart or medulla, is necessary for the immediate functions of life; injuries to other organs may not be followed by immediate death unless very severe and with great shock. A wound of the lung may not be followed by death for some time.

In a healthy person the violence necessary to prove fatal ought to be greater than in one diseased, and pathological conditions may be found post-mortem, which were pre-existent to the injury, e.g. degeneration of blood-vessels, aneurysm, valvular disease of the heart, phthisical cavities which may have bled, gastric ulcer which may have ruptured. Such conditions might influence the findings of a jury, as, for example, it is not always possible to form the opinion that death has been directly due to violence when signs of injury are slight; a man may receive a blow on the head while in the act of falling in a fight, and post-mortem a cerebral hæmorrhage be found with diseased vessels, when it would be difficult to say with certainty that the hæmorrhage was directly caused by the blow or preceded it.

Fatal Complications.—In English law if death follow injury inflicted by a person within a year and a day, the assailant may be tried and punished; beyond that time the person is not held responsible for the death. The infective processes mentioned above may supervene at any time during the course of wounds with fatal result. Further, as a result of altered conditions left by injuries which in themselves have not proved fatal, and from the immediate effects of which the person has recovered, fatal complications may follow, e.g. a person may have received an abdominal wound which after healing may become the seat of hernia which may strangulate; or an injury to the spinal cord, which may cause death at a late date from bedsores and exhaustion.

Septic Processes.—These may cause death at an early date according to their nature and virulence and the power of resistance of the person. In such cases the original injury need not have been dangerous to life. In other cases the infection may persist after the wound has healed, as infective endocarditis might conceivably do.

Surgical Operations.—Should a surgical operation be considered necessary for the treatment of the injury or in order to save life, and the person dies after it, the prisoner will be held responsible for the death. This holds good if the operation has been done in good faith and performed with reasonable skill and care. If, however, it can be shown that the operation was unnecessary, or performed unskilfully and death resulted, the prisoner would not be held responsible unless it can be proved that the injury apart from the operation could have caused death, when the jury might convict.

Where from improper treatment of an injury an operation is called for because of the improper treatment and the person dies, the prisoner would not be held responsible. The main points to be considered in reference to surgical operations for criminal injuries are:

• (1) The operation must be absolutely necessary.
• (2) The operator must have acted with reasonable skill and care.
• (3) That the wound was dangerous to life, and without operation
• would most probably have proved fatal.

(a) On the part of the Person Injured.—If the wound is not in itself sufficient to cause death, but by negligence in the care of it by the injured person, complications arise which cause death, then the punishment would probably be mitigated; but in law a person accused of criminally injuring another is held responsible for the immediate and remote results. “No man is authorised to place another in such a predicament as to make the preservation of his life depend merely on his own prudence.” If, however, it can be proved that death was largely due to the imprudence or recklessness of the deceased, it is probable that this would lessen the punishment.

(b) On the part of the Doctor.—A person accused of criminally injuring another being held responsible for the results immediate and remote, may plead that the latter, i.e. complications, or the death itself are not due to the injury directly, and endeavour to throw the responsibility on someone else, either the injured person through negligence, or on the doctor for unskilful treatment. In reference to the complications, the medical witness may be asked for his opinion as to the cause and effect of the complication, and how it might have been avoided. Having considered all the facts laid before him and made his deductions, he must give his opinion fairly, and leave it to the Court to decide in what way his opinion may influence its judgment and the amount of punishment for the offence.

When there is an allegation that the treatment has been unskilful or negligent, and contributory to complications and death, and a defence raised accordingly, the prisoner has to prove this to the satisfaction of the Court in order to mitigate the offence and punishment. The medical man is expected to have exercised reasonable skill. If the person treating the injury is a registered medical practitioner, and has applied his treatment in good faith and for cure, even if the treatment were improper, the assailant would be held responsible.

The care which the medical man ought to exercise is that which everyone ought to exercise who has received the statutory education and passed the statutory examinations.

(1) Incised; (2) Punctured; (3) Lacerated and Contused; and (4) Gunshot.

Made by sharp instruments.

General Characters.—Incised wounds are somewhat spindle-shaped, their superficial extent being greater than their depth; the edges are smooth and slightly everted, and the wounds are always larger than the weapon which inflicted them—due to retraction of the divided tissues. If a wound be in a line with the fibres of a muscle, there will be less “gaping” than when the wound is directly or obliquely across the muscle. From muscular contraction, or the elasticity of the skin, an incised wound may assume a crescentic form. The cellular tissue is infiltrated with blood, and coagula are found at the bottom and between the edges of the cut. It must be borne in mind that a wound with smooth edges may be made by a blunt weapon over bones near the surface, as on the scalp and over the tibia or shin, but a certain amount of contusion may, in most cases, be detected by careful inspection a short time after the receipt of the injury.

It is often of importance to distinguish where the weapon entered, and where it was drawn out. The end where the weapon entered is usually more abrupt than the other, which is naturally more drawn out. But in some cases I have seen, when the weapon was simply drawn across the part, both ends of the wound alike.

The orifice is generally a little smaller than the weapon.

A stab may sometimes present the appearance of an incised wound; the depth will, however, help to distinguish the one from the other. The wound may not at all correspond with the shape of the weapon, and the same pointed instrument may produce very different-shaped wounds in different parts of the body. Much depends upon the movement of the instrument in the action of puncturing; in the case of a double-edged instrument the wound will most probably be fusiform or diamond-shaped. When made with a knife the wound may be wedge-shaped if the knife have a thick back. A circular weapon splits the skin and leaves a slit; broken glass and pottery act in a similar way, but the wounds may have jagged edges and show signs of contusion in them. On dissection, two or more punctures may be found in the soft parts, with only one external orifice; these are due to the weapon being only partially withdrawn at each stab. Punctured wounds are always more dangerous than incised. They cause little, if any, hæmorrhage externally, unless a large vessel, such as the femoral artery, be injured, but they may cause internal hæmorrhage or penetrate a viscus, e.g. the lung or heart. These wounds generally heal by suppuration, and not infrequently an abscess is formed in and around the track of the wound. Perforating wounds generally have a large entrance wound with inverted edges, and a small exit with everted edges; if the weapon be rough, the reverse may be the case.

The edges of these wounds are never smooth, and generally do not correspond at all with the weapon. A considerable amount of contusion or bruising surrounds the solution of continuity of the part. Hæmorrhage from these wounds is usually slight. A point of considerable interest may arise in connection with this class of wounds; the defence may declare that the injury was the result of a fall, and not due to a blow. The history of the case, and the presence of a bruise where no theory of a fall can explain its existence, will often afford the only solution of the difficulty. Lacerated wounds heal by suppuration, generally with more or less sloughing, and leave a permanent scar. Scratches with the finger-nails may be considered as lacerated wounds, but the skin is merely abraded, not divided. They are never important as wounds, but often as a proof of a struggle in cases of rape, &e. Bites are also lacerated wounds. The diagnosis of lacerated and punctured wounds, whether inflicted before or after death, will depend on much the same grounds as those of incised wounds, hæmorrhage, vital reaction, &c.

Table of Differentiation Between
Ante-mortem and Post-mortem Wounds:

The appearance which gunshot wounds present will to a great extent depend upon the form of the projectile, and the distance at which the firearm was discharged. Round halls make a larger opening than conical. Small-shot, fired within a short distance of the body, make one large ragged opening. The scattering of the shot depends on the calibre of the gun, on the charge of powder, and essentially on the distance. A charge of ordinary (No. 5) shot, to make a single hole, must have been fired at less than one foot; but experiments should always be made with the alleged weapon. A patent cartridge would make a single hole at a considerable distance—five or six yards. Round bullets may split, but the conical ones seldom do. The edges of wounds produced by the discharge of firearms are always more or less ecchymosed; this condition appears in about an hour after the infliction of the injury. If the ball strikes obliquely, the edges of the wound may be much lacerated, or the opening may be valvular and of small size, if the skin over the part be in any way tightened, or if a conical ball has been used. The injury to bones is greater from conical than from round balls. The old round balls were easily deflected; the conical are not so easily turned aside. The track of the ball widens as it deepens. This is the reverse of an ordinary punctured wound. The ball may either lodge in a part, or perforate it. Should it have lodged, it must be preserved and compared with the alleged firearm. Bits of clothing or wadding may be carried into the wound. The latter should be carefully kept, as they may prove important as a means of identification.

The aperture of entrance and exit must, if possible, be determined. On this point there is much difference of opinion. The wound of exit is always smaller than the wound of entrance (Casper). In this opinion Casper agrees with M. Malle, Olliver d‘Angers, and M. Huguier, but is opposed by Taylor, M. Matthysens, and others. “The characters of a gunshot wound,” says Assistant-Surgeon Neill, “are those of a contusion and laceration of all the tissues. Sometimes they are so simple as to bear resemblance to a punctured wound, particularly if a rifle-ball (conoidal), revolving on its long axis, has passed through the soft parts at a great speed, but within a few hours it resembles a contusion. The wound of entrance, as it has been termed, bears no comparison in size or shape to that of the exit when a rifle-ball has caused the injury. In the former you see the edges of the wound curving inwards, and the circumference small, with little or no hæmorrhage. In the latter, the wound is large, with torn and irregular edges projecting outwards, and perhaps only slight oozing of blood. In a short time, averaging an hour, round the entrance wound slight redness begins, gradually extending to about two inches round its orifice. Again, this colour changes to a blue- or greenish-black, and you see all the appearances of a severe bruise, with a small wound of the skin, its edges still curved inwards. In the exit wound the discoloration of the skin is not apparent.” The probable reason for the discrepancies in the statements of observers, as to the characters of entrance and exit wounds, may be found in the fact that experiments have been conducted with different-sized balls, different kinds of weapons, with varying quantities and qualities of the powder used, the character of the wads, and with varying velocities and distances. As pointed out by M. Roux, the two openings may be equal if the ball preserves the same velocity through the tissues as it possessed before entrance; the entrance hole is smaller than the exit, when the ball has lost much of its trajectile force, and enters the softer parts of the body first; the entrance is larger than the exit, when the ball first enters through the denser tissues of the body, and leaves through the softer.

The opening of entrance made by the ball has generally, but by no means always, inverted edges. The edges of the exit opening are everted, bloody, and raw; but both the entrance and exit wounds may be everted in fat persons, due to the protrusion of the fat; and this eversion may also result from the expansive power of the gases generated during putrefaction, should this condition be present. Wounds made by double shots, as from double-barrelled guns, or pistols, or from slugs fired from one barrel, diverge after their entrance into the body.

Observations during the war in South Africa threw fresh light upon the results of gunshot wounds produced by modern projectiles. Of wounds produced by the Mauser bullet, one correspondent (The Physician and Surgeon, 1900, p. 49) states that “the aperture of entrance seldom shows any bruising of surrounding tissue; frequently it has been difficult to locate it, for where the skin is dense and elastic, there is seldom any bleeding. There is never any inversion of the edges, which are sometimes circular in form, and sometimes triangular like a leech-bite. The aperture of exit, where the bullet has not been distorted, is seldom any larger than that of entrance; there is no bruising of surrounding tissue, and no eversion of the edges; bleeding varies, of course, in accordance with the proximity of large, medium, or small blood-vessels in the track, but in the vast majority of cases it is slight.”

The late Sir William MacCormac, quoted by Sir William Stokes (B. M. J., vol. i., 1900, p. 1453), says: “I saw a large number of injuries inflicted by the Mauser bullet, which is remarkable for the small wound it produces. In three-fourths, if not a larger proportion, it was impossible to tell the exit from the entrance wound, they were so similar in appearance.”

In the examination of gunshot wounds we have to consider—

1. Direction in which the Gun was fired.—The track and position of the ball in the body, coupled with the relative position of the body to a window or door through which the gun may have been discharged, and the place where the ball is found, should it have passed through the body, may assist us in forming an opinion. It is often impossible to trace the course of the ball through the cavities of the body, but through the muscles and denser structures this is more easily accomplished. The effects of the ball on surrounding objects may assist very much in finding the direction of its course. Sir Astley Cooper, by a careful consideration of the above suggestions, once correctly determined that a left-handed man had fired the fatal shot.

2. Distance at which the Charge was fired.—In the case of wounds inflicted by a small shot, the scattering of the shot must be our guide. Dupuytren has related a case in which a fowling-piece charged with powder alone and fired at a distance of two or three feet from the abdomen made a round hole in it and killed the man. If the weapon be fired a short distance, e.g. a few inches from the body, the skin will be scorched, smoke-blackened, and tatooed with powder, the flame may singe the hair or clothing. If discharged quite hard up to the body, the edges of the wound are freely lacerated, ecchymosed, and burnt. Smokeless powder will not cause blackening of the skin. The absence of scorching, or marks made round the wound by the half-burnt powder, allows of the assumption that the shot must have come from some distance—rather more than four feet. The absence of any of the above, however, is not an absolute proof that the shot has come from a distance.

There is no means of deciding, from an examination of a pistol or gun, when the weapon was last used. In all cases, medical men, unless sportsmen and familiar with firearms, should hand over the weapon to a gamekeeper or gunsmith, and not attempt to give an opinion on matters about which they know nothing. The following may be of use to students for examination purposes, but for nothing else: Among the products formed when gunpowder is exploded is the sulphide of potassium, but if exposed to the air some portion of this substance is converted into the sulphate of potash. If, then, the gun-barrel be washed out with distilled water, and the washings filtered, and, on the addition of a solution of acetate of lead, a black precipitate of sulphide of lead be formed, this is supposed to point to recent use; if, on the other hand, a white precipitate of sulphate of lead forms, to the use of the weapon at some more distant date than the period alleged.

CHAPTER VI BLOOD-STAINS — EXAMINATION OF BLOOD-STAINS — Physical Examination — Microscopical Examination — Chemical Examination — Spectroscopic Examination — Blood Spectra — Biological Tests for Blood — Vegetable and other Stains which resemble Blood

It is important in medico-legal investigations to determine the nature of stains found on clothes, weapons, articles of furniture, &c. In the case of blood-stains note should be made of their incidence upon the body or in its vicinity. Blood-stains may vary in their character, incidence, and magnitude, as sprays, spirts, or jets, smears of various forms, or pools of blood.

Notes should be made of the relation of the direction of a spray of blood to the position of a wounded body when found. A plan with the position of the stains should be sketched upon the spot, and measurements taken carefully.

In the examination of blood-stains the purpose of the medico-jurist is not to demonstrate all the properties of blood, but to identify it. There is not much difficulty in ascertaining whether stains are due to blood or not; but when the question arises as to whether the blood be human or that of some other animal, the identification is more difficult and less certain.

Blood-stains vary in colour, according to the age of the stain, the quantity of blood in it—the thicker the stain the darker—and the nature and colour of the material upon which it is. Recent stains are reddish in colour, old stains brownish. This change of colour depends upon the free access of air and the presence or absence of chemical substances in the air, so that it is almost impossible to infer the age of a blood-stain by its colour. On dark-coloured materials the stains are rendered more visible by the aid of artificial light, such as candle-light; on light-coloured materials, on leather, wood, iron, and stone, they are more visible in good daylight. By reason of the coagulation and the albuminous composition of blood, dry stains stiffen the fabric when thin, and on thicker woollen materials the fine fibres become matted. On metals, such as iron or steel, they appear as dark shiny spots or smears, and when dried are often fissured or cracked. Rust may so alter blood as to produce a difference between the stains on the blade and handle of a knife. In quite recent blood-stains the general appearances are sufficient to give rise to a conclusion as to their nature, especially if the stains are large. The general features as seen by the naked eye are such that one may often recognise blood-stains as arterial by the comet shape they retain when falling slantwise on an object. Venous blood is not spurted in small jets like arterial, but blood from veins may become splashed upon objects and assume shapes similar to those produced from an arterial jet.

The examination of blood-stains should be carried out in the following way:

1. Examine the stains carefully with a good pocket lens or a low power microscope lens. A fabric will show matting of its fibres, red filaments, and minute coagula in its meshes. In old blood-stains coagula may be absent and the fabric appear as if dyed. The characters of any fibres or hairs adhering to the stain and the nature of the substance upon which the stain is should be noted.

Fig. 4.—Photo-micrograph of wool fibres, × 250.
(R. J. M. Buchanan.)

2. Make accurate notes of the position and shape of the stains on the material examined.

3. Take one stain, if there are several, or part if single, and note the solubility of it in water, or in a mixture of water and some other substance. The solubility of the colouring matter is greater if the stain be recent than if it be old. The older the stain the less soluble it becomes, as the hæmoglobin is gradually changed in course of time to insoluble hæmatin.

An endeavour should be made to obtain a solution for microscopical, chemical, and spectroscopical examination. The solvent, in order to obtain the blood corpuscles in as natural a form as possible, should approach in its specific gravity the liquor sanguinis.

The following solvents fulfil this purpose:

If distilled water alone be used, the red corpuscles lose their hæmoglobin and become “laked” or “phantom” corpuscles; if the solution be of higher sp. gr. than liquor sanguinis, then the corpuscles become crenated and irregular in shape.

Fig. 5.—Photo-micrograph of flax fibres, × 250.
(R. J. M. Buchanan.)

The technique of examination has to be varied in certain details, according to the material upon which the stain is. Stains may have to be examined upon cloth-fabrics, wood, plaster, metal, or leather. These will be taken separately, and the methods of examination described which will prove most reliable in each case.

1. Cloth-fabrics.—Cut out a stain, or part of one, and macerate it in a quantity of one of the solvents mentioned above, sufficient for the purpose. If the stain be very small, squeeze with fine forceps one or more drops upon microscope slides for microscopic, and keep the remainder of the solution for spectroscopic, examination. In dyed fabrics, which have been mordanted, the mordant may fix the blood-stain so as to prevent solution, and especially so when the attempts have been made to wash out the stain with soap and water.

To make a solution of the stain in such cases it is best to use distilled water to which a small quantity of ammonia or citric acid has been added; in one or other of these the colouring matter will dissolve.

2. Wood.—Note the kind of wood, cut off a thin shaving and treat with one of the solvents mentioned above. If on wood containing tannic acid, such as oak or elm, the best solvent is a two per cent. solution of hydrochloric acid.

3. Plaster.—Scrape off some of the stained plaster, and treat as for cloth or wood.

4. Metal.—If the stain be upon a clean and unrusted metal, e.g. the clean blade of a knife, then gently heat the metal on the side opposite to the stain, when the latter, if recent, will peel off or can be easily detached. This requires some care and dexterity. It is easy, however, to scrape the stain off into a watch-glass, and this procedure is necessary when the metal is rusted and the stain mixed with the rust, or when the stain is thin.

Fig. 6.—Photo-micrograph of silk fibres, × 250.
(R. J. M. Buchanan.)

If on iron and mixed with rust the borax solution may be used, with a drop or two of solution of ammonia; use a fine camel-hair pencil dipped in the solution, and brush the stain off into a watch-glass. Becker advises that stains mixed with rust should be digested with a weak solution of ammonia and common salt for a few hours; decant the solution and evaporate it upon a microscope slide to dryness, then test the residue by the “hæmin test.”

Ganttner‘s test should be used to a portion of a stain upon metal when thin or mixed with rust. It may be carried out upon the metal itself or upon a scraping of the stain in a watch-glass resting upon a black surface. Moisten the scraping in a watch-glass with a drop or two of distilled water rendered feebly alkaline, then add a minute drop of hydrogen peroxide. Wherever blood is present bubbles of gas develop, which give the material a white beaded appearance. The froth develops from the outside of the drop towards the centre when the stain is mainly composed of blood. In a scraping consisting of mixed particles of rust and blood, the reaction only appears upon the particles of blood, and rust to which blood adheres; it does not take place on those particles of rust free from blood. Before adding the peroxide of hydrogen it may be necessary to dissipate any air-bubbles which may cling to the scraping in the alkaline water by gentle agitation with the point of a fine glass rod. Should the above reaction with peroxide of hydrogen not take place, then one can rest assured that no blood is present. The test, however, is a negative one; it is not a positive test for blood only; other fluids and exudations from the body, such as saliva and pus, give the reaction. The reaction will take place with blood-stains of any age.

Fig. 7.—Photo-micrograph of cotton fibres, × 250.
(R. J. M. Buchanan.)

In examining a clasp-knife or any hinged weapon for blood-stains, the instrument should be taken to pieces and all the hinges and recesses carefully examined, for in these places blood may be found, although the weapon had previously been wiped clean, and appear free from stains.

5. On Leather.—The tannic acid in leather forms a compound with blood which is insoluble in the solvents generally used. A thin shaving of the stained portion should be taken and folded, with the stained surface outwards, in the form of a loop. If the outer surface of the loop with the stain be made to touch the surface of the glycerine and water solution, at the same time taking care that the leather itself be not moistened, a recent stain may yield a sufficient quantity of colouring matter for the purposes of examination. Failing this, the shaving should be digested in a small quantity of a two per cent. solution of hydrochloric acid in distilled water (Sorby).

The microscopical examination of blood-stains, for the purpose of identifying the presence of the red blood corpuscles, is especially applicable to recent stains. In these the corpuscles may retain, to a great extent, their normal characters; but their condition varies with the age of the stain; they become altered in appearance and irregular in shape with increasing age, until a stage is reached when they become completely disintegrated and unrecognisable. Having obtained a solution of a stain by one of the methods recommended, a few drops should be placed upon a clean microscope slide and covered with a No. 1 cover-glass. In a recent stain, where minute coagula are present, one may be placed on a microscope slide and moistened by breathing upon it several times, and then covering it with a No. 1 slip, or a drop of the glycerine solution may be allowed to act upon it on the slide until it be sufficiently moistened, when it should be covered in the same way. The preparation should be examined through the microscope with a good lens (preferably a ¹/₁₂th oil immersion), magnifying 300 to 400 diameters, and if any corpuscles be found, their characters should be carefully observed and noted.

All such specimens should be carefully preserved and labelled with a description of the method of preparation, the case to which they belong, the date of preparation, and the signature of the individual who has made and examined them. It is essential that the preparation and examination of the specimen should be made by the same individual. In certain cases the conditions may be sufficiently favourable to allow of the production of stained specimens, which can be mounted so as to retain their original characters permanently. In every case it is advisable to pursue the investigation with this object in view.

This process is especially applicable to recent blood-stains, in which, from preliminary examination, the presence of blood corpuscles has been determined; where complete disintegration of the blood corpuscles has taken place it would not be of any value.

It may so happen that by means of stained specimens the identity of blood corpuscles may be more easily established, when the result of examination is uncertain in a specimen not so prepared.

By the action of certain dyes upon the corpuscles their special features are rendered easier of recognition. Any of the approved methods of preparing blood films for general clinical purposes, which will suit the circumstances, may be employed. An easy and reliable method is as follows. A drop of the solution of the blood-stain properly prepared as previously recommended, or if obtainable a small coagulum moistened with normal saline solution, is placed on a clean coverslip and spread evenly over its surface with the aid of a fine glass rod. The film is allowed to dry in the air, covered with a watch-glass for protection against dust. When dry it is passed three times through the flame of a Bunsen burner, or placed in a mixture of equal parts of absolute alcohol and ether, to fix it. After fixation it should be placed for a minute or more in an aqueous solution of eosin.

Any excess of stain should be removed by washing in distilled water, and the specimen allowed to drain by standing it on edge upon a piece of filter paper; it should then be allowed to dry, and then counterstained with a freshly prepared aqueous solution of methylene blue, hæmatoxylin solution, or other nuclear dye. Wash again in distilled water, allow to dry, and mount in Canada balsam. By this method the corpuscle will be stained pink, and if nucleated, the nucleus will be stained by the methylene blue, hæmatoxylin, or other nuclear stain which may have been used.

Leishman‘s stain may be used. This stain being a methyl-alcohol solution is used for fixing and staining at the same time. A few drops of the stain is placed on the dried film; after standing until evaporation is almost complete, distilled water is dropped on to the slide, and left to stand for two or three minutes, it is then drained off, and a few more drops of distilled water added until the film is pink in colour, then dried with filter paper. Red corpuscles are tinted red with the eosin, and nuclei of leucocytes or nucleated red cells violet or deep blue. The specimen may be examined direct with the oil immersion or mounted in Canada balsam.

When examining specimens prepared from blood-stains, it is necessary to search carefully for other cellular structures such as epithelial cells, spermatozoa, or fragments of hair.

It may be advisable, in certain cases where the amount of material submitted for examination is small, to centrifugalise some of the solution in a fine glass tube, in order to determine any cellular elements present to one spot. By making use of this concentrated portion containing the cellular elements for the preparation of a microscopic specimen, one not only facilitates the microscopical examination, but is able to place more reliance upon the results obtained.

The Results of Microscopical Examination of
Blood-Stains in Their Medico-Legal Relations.

As previously stated, the examination of alleged blood-stains from a medico-legal standpoint is pursued essentially for the purpose of testifying as to whether they have been produced by blood or not. Where the examination yields a negative result, further procedure is necessary with a view of identifying the true nature of the stain. Should, however, the result be positive, the question arises as to the possibility of distinguishing between human blood and the blood of other animals, and determining the exact animal from which the blood has been derived. Such an examination should be pursued in full recognition of its importance as a factor towards the establishment of truth essential to the administration of justice.

To fulfil this obligation the methods employed should be so selected as to produce results bearing testimony free from any possibility of doubt.

Certain differences exist, and may be detected by microscopical examination, between the red corpuscles of human blood and those of some other animals sufficiently well marked to render differentiation possible. The differences are those of form and structure.

(1) In man the red corpuscles appear as circular biconcave discs, averaging ¹/₃₅₀₀ of an inch in diameter, and are non-nucleated.

The red corpuscles of mammals present the same features, with the exception of the

(2) Camel tribe, in which the corpuscles are oval in form, but non-nucleated.

(3) In birds, fishes, reptiles, and amphibians the red corpuscles are oval in shape, and possess a nucleus.

Guided by the above facts, one is able to testify whether or not the corpuscles exhibit the characters of mammalian blood.

Many attempts have been made with a view to establishing a reliable means of differentiation between the red blood corpuscles of man and other mammals (the camel excepted), and with a certain degree of success, such as might be expected, under select conditions favourable to histological research, but which do not obtain in medico-legal practice. Differences in size of the red corpuscles, as revealed by micrometric measurement, have been suggested as a possible means of distinguishing between the blood of different mammals. Of the common animals, the red blood corpuscles of the sheep present the most marked difference in size compared with those of man. The following table of the dimensions of red blood corpuscles is derived from measurements made by Treadwell, and quoted by White (The Medico-Legal Journal, New York, 1895):

Menstrual blood contains no fibrin, has an acid reaction due to the vaginal mucus which keeps it fluid, and contains squamous epithelial cells. None of these characters can be differentiated on fabrics, especially when contaminated with urinary stains in addition. Hence, in cases of alleged rape, no distinction can be drawn between blood-stains on the underclothing of the female, which may have arisen from hæmorrhage the result of violence to the sexual parts, and those which might have arisen from the ordinary menstrual flow or metrorrhagia. The detection of spermatozoa, however, would add considerable value to the observation.

Fig. 8.—Measurement of Blood Corpuscles.

Fig. 9.—Measurement of Blood Corpuscles.

Blood Crystals.—Professor Preyer of Jena pointed out many years ago that the hæmoglobin crystals from the blood of some animals differed in shape from those of man, and this fact has given rise to many attempts to trace the identity of the blood to the animal from which it has been derived. The results have not been of sufficient value to establish it as trustworthy for medico-legal purposes. Dr. Monckton Copeman (B. M. J., vol. ii. p. 190, 1889) has carefully investigated the subject, and his researches, partly confirmed by Professor Glaister of Glasgow, show that from the guinea-pig, rat, and squirrel, crystals of hæmoglobin may be easily obtained, but the solubility of human hæmoglobin renders it much more difficult to crystallise. Crystals may, however, be obtained in the following ways:

Crystals of human hæmoglobin appear in the form of rectangular plates, with a greenish or pale claret colour. On spectroscopic examination they exhibit the characters of reduced hæmoglobin, in contradistinction to the crystals derived from the lower animals, which produce the spectrum of oxyhæmoglobin.

The blood of the bullock, sheep, and pig is very difficult to crystallise. By the method adopted by Gamgee of adding to defibrinated blood one-sixteenth its volume of ether, shaking until the mixture becomes transparent, and allowing to stand in an ordinary temperature for 48 hours, crystals may be obtained from the blood of the following animals:

Crystals from human blood are not easily obtainable by this process, but when they are, they always give the spectrum of reduced hæmoglobin, whereas those from the animals mentioned above give the spectrum of oxyhæmoglobin.

Having obtained a coloured solution from a supposed blood-stain, if sufficient in quantity, apply the following chemical tests to separate portions:

1. Add a few drops of a weak solution of ammonia in distilled water. The colour may remain unchanged, or, at the most, a slight heightening may take place, if it be due to blood. If the solution of ammonia be too strong, a brown colour may be produced if blood be present.

2. Heat to boiling, when the following changes take place if blood be present:

Fig. 10.—Photo-micrograph of red blood corpuscles from domestic fowl, × 250.
(R. J. M. Buchanan.)

Fig. 11.—Photo-micrograph of blood corpuscles of fish, × 250.
(R. J. M. Buchanan.)

Fig. 12.—Photo-micrograph of blood corpuscles from a dried stain of the blood of a codfish, × 250.
(R. J. M. Buchanan.)

3. Add tincture of guaiacum, freshly prepared: an opaque, cream-coloured precipitate of the guaiac resin will form in the aqueous solution. On the addition of ozonic ether, turpentine, or peroxide of hydrogen, a blue colour will be produced at the junction of the fluids: proportionate to the amount of blood-colouring matter present, the blue colour will vary in intensity.

This test, known as Day‘s or Schönbein‘s, is extremely delicate, and reacts to no coloured substance except blood.

In cases where the blood-stain is small, the test may be applied as follows. Moisten a pure white filter paper with a drop of distilled water, or one of the solutions recommended in the section on physical examination, and touch the stain with the moistened portion. On adding a drop of tincture of guaiacum followed by a drop of ozonic ether to the wet filter paper the blue colour will be produced and easily recognised on the white surface.

The guaiacum test, although extremely delicate, can only be accepted as providing negative evidence. The absence of reaction proves the absence of blood, except in very old blood-stains, which may not respond to the test. The blue colour produced indicates that the substance may be blood, but it cannot be accepted without corroboration. Gluten, raw potato, milk, bile, sweat (Ogston), and other oxidising substances give a blue colour with guaiacum and ozonic ether; some substances give the blue colour with guaiacum alone.

With blood, however, the test is sufficiently delicate to detect one drop in six ounces of water.

4. Nitric acid added to a portion of the solution of blood in distilled water produces a whitish-grey precipitate.

Fig. 13.—Photo-micrograph of frog‘s blood showing oval nucleated red corpuscles, × 250.
(R. J. M. Buchanan.)

5. Hæmin Crystals.—Concentrate a portion of the solution upon a microscope slide, add to it a minute crystal of chloride of sodium and a few drops of glacial acetic acid. Heat gently to dryness or to a lesser degree under a coverslip; examine with the microscope; if blood be present, crystals of hæmin, or the hydrochloride of hæmatin, will be found. They are of a yellowish-red to brownish-black colour with a metallic lustre. They occur in rhomboidal prisms, or six-sided in shape, or in the form of “whetstones,” often in clusters; many of the crystals exhibit a lipped projection on one side. They are known as Teichmann‘s crystals. It is well to verify their origin from blood by placing upon them a drop of hydrogen peroxide, when they will give off bubbles of oxygen gas.

They are insoluble in water, alcohol, and dilute acetic and hydrochloric acids. They dissolve in boiling acetic or hydrochloric acids, and the caustic alkalies. They respond to the guaiacum test, and the ash produced by incineration shows the presence of iron by the red colour produced on the addition of a drop of hydrochloric acid and a solution of potassium sulphocyanide.

The production, by the methods described, of such crystals affords conclusive proof of the presence of blood.

To a portion of the coloured solution, filtered if necessary, the spectroscopic tests should be applied. The following points must be remembered in carrying out a spectroscopic examination:

(a) The colouring matter of fresh blood is hæmoglobin, and it may exist in two states, according to the degree of its combination with oxygen.

In arterial blood it is present as oxidised hæmoglobin, and the same obtains in blood which has been exposed to the air under certain conditions and for a varying period of time.

Fig. 14.—Photo-micrograph of crystals of hæmin, × 250.
(R. J. M. Buchanan.)

In venous blood, especially when obtained under conditions preventing oxidation, as from the heart cavity of an animal newly asphyxiated, it is present as deoxidised hæmoglobin.

(b) In dry stains, especially if they have been subjected to the action of impure air containing the products of coal-combustion, the colouring matter becomes changed into methæmoglobin, or hæmoglobin in which its combination with oxygen has been altered in such a way that a current of a neutral gas, such as hydrogen or nitrogen, will not dissociate it, as it does with oxyhæmoglobin. Such stains have a brownish colour, and may give an acid reaction.

(c) In stains which have retained moisture, from having lain in damp places, the hæmoglobin becomes converted into hæmatin. The same change takes place in dry stains after a longer period of time.

On examining the solution of the colouring matter from a blood-stain with the spectroscope, the spectrum will vary according to its condition and the nature of the solvent used.

The spectra of hæmoglobin and its derivatives are characteristic, and afford conclusive evidence of the presence of blood. The spectra must be recognised, however, in more than one condition. Other substances may yield spectra very similar to that of oxyhæmoglobin, but when subjected to certain tests they do not alter in the same way. They cannot be made to give the spectra of reduced hæmoglobin and reduced hæmatin, and any colouring matter which may be made to yield the spectra of reduced hæmoglobin and reduced hæmatin is derived from blood.

1. Oxidised hæmoglobin (O₂Hb) is characterised by the presence in its solar spectrum of two absorption bands between the D and E lines. The first band commences at the D line and extends a short distance towards the E. The second commences at a little distance from it, and terminates at the E line; it is about twice the breadth of the first. The band at D is more defined than the other (Fig. 15, 1).

2. Deoxidised or reduced hæmoglobin presents one broad band occupying almost the whole of the space between D and E slightly to the left of these lines (Fig. 15, 2).

3. Methæmoglobin presents two bands between D and E, in the same position as those of O₂Hb, but in addition a third band between C and D and near to the former (Fig. 15, 3).

A solution of oxyhæmoglobin or methæmoglobin may be reduced by the addition of a reducing agent, such as Stokes‘ reagent, consisting of ferrous sulphate with a small quantity of tartaric acid dissolved in water and rendered alkaline at the time of using with ammonia, or, better still, by the addition of ammonium sulphide. The spectrum will change to that of reduced hæmoglobin.

4. Acid hæmatin presents a spectrum with a band between D and E, commencing at a little distance from D and ending at E, also a narrower band between C and D and commencing at C. It is a difficult spectrum to obtain.

5. Alkaline hæmatin presents a spectrum with a single band between C and D near to the D line. It is more difficult to obtain than the spectrum of acid hæmatin.

It is not necessary, however, to obtain these spectra, viz. 5 and 6, but it is necessary to reduce solutions of either acid or alkaline hæmatin in order to obtain the spectrum of reduced hæmatin. To do so proceed as follows. To some of the solution of colouring matter obtained from the stain add a small quantity of a 20 per cent. solution of sodium hydrate; the solution will alter in colour, and the spectrum of O₂Hb or MetHb will disappear. On adding to this solution of alkaline hæmatin a few drops of ammonium sulphide, or Stokes‘ fluid, it becomes claret-coloured, and on examination with the spectroscope the spectrum of reduced hæmatin will be seen. This is the most pronounced of all blood spectra. Its production can be hastened by gently warming the solution.

If the stain be old and already changed into hæmatin, its solution will yield the spectrum of acid hæmatin, and will give the spectrum of reduced hæmatin on the addition of ammonium sulphide or Stokes‘ fluid without previous alkalisation.

6. Reduced hæmatin presents a spectrum with a dark band about midway between D and E, and a broad but paler band commences near the E line and extends to the b line (Fig. 15, 4).

Fig. 15.—Blood Spectra.

In cases of death by asphyxia, in which the hæmoglobin is in combination with CO₂, the blood, if removed and examined immediately after death, gives a spectrum of reduced hæmoglobin, but on exposure to the air it rapidly changes to oxyhæmoglobin. The period after death at which blood is usually submitted for medico-legal examination is sufficiently late to allow of this change, and so prevents the possibility of determining death by asphyxia by spectroscopic examination of the blood. Where death has been caused by the action of carbon monoxide, the blood is of a cherry-red colour, and it will retain this colour unchanged for a long time, in fact for years, due to a stable combination of the CO and hæmoglobin, called carboxyhæmoglobin. Such blood yields a very characteristic spectrum, with two bands similar to those of O₂Hb, but nearer to the violet end (Fig. 15, 6). Their position should be assured by accurate measurement and comparison with a spectrum of O₂Hb. The CO hæmoglobin, however, cannot be reduced; on the addition of ammonium sulphide or Stokes‘ fluid the bands remain unaltered.

In cases where the amount of fluid obtainable for examination is very small, recourse must be had to the micro-spectroscope, using a Sorby‘s cell to hold the fluid, and substituting for the eye-piece of the microscope a specially constructed spectroscope arranged so as to throw the spectrum of a known solution of blood-colouring matter alongside of that yielded by the solution under examination. Artificial light should be used, and the D line located by placing in the flame a platinum wire carrying a salt of sodium.

The results of the experimental investigations of Friedenthal,[3] Deutsch,[4] Uhlenhuth,[5] Wasserman and Schutze,[6] Nuttall,[7] Tarchetti,[8] Grünbaum,[9] Metchnikoff,[10] and M‘Weeney[11] into “blood relationships” have led to the suggestion of a new method—the “biological test,” by which different kinds of mammalian blood may be distinguished one from the other. Their experiments show in a general way that the “serum from an animal which has been injected intraperitoneally with any given organic fluid will, if mixed in small quantity with a dilute solution of the fluid used for the injection, produce a more or less definite precipitate.” If human defibrinated blood be injected into the peritoneal cavity of a rabbit, the serum obtained from the rabbit‘s blood, when mixed with a clear solution of the blood of man or ape, will produce a precipitate, and agglutinate the red blood corpuscles if present: the same reaction will not follow if such serum be added to a solution of the blood of any other animal.

The introduction of substances of albuminous or proteid nature into the body of an animal, and which can be taken up by its cells as a food, produces in the body of the animal a series of substances called antibodies, of which one is designated precipitin from its power of producing a precipitate with the substance introduced. The organic substance introduced capable of producing antibodies is called the antigen. The precipitin is formed and present in the blood serum of the inoculated animal.

Metallic poisons, alkaloids and carbohydrates, do not produce antibodies; some vegetable proteids do.

The serum containing the precipitin is called the antiserum.

The precipitin in the antiserum is specific, and produces the effect only with its own antigen, not with that derived from another species of animal, but will act with one derived from a closely allied species, e.g. man and the higher apes, sheep, and goat.

In order to eliminate this the antigen should be diluted to 1:1000.

The blood used as antigen may be dried and sterilised, thus it may be kept for a long time, and when required for use dissolved in normal saline.

The most convenient human antigen for general use is ascitic or pleuritic fluid, and may be kept in good condition when mixed with a small quantity of chloroform.

To produce the antiserum 3 to 10 c.c. of the antigen serum is injected into a vein or the peritoneal cavity of a rabbit, and repeated at an interval of four or five days until 25 c.c. have been injected. The serum of the rabbit is then tested with the antigen diluted 1:100. The injections are then continued until 70 to 80 c.c. have been administered. The animal is then killed, the blood collected, and stood in a refrigerator for the serum to separate. This is then drawn into sterile pipettes, sealed, and kept in the cold. For purposes of preservation one-tenth its volume of 5 per cent. phenol may be added before pipetting. The antiserum may be dried on slips of black paper for future use.

For medico-legal purposes, the antiserum should always be tested with its antigen to be sure of its efficacy.

The antigen to be tested should be diluted 1:1000 at least, as potent antisera may give reactions with strong solutions of antigens derived from other species of animals. Various antisera may be made by inoculating rabbits with the serum of different animals.

Metchnikoff has shown that intraperitoneal injection is not absolutely necessary in order to produce an antiserum, feeding a rabbit on the blood will act in the same way.

The procedure for testing a stain is as follows. First of all the stain must be proved to be blood by the usual methods; this because the antiserum will give reactions with other albuminous substances, e.g. mucus, pus, semen, milk, or albuminous urine derived from the animal providing the antigen.

Having proved the stain to be blood, a solution of it should be made in normal saline, sufficiently strong to give the HNO₃ reaction for albumin, or to foam when shaken up. If the amount of solution be small, the tests can be carried out in capillary tubes or pipettes. The solution of the stain must be cleared by filtration or the centrifuge.

The tests must be controlled by comparison with known human blood, and blood from several domestic animals. For this purpose the various antisera should be kept in stock.

Two sets, A and B, of six small tubes are used, into each of A is placed 0.05 c.c. of human antiserum from a sensitised rabbit. Into each tube of Set A is then added double the amount of diluted antigen, as follows:

Set B is now charged as follows:

To each tube in Set B is now added about 0.1 c.c. of the extract of the suspected stain.

It will thus be seen that in Set A known antigen is added to known precipitin, with the exception of tube 6, which receives suspected antigen, while in Set B the suspected antigen is added to known antisera, with the exception of No. 1, which contains normal rabbit serum.

The tubes are observed in an hour and the results noted. Should the stain be human blood, positive reactions will be present in tubes 1 and 6 of stand A, and tube 2 of B.

The negative reactions in the other tubes in stand A prove that the antiserum used is specific, and will only react with its own antigen; in stand B that the stain is composed of specific human antigen, reacting only with its own antiserum.

Should the stain suspected be other than human, and derived from one of the other animals used for antiserum in stand B, then the positive reaction will occur in the particular tube.[12] The test is now recognised as very sensitive and reliable, and is also applicable to the detection of the flesh or fluids of animals, and has thus been used for the detection of meat stuffs.

Tarchetti advises the following procedure in the examination of blood-stains: Dissolve the stain in a few drops of a 0.9 per cent. aqueous solution of sodium chloride, filter, and divide the filtrate into two portions; to one (a) add 0.5 c.c. of the prepared rabbit serum (the so-called antiserum); to the other (b) serum from a rabbit which has not been injected with human blood. Both are to be placed in an incubator at 37° C. for an hour. By this time, if the solution of the stain be of human or anthropoid origin, the contents of the tube (a) will have become turbid, the contents of tube (b) will remain clear. From a series of experiments with blood-stains of man and other animals on a variety of materials, Tarchetti states that this method is reliable. Prepared rabbit “human antiserum” has been shown to have no such reaction with the blood of the pig, ox, calf, mouse, or rat.

From the result of his investigations Grünbaum points out that these reactions must be looked upon rather as “special” than “specific,” in view of the fact that his “chimpanzee antiserum” gave a slight but distinct turbidity after a few hours with horse blood. He also suggests a method for the microscopical application of the “biological test,” by using a 1 per cent. blood solution with a drop of “antiserum.” This method has enabled him to distinguish between human and anthropoid blood, the reaction occurring earlier and being more complete when the “antiserum” is used on its own blood.

Certain vegetable colouring matters give spectra which may be mistaken for blood, from their close similarity. Of these cochineal dissolved in a solution of alum gives two bands similar to O₂Hb. On the addition of boric acid the bands move to the violet end of the spectrum, but they are unaffected if the colouring matter be blood. Lac-dye, alkanet root, madder, and others also give spectra resembling O₂Hb, but they are changed or disappear on adding ammonia or sulphite of potassium, while the spectrum of blood remains unaltered.

As stated previously, spectra of colouring matters other than blood are not capable of being altered by reducing agents, so that, however similar they may be to O₂Hb, they cannot be accepted as derived from blood unless the spectra of reduced Hb and reduced hæmatin can be obtained in the way described.

Cochineal, colours of certain roots and wood, turn crimson on the addition of ammonia, logwood bluish-black.

The colour of the rose and certain flowers turn green on adding ammonia.

Fruit-stains from mulberry, currants, gooseberries, &c., turn bluish-green with ammonia.

Vegetable stains have their colour heightened by the action of dilute acids.

Chlorine bleaches fruit-stains, but turns the colour of blood-stains to an olive-green.

Red dyes fixed by a mordant are not influenced by ammonia.

Iron stains are usually blackened by ammonium sulphide.

Red paint may contain red oxide of iron; digest with hydrochloric acid and test for iron, by adding ferrocyanide of potassium to obtain the Prussian blue. Iron stains may be of a reddish-brown or orange colour, and insoluble in water, so that HCl is used to dissolve them.

Citrate and malate of iron stains are soluble in water; the addition of ammonia to an aqueous solution produces no change; guaiacum will give a blue reaction if a persalt of iron be present. The addition of hydrochloric acid and ferrocyanide of potassium will give the Prussian blue reaction. A drop of nitric acid added to the solution will oxidise the iron to the ferric state, and on the addition of a few drops of fresh-made aqueous solution of sulphocyanide of potassium the port-wine colour of sulphocyanide of iron will be produced.

A control test must be made with distilled water to prove the purity of the reagents, and the two results compared with each other.

Aniline stains resembling blood are changed to greenish-yellow or yellow on the addition of dilute nitric acid. Eosin stains produce a fluorescent solution when dissolved in water. Grease, tar, pitch, snuff, and paint may be mistaken for blood, especially on dark fabrics. They may be detected by two methods:

(a) The Wet Method.—Having failed to obtain a solution by the aid of the ordinary solvents for blood, other solvents must be used; ether or benzene for grease, paint, or tar. The solution obtained must be examined with the spectroscope.

(b) The Dry Method.—Place the cloth or other fabric stain down upon a clean white filter paper; then on pressing the cloth with a hot laundry iron, grease, tar, or pitch will stain the paper, paint or snuff will not.

CHAPTER VII BURNS AND SCALDS, CONTUSIONS AND BRUISES — BURNS AND SCALDS — Post-mortem Appearances — Preternatural Combustibility — Burns due to X-Rays — CONTUSIONS AND BRUISES

Burns and Scalds are lesions characterised by a more or less marked destruction of the tissues of the body, caused by the action upon its internal or external surfaces of a temperature higher than that of the body itself, or by the action of corrosive chemical substances.

Scalds are produced by the application of heated liquids, at or near their boiling-points, or in a gaseous form—as steam.

The injuries produced will depend upon the degree of temperature, the period of exposure to its action, and the extent of surface involved.

The danger to life depends more on the extent of surface injured than the intensity of the burn or scald upon a limited area, unless the position of the burn render it peculiarly dangerous. Even though the injuries be comparatively superficial, if they involve one-third or one half of the surface of the body they must be regarded as fatal. They may prove fatal by shock, by asphyxia, by constant and profuse discharge from the injured surface, from absorption of septic matter, from secondary inflammations of internal organs and serous membranes—pleurisy, peritonitis, meningitis, perforating ulcer of the duodenum. Children succumb more quickly than adults to burns and scalds—the simplest, in their case, often proving fatal.

The cause of early death from burns and scalds is looked upon as a disorder of the blood following injury to the red corpuscles by the heat, and that this is more easily brought about in children, because of the thinness of the skin, and the red corpuscles being less capable of resistance.

The following table gives the different degrees of burns:

These will vary according to the extent of the injuries, the length of time the individual lived after receiving them, and the causative agent.

External Appearances.—1. Burns.—Radiant heat whitens the skin, flames blacken it, from deposit of carbonaceous material. The hair and clothing of the body are singed. Blisters may be present on various parts, and roasted patches of the skin or deeper parts may be present. The flame of an explosive, such as a mixture of coal gas and air, scorches and mummifies the skin. The skin is blackened by the explosion of gunpowder, and particles of the powder may be driven into it; similar results follow explosions in coal mines, but to a greater degree. Burns caused by red-hot solids or molten metals vary in appearance according to the length of time they have remained in contact with the surface: if short, there may be injury to the skin only, with blistering; if for a longer period, there will be roasting or charring of the part, and blisters may not be present.

All stages of burns may be present.

The uncovered parts of the body, as a rule, are more affected than the clothed, unless the clothes become ignited, when the converse would hold good. In cases where the clothes have been saturated with an inflammable oil like petroleum the burns are much more severe.

2. Scalds.—The appearances produced and the severity of the result will vary directly with the boiling-point of the liquid. Boiling water and steam produce vesication; the hairs are not affected. If the steam be superheated, blistering may be absent, and the skin appear sodden and devoid of elasticity. If the person survive the injuries for some days, the skin will present appearances of reaction. After exposure to great heat the bodies of the victims are usually contorted, with the limbs flexed and the arms fixed in a defensive attitude—the “pugilistic attitude.” This condition is due to heat rigidity.

Internal Appearances.—The brain is shrunk, usually without any alteration in form, the lungs also shrunk, and the larynx, trachea, and bronchi may contain carbonaceous material; their membranes may be injected and covered with frothy mucus. The kidneys may present reddish-brown markings from altered blood, and degeneration of the epithelium of the tubules and Malpighian bodies.

There may be a reddened appearance of the mucous membrane of the stomach and intestines, and in a certain number of cases, where death has occurred some time after the injuries, ulcers may be present in the duodenum.

The uterus and testicles resist the action of fire in a marked degree, and may be changed but slightly, although the rest of the body has been almost consumed.

The blood of persons who have been exposed to the action of CO during a fire will present the usual cherry-red colour and the spectrum of COHb. A similar cherry-red colour of the blood is found in bodies of persons burnt to death which is not due to the action of CO. The cause is a physical one, the alteration in colour being due to the coagulation of the albumin in microscopical particles by the heat. In this condition the spectrum is that of O₂Hb, and can be reduced in the usual way. The same peculiar condition of the blood may be produced in corpses by exposure to a sufficiently high temperature.

If on the examination of the blood COHb is detected, it indicates that the person in whose body it is found was alive during the progress of the fire.

Corrosives.—The appearances produced by the application of corrosive chemical substances are peculiar to them, and depend upon their special actions upon the tissues. Sulphuric acid acts by rapidly extracting water from the tissues and producing local rise of temperature; nitric acid combines with the tissues to form picric acid; nitrate of silver acts upon the tissue by hyperoxidation, and combines to form albuminate of silver, nitric acid being liberated. A solution of phosphorus in carbon disulphide, known as Greek fire, by the rapid oxidation and burning of the phosphorus produces combustion of the tissues.

The diagnosis of lesions produced by corrosives from those by fire or heated fluid or steam rests upon the absence of vesication, the presence of the stains on the skin or clothing which they produce, and the chemical analysis of the stains. Sulphuric acid produces a grey or brownish-black eschar on the body; hydrochloric acid may leave a whitish-grey stain; nitric acid produces a yellow stain on the skin, and may produce sloughing.

Was the burn inflicted before or after death?—The answer to this question depends upon careful consideration of all the evidences afforded by the external and internal appearances, and upon the presence or absence of vital reaction in the lesions found.

Two characteristic appearances—redness and vesication—are present in burns inflicted during life when the surface of the body is not charred and the tissues destroyed. The redness affects the surface and entire substance of the true skin, which is dotted by the deep red openings of the sudoriferous and sebaceous ducts. This appearance cannot be produced after death. Blisters are formed by a temperature somewhat less than that of boiling water. Vesication, according to Orfila, is characteristic of a burn inflicted during life, and the late Sir Robert Christison found that in burns caused before and after death the vesicles in the former contained serum, the latter air. In anasarcous subjects, however, serous blisters may be formed, especially if the heat employed be not too severe. A case is recorded by Taylor in which vesicles containing bloody serum were formed on the body of a man who had just been drowned and who had been put into a hot bath.

Ante-mortem vesicles in which vital reaction has taken place present the following characteristics:

In burns produced after death, the surface and substance of the skin is of a dull white colour, dotted with grey openings of the sudoriferous and sebaceous ducts, and the subcutaneous tissues are uninjected. Vesicles produced by burns may have to be distinguished from the phlyctænæ, the result of advanced putrefaction. The latter possesses none of the characteristics of the former.

If a vesicle present the following characteristics it may be accepted as a post-mortem origin without doubt: if it be small and its contents scanty, if the fluid it contain be free from albumin and chlorides, if it contain air, and if there be no signs of inflammatory reaction.

Was the burning homicidal, suicidal, or accidental?—No general rules for guidance can be here laid down. In most cases the conditions under which the body is found will point less to suicide than to homicide or accident. In cases of murder, the body is often burnt in the attempt to destroy all traces of the crime. It must, however, be borne in mind that intense heat applied to the body may give rise to a wound on the surface like that caused by a cutting instrument. Casper mentions such a case, in which a wound was found over the liver, due to the application of intense heat to the body. The conjunction of robbery will greatly assist in helping to solve the difficulty. It may be very confidently stated that to dispose of a body by burning is no easy matter.

The possibility of “spontaneous combustion” occurring in bodies during life has been mentioned in the earlier writings on medical jurisprudence, and cases have been recorded in which it has been alleged to have taken place. Up to the present time no undoubted case of “spontaneous combustion” during life has been seen. On the other hand, the possibility of its occurrence is contra-indicated by the following facts: that the human body must consist of 75 per cent. of its weight of water, to be compatible with life, and that a dead body steeped in methylated spirit for many months or even years will never be consumed, if set on fire, in the rapid and complete manner alleged as occurring in cases of so-called “spontaneous combustion.”

A case is recorded by Beatson (B. M. J., vol. i., 1886, p. 295) of a man, subject to foul eructations from the stomach, who got out of bed during the night and struck a match to see the time; while blowing out the light his breath took fire, producing an explosive noise sufficiently loud to awaken his wife. Such cases are very rare.

It is a fact that by the action of certain micro-organisms upon organic matter inflammable gases are produced. That such an occurrence is possible, in the dead human body, is supported by cases recorded by Gull (Med. Times and Gazette, 1885) and Reynolds (Med. Chron., 1891). In Gull‘s case inflammable gases escaped through punctures made into the abdomen, and they burned spontaneously on contact with the air. In Reynold‘s case no flames were seen, but extensive and deep marks of burning were present, especially on the trunk and thighs. It has been suggested that the habitual use of alcohol in excess during life renders the tissues of the body more inflammable, but the matter is not yet decided. Tissues steeped in alcohol are not rendered more inflammable.

Dr. Ogston, who cautiously avoids committing himself to the belief in “spontaneous combustion,” yet thinks that the subject of preternatural combustibility in certain conditions of the body may perhaps, to say the least of it, be set down as one still sub judice. “There is no evidence to justify the use of the word ‘spontaneous,’ but there can be no doubt that an extraordinarily high degree of combustibility occurs in rare instances, to which the term preternatural combustibility would more correctly apply” (J. Dixon Mann).

Over-exposure to the action of X-rays produces burns of a peculiar character, and in cases of unprotected skin exposed to the action of the rays in those who are constantly working with them, forms of dermatitis have arisen which are intractable and tend to become epitheliomatous in character.

The results of slight over-exposure, or repeated short exposures vary from a simple redness of the skin to severe dermatitis, the hair of the part being shed. When the over-exposure or dosage has been severe, the skin may vesicate and ulcerate. I have seen this in cases where the rays have been used for reduction of the spleen in leukæmia and Banti‘s disease. The burns heal with cicatrisation of radiate shape, the skin around the scar being permeated with numerous capillary vessels which produce the appearance of capillary nævi, and in other instances large stellate superficial vessels are formed. In addition, marked pigmentation of the skin may follow the burn. X-ray burns which have produced vesication and ulceration or sloughing take a long time to heal in comparison with ordinary burns.

In repeated exposure to the rays, even when little redness has been noticed at the time, the formation of capillary vessels may become evident some time after the exposures have been stopped. This may cause disfigurement, by the formation of telangiectasis, especially if they appear on the face or neck. The falling out of the hair is produced by X-rays as a therapeutic measure in cases of ringworm, and due precaution must be taken to limit the effect and area of exposure by proper screening. The same precaution should be used to protect parts of the body other than the part which requires treatment or examination in other conditions.

With increasing knowledge of the effects of X-ray exposures, special precautions have been devised to prevent untoward effects, so that burns from over-exposure, and dermatitis amongst X-ray workers are prevented.

In the living these injuries are accompanied with swelling, pain, and more or less discoloration of the part affected. Among malingerers it is not an uncommon practice to bruise the body to imitate the spots of purpura and scurvy. In scurvy, the condition of the gums common to that disease, and the state of the general health, will point to the true nature of the spots. The diagnosis of purpura will be assisted by noting the diffusion of the spots over the body. In old people purpuric spots frequently extend round the limbs, chiefly on one of the lower extremities. Many blood diseases are associated with ecchymoses and purpuric eruptions. Some persons are very easily bruised, and a pinch, by no means severe, will cause on their arms a severe bruise. Discoloration—ecchymosis—may take place in the skin, cellular tissue, muscles, or internal organs as a result of external injury, or it may be due to sudden and powerful contraction of a muscle or group of muscles. Not infrequently the discoloration does not appear over the seat of injury, but at some distance from it; and when the effusion is deep-seated, days may elapse before any discoloration of the skin takes place, and then it is not blue, as in superficial parts, but of a violet, greenish, or yellowish hue. A deep-seated ecchymosis may give no external sign of its presence; hence in all cases deep incisions should be made before an opinion is ventured as to the entire absence of this occurrence. This is very noticeable among the deep-seated muscles of a limb. In these cases, forty or fifty days may elapse before the deep-seated bruise shows its existence on the surface, and then only as irregular, yellowish, green, or bluish spots over the part. A very slight contusion, as a sprain of the ankle, may give rise to extended discoloration of the leg. An ecchymosis is not necessarily situated directly under the seat of injury. A blow given during life may not appear as an ecchymosis till after death. The change of colour in bruises begins at the circumference, and travels inwards. During the first three days the colour of the bruise is blue, bluish-black, or black; greenish on the fifth or sixth day; and yellow from the seventh to the twelfth. The extent of an ecchymosis depends greatly on the looseness of the cellular tissue. A slight contusion causes a slight redness and swelling, and may leave no mark on the dead body, unless death has taken place within thirty-six hours. Injuries of this kind sometimes leave a parchment-like hardness and discoloration of the skin. The part looks slightly depressed, due probably to the epidermis having been partly rubbed off, and the skin then drying. Similar marks are sometimes made by blisters. These marks may be produced on the dead body by friction and exposure to the air.

The diagnosis of ecchymosis from hypostasis has been given (see p. 46). A tolerably severe blow after death would be necessary to produce appearances similar to those produced by a slight one during life. In scourging, there are parallel ecchymosed lines, of small spots resembling petechiæ. An internal organ may be ruptured, and yet there may be no appearance of injury externally. The liver is the organ most commonly ruptured. The rupture is almost always longitudinal, and in some cases a portion of the gland is more or less detached. The spleen is also not infrequently ruptured; and this occurs most frequently in countries where ague prevails. Rupture of the lungs and brain is rare. When the pelvis is fractured, the bladder is frequently found ruptured.

Death in most cases is due to internal hæmorrhage or shock, when any of the internal organs are ruptured.

Can the appearance of a bruise be produced after death?—It is possible that the appearance of a bruise inflicted during life may be produced within two hours after death, and in some rare cases even after the lapse of three hours and a quarter (Christison); but these ecchymoses are limited in extent, and when large are due to a rupture in a vein which can be readily ascertained. The experiments of the late Sir Robert Christison, relating to this question, are detailed in the Edinburgh Medical and Surgical Journal, vol. xxxi. The amount of violence required after death to produce appearances like those made before death is such as would seldom, if ever, be inflicted on a corpse, and, therefore, where we find a well-marked bruise we ought to infer that it was made before death.

The following table, compiled from the experiments of Christison, may assist the diagnosis:

N.B.—Extensive effusion may occur without affecting the skin, but when the skin is so affected Christison thought it decisive of ante-mortem injury.

The Size and Form of a Bruise should be noted.

Why?

1. In Hanging and Strangulation.—The mark due to pressure of the cord on the neck in hanging runs obliquely round the neck; in strangulation, the mark encircles the neck. The mark is frequently interrupted, and may present very varied appearances in different parts of the neck. The mark of the knot may be found under the chin.

2. In Throttling.—The pressure exerted on the throat of the deceased by the fingers of his assailant may leave marks which may point to the means used to cause death.

3. In other Cases of Death by Violence.—The impression made by the weapon used may lead to the identification of the murderer. The marks left by the wards of a large door-key once led to the identification of the assailant.

CHAPTER VIII SUFFOCATION, HANGING, STRANGLING, AND THROTTLING — SUFFOCATION — HANGING — STRANGLING — THROTTLING

Death from suffocation is said to result from any impediment to the respiration which does not act by compressing the larynx or trachea.

Suffocation may therefore be caused by pressure on the chest, as in persons crushed in a crowd. It may also be due to the respiration of certain gases, or to the presence of pulverulent substances in the air, which act by choking up the air-passages. Imprisonment in any confined space may cause death from suffocation, and abscesses bursting into the trachea, or vomiting matters in drunken persons lodging in the windpipe, may be attended with a like result. Pressure on the umbilical cord whilst the child is in the maternal passages causes death from suffocation.

Signs of Death by Suffocation.—The first effect of arrest to the passage of air into the lungs is the stagnation of blood in the capillaries of the lungs. Non-arterial blood then goes to the brain and consciousness is soon lost. The respiratory sensation is then arrested by the circulation of venous blood. The left side of the heart becomes emptied, and then weak; the right side full and engorged. The great venous trunks are also more or less full, and the abdominal viscera, liver, spleen, and kidneys congested. The arrest of the heart‘s action is a secondary effect; the right side is paralysed by being too full, the left by being empty. These signs may be said to be typical, or, rather, are to be expected in death due to suffocation, but it must be distinctly stated that they are not always present. The right side of the heart is not in all cases engorged with blood; and Christison warns medical men against expecting “strongly marked appearances in every case of death from suffocation.” The heart, moreover, continues to contract after the lungs have ceased to perform their duty. Death is thus due to apnœa—that is, death beginning at the lungs—and not to syncope. Death in some cases is from neuro-paralysis or nervous apoplexy. In death by shock, which in most cases is instantaneous, both sides of the heart are equally filled. Death, the result of disease, may present all the signs of death from suffocation, and no suspicion may be aroused as to the cause of death from the post-mortem appearances, especially if putrefaction have set in.

The following table is given as an aid to diagnosis in this form of death:

Points to be noticed in forming a
Diagnosis of Death by Suffocation

1. The Blood.—There is unusual fluidity of the blood found in death by suffocation, however produced. This condition is sometimes present in deaths due to certain diseases, fevers, &c., and in cases of narcotic poisoning. Even with the blood in this condition, the presence of coagula in the cavities of the heart is not infrequent. The colour of the blood is changed to a dark purple, but in suffocation by carbon monoxide it is red.

2. Animal Heat.—In persons who have died from suffocation the animal heat is long retained.

3. Cadaveric Rigidity.—Other things being equal, the rigor mortis is as well marked in this kind as in other forms of death.

4. The Lungs.—Hyperæmia of the lungs is rarely absent. In most cases both lungs are engorged in about equal proportions. Hypostasis—post-mortem stains—must not be mistaken for capillary engorgement.

5. The Heart.—Engorgement of the right side of the heart, the left being empty, or nearly so. It is advisable always to examine the heart first, and then the lungs. The pulmonary artery is also much congested.

6. Capillary Ecchymoses.—These appear as purplish-red spots on the pulmonary pleuræ, on the surface of the heart, aorta, in the thymus, and on the diaphragm. They may appear on the above-mentioned parts in a fœtus suffocated in utero by pressure on the cord. These ecchymoses are rarely seen on adults, most frequently on infants, due probably to the thinness of the coats of the capillaries, which are ruptured in the efforts made to breathe. They are not a positive sign of death from suffocation, as they have been seen in death due to cholera, typhus, and other diseases. They are present also where death is due to hanging, drowning, &c.

7. Condition and Appearance of the Trachea.—The mucous membrane of the trachea is injected, and appears of a cinnabar-red colour. This is present in every case of death by suffocation, and must not be confounded with the dirty cherry-red or brownish-red coloration due to putrefaction. Remember also that the trachea putrefies early. If suffocation be slowly produced, a quantity of frothy mucus may be found in the windpipe, and also in the smaller tubes of the lungs. Always examine, especially in cases of supposed infanticide, the trachea for foreign bodies, the presence of soot, &c. The presence of sand, ashes, &c., in the œsophagus and stomach in persons buried in these materials, is presumptive of the person having been placed in them prior to death.

8. Kidneys, Vena Cava, &c.—The quantity of blood in the kidneys is always considerable. The abdominal veins are all more or less congested, and the external surface of the intestines presents numerous traces of venous congestion.

9. The Brain.—Apoplexy of the brain, as secondary to the pulmonary apoplexy, may be more or less present, attended by its well-known appearances.

10. Face, Tongue, and Mouth.—The expression of the face is not characteristic of death by suffocation, and differs in no particular from that common to other forms of death, being more frequently pale than turgid; and the starting of the eyes, popularly ascribed to this form of death, is not often seen. The tongue may or may not be protruded beyond the teeth. The presence of froth about the mouth is not constant, and is of common occurrence in those dying from natural causes. The tympanum may be ruptured.

Was the suffocation homicidal, suicidal, or accidental?—Suffocation may occur accidentally during the act of swallowing, and by foreign bodies placed carelessly in the mouth and then drawn suddenly into the windpipe, or by blocking the pharynx or œsophagus, also from being smothered by sinking into sand, grain, mud, and such-like, or by the bed-clothes in cases of epilepsy during a fit. Examine the lips for the presence of ecchymosis and other marks of violence. A man, some years ago, was accused of having caused the death of his wife by strangulation, for which he was indicted, and tried before the High Court of Justiciary in Scotland. The post-mortem examination revealed the cause of death as due to suffocation, and the following injuries were found on dividing the windpipe, which contained a quantity of frothy mucus: in the interior of the larynx there was a considerable extravasation of blood lying beneath the investing membrane, and passing up on both sides and behind, as far as the chink of the glottis, and above that opening into the ventricles of the larynx. There was here, also, a fracture of the right wing of the thyroid cartilage, by which its lowest horn was wholly detached, and the cricoid cartilage was broken in two places at opposite sides of its ring. The defence was that she had fallen accidentally while in a state of drunkenness, and had thus produced the fatal injuries.

The man was acquitted, the legal opinion in favour outweighing the medical opinion against the theory of accident. The above case created some discussion at the time, and induced Dr. Keiller to make several experiments as to the possibility of fracturing the cartilages of the larynx. The following are his conclusions:

Homicidal suffocation may be due to forcibly introducing foreign bodies into the air-passages, especially in children; adults suffocated thus are generally under the influence of alcohol or drugs, or enfeebled from disease. Suicidal suffocation by these means is generally limited to lunatics.

Fig. 16.—The pulse in this case became slower than normal. Five minutes after the drop the type reached that of bradycardia, then recovered itself, and even 14½ minutes after the drop was beating with normal frequency, but in the meantime had become very feeble.

Fig. 17.—The pulse in this case became accelerated and then fell again, but was feeble throughout.

Fig. 18.—In this case the pulse rate increased, and then fell to 72 per minute towards the end.

Homicidal suffocation by compression of the chest has been effected in infants; in adults it is combined with the covering of the nose and mouth. The victims are generally old or enfeebled. Suffocation of infants may be homicidal, or accidental, due to “overlaying”; in the latter the greatest mortality is amongst the youngest infants. A child ten months old may struggle and free itself or awaken the mother.

In France a favourite mode of committing suicide by suffocation is the use of irrespirable gases—carbonic acid, carbon monoxide, and the like. Collateral circumstances must be taken into consideration, and will more or less help to point to the true cause of death.

The cause and nature of the death in all of its forms just mentioned are in general the same. Pressure on the trachea—thus arresting respiration—and also on the important vessels and nerves of the neck, results in death, which may be brought about in four different ways:

• 1. Cerebral congestion, or apoplexy.
• 2. Congestion of the lungs and heart—apnœa or asphyxia.
• 3. Combination of above—apoplexy and asphyxia or apnœa.
• 4. Neuro-paralysis—nervous apoplexy, or syncope.

The following table will show the relative frequency of each form of death:

Traumatic asphyxia occurs when a heavy weight such as a fall of earth or masonry compresses the chest, and thoracic respiration is impossible. The head and neck appear ecchymosed, the purplish-blue lividity generally ending abruptly at the lower part of the neck or upper part of the thorax, about the level of the clavicles. The conjunctivæ are ecchymosed, and there may be epistaxis. This discoloration does not disappear on pressure by the finger, indicating its petechial character. If the person survive long enough, the discoloration gradually disappears, passing through the colour changes of an ordinary ecchymosis.

The effects on the eyes may be such as to be followed by changes in the retina, and optic atrophy leading to loss of vision.

Parts of the neck pressed upon by clothing may escape ecchymosis, and present a white mark of almost normal skin.

Death by hanging is caused by the more or less perfect suspension of the body by a cord applied around the neck, the weight of the body acting as the constricting force.

The body need not hang completely, partial suspension is sufficient to cause death. The ligature surrounds the neck above the thyroid cartilage, the epiglottis is pushed against the back of the pharynx, the base of the tongue and the soft parts are pressed into the cavity of the pharynx, so that the obliteration of the naso-pharyngeal and the laryngeal passages is complete. Death is due to asphyxia and pressure on the cervical blood-vessels, even if the air-passages be not completely occluded; stoppage of the cerebral circulation being sufficient to cause death; in such a case the signs of asphyxia are absent.

Consciousness is quickly lost, due to pressure on the vessels, and, for this reason, in accidental or suicidal hanging the person is prevented from making any effort to save himself.

Post-mortem Appearances.—The external appearances are more or less those described under “Death from suffocation.” In the greater number of cases the face bears a quiet, placid expression, no turgidity or lividity being noticeable. The eyes are usually half open, but not protruded, and the condition of the pupils variable. The tongue may be protruded, but just as often not. The face may be pale or livid, and a bluish colour present on the free border of the lips. Cyanosis and swelling of the face are only present when the death agony has been long; they soon disappear.

Ecchymosis of the conjunctiva, and on the outer surfaces of the lids may be present. The escape of urine, fæces, and semen may take place, but are not characteristic, and are extremely rare.

Casper states that in not one of the many cases he had examined of persons hanged has he ever “found an erection of the male organ,” and he also asserts that the emission of semen is extremely rare. Seminal emissions take place more frequently in persons who have been shot, and also in those who have been poisoned by irrespirable gases or by hydrocyanic acid. As a test of strangulation, it is therefore worthless. Tardieu, however, only noticed the escape of urine and fæces in two out of forty-one cases; it is by no means a test of hanging, as it may occur after death if the body is shaken in a cart, or roughly used when first found. A fat person dying of apoplexy may have a mark round the neck as if strangled. Injury to the spinal cord due to fracture or dislocation of the cervical vertebræ is rare in suicidal hanging. Fracture of the spinal ligaments and of the hyoid bone is also rare. Rupture of the internal and middle coats of the carotid arteries sometimes occurs. But it appears that considerable damage is done to the soft parts of the neck by the present judicial mode of hanging with the “long drop.”

Dr. Dyer has recorded (New York Medical Journal, vol. iii., 1866) some experiments he made on the eyes of a man and some dogs killed by hanging. He found certain transverse fissures across the lens, which he is inclined to think are characteristic of this mode of death. Dr. R. F. Hutchinson states that an invariable sign of death from hanging is the flow of saliva out of the mouth, down the chin, and straight down the chest. The appearance is unmistakable and invariable, and could not occur in a body hung up after death, the secretion of saliva being a living act (Chevers). Death from hanging may take place although the toes or other parts of the body rest on the ground. Death is complete in four or five minutes.

Marks of the Cord, &c.—The mark of the cord is nearly always present. It varies with the breadth and hardness of the ligature, but is often interrupted. Its irregularities are reproduced on the skin. It is sometimes only seen on one side. In strangling, the mark is low down, most frequently encircling the neck; in hanging, the mark is generally above or on the thyroid cartilage, and carried obliquely upwards. The mark of the cord may be of a dirty yellowish-brown colour, and, when cut into, feels more or less hard and leathery. In general appearance it is not unlike the mark left by mustard-plasters or blisters applied within a short time of death. This effect is probably produced by the rubbing off of the epidermis, and subsequent drying up of the cutis on exposure to the air. At other times the mark may be of a dirty reddish or bright blue colour; or, lastly, there may be little or no mark present, or the edges may assume a livid red coloration, being nothing more or less than a post-mortem stain.

May the mark of the cord be produced after death?—On this point Casper says: “That any ligature with which any body may be suspended or strangled, not only within a few hours, but even days after death, especially if the body be forcibly pulled downwards, may produce a mark precisely similar to that which is observed in most of those hanged while alive.” And the same authority also adds that “the mark of the cord is a purely cadaveric phenomenon.”

Accidental hanging is rare, and generally happens with children while playing at hanging, or by accidentally becoming entangled in a window-blind cord or swing rope, or by the neck-band of an article of clothing by which they may become accidentally suspended from the spike of a railing.

Homicidal hanging is rare, but the body may be suspended after death from violence, to simulate suicide; and it may have to be decided whether the hanging took place during life or after death.

The mark of the cord is of no assistance, rents in the carotids with extravasation into the coats of the vessels indicate ante-mortem suspension. The flow of saliva down the chin to the body indicates suspension before death. It is important to examine the body for injuries which could not be self-inflicted, and to remember the possibility of poison having been administered with suspension after death.

Suicidal hanging is the most common, as it is a favourite mode of death with suicides. The absence of marks of injury on the body found suspended, and the want of evidence as to a previous struggle having taken place, all point to suicide. The fact that the feet are found in contact with the ground does not militate against the probability of suicidal hanging; and it appears that in India the natives seldom hang themselves from any height, and are most frequently found with their feet on the ground. A person may take poison first, and hang himself before the poison has had time to prove fatal.

Death is due to pressure made on the neck by any form of ligature carried circularly round the neck, without suspension. The cord in hanging is, as a rule, placed more obliquely than in strangling.

The mode of death is the same as in hanging. The post-mortem appearances are similar to those of hanging, practically those of asphyxia. The mark on the neck is the principal feature. In position it is generally horizontal and situated below or on a level with the thyroid cartilage. It more completely encircles the neck. It may be interrupted in places if an irregular ligature has been used, causing irregular pressure. Its character depends largely upon the nature of the ligature. If the constriction has been uniform a continuous depression is produced which may be marked by ecchymosis. If the skin has been abraded, the line dries, and has a brownish, parchment-like appearance and feeling. If the ligature has been removed before life is quite extinct, the depressed line may disappear or be but slightly evident.

A soft, broad ligature may leave no mark on the neck, if not applied too tightly, or for too long a time. Should the victim have been strangled in the recumbent posture, and dragged upwards and backwards by the ligature, the mark will be on a slant as in hanging. According to the amount of violence used injuries may be caused to the deeper structures of the neck, such as effusion of blood into muscles, fractures of the thyroid or cricoid cartilage; rupture of the tympanum and epistaxis may take place.

Accidental strangulation may occur when a cord suspending a weight on the back and passing across the chest slips and encircles or compresses the neck.

Falling out of bed, with entanglement in the clothes or nightdress, may cause strangling by tightening of the neck-band round the neck.

Homicidal strangling is as common as homicidal hanging is rare. It is difficult to hang a man, but easy to strangle him, because consciousness is rapidly lost, and the victim is unable to offer any resistance once the cord is tightened round the neck. In homicidal strangling the murderer generally uses a great deal more violence than is necessary, and so there is found after death much more local injury in such cases.

Severe local injuries, such as fracture of the laryngeal cartilages or hyoid bone, denote homicide, as they are rarely noticed in suicidal strangulation.

There may also be signs of general violence about the face, neck, chest, or other parts of the body. The position of the knot affords no material help, as the murderer may tie it in any position, but more than one knot, especially if in different positions, points to homicide. It must be remembered that finger-nails or other marks in the vicinity of the ligature may be present in cases of suicides, from the slipping of the cord or the determined attempts of the suicide to carry out the act, or plucking at the cord involuntarily. When a person is first strangled, then hung, there would be two marks—one probably horizontal, the other slanting.

Suicidal strangulation is rare. The knot is generally adjusted at the front or side of the neck, the cord may encircle the neck several times. Injuries to the deep structures of the neck are absent. Signs of general violence are not necessarily present.

If there be two marks upon the neck, one due to an attempt at strangulation, the other to suspension, in a suicide, the first would be the less marked, the latter more pronounced, whereas in homicide the strangulation mark would be most distinct.

Throttling is strangling by means of the hand or hands alone, and is due to constant pressure of the fingers upon the throat. Very little pressure is required to occlude the glottis; it can be done with slight pressure of the thumb and forefinger on the side of the thyroid cartilage.

The impression of the fingers and thumb upon the throat have characteristic marks. They are usually to be seen on both sides of the throat. The thumb mark is on one side, and the marks of the fingers, separated from one another or clustered together, are on the other, the thumb mark being the highest. When grasped from the front by the right hand, the thumb mark will be on the right side of the throat. If the victim be throttled by the two hands at the same time, as when on the ground, the thumb marks are on the same side. If the assailant be left-handed, and has used this hand to grip the throat, the thumb mark will be on the left side of the victim. The finger marks are one above the other. The marks may appear as ecchymoses if the examination be made soon after death; if later, they may appear and feel like parchment, and of a brownish colour. Crescentic marks of finger-nails may be present, also other scratches in the vicinity. Other marks of general violence may be present, and should the victim have fallen to the ground, the head may be injured. Much blood is effused in the tissues of the neck and the laryngeal cartilages, and the hyoid may be found fractured; the carotids may escape injury, but not always.

The mucous membrane of the cheeks may be found lacerated. Where the victim is thrown to the ground and knelt upon, fracture of the ribs and ecchymosis of the chest wall may occur.

In a case examined by me of combined strangling and throttling, marks of the ligature and fingers were both present, and on the clavicles separate marks produced by the knuckles while tying the cord. These knuckle marks did not show up till some time after death. Effusions of blood were present in the tissues of the neck on each side of the larynx, and amongst the muscles on both sides, and in the sheath of the left carotid artery.

The hyoid bone was fractured in two places in its left half. The thyroid cartilage was fractured vertically on each side of the middle line into three pieces, the central portion having fallen behind the other two into the cavity of the larynx. The right wing of the thyroid was comminuted. The cornua were fractured. The cricoid cartilage was also fractured posteriorly, and into three pieces in front. Effusions of blood in the fractured areas had formed beneath the mucous membrane. Effusion of blood was present on the front wall of the pharynx and the upper part of the œsophagus. The right carotid artery was atheromatous, and linear and star-shaped fissures were present, the latter surrounded by a ring of sub-intimal effusion of blood.

On the right side of the thorax the fifth rib was fractured at the junction with its cartilage, and on the left side the second, third, fourth, fifth, and sixth ribs were fractured close to their cartilages, and again from three to five inches further back. Blood effusions in the tissues of the chest wall and under the pleuræ were present in the region of the fractures.

A handkerchief was found tight on the neck and tied with two knots both fastened securely. It was probable that the handkerchief had been tied on after the throttling, as the knot ends were too short to allow a sufficient pull on them to cause the injuries. Throttling may be regarded as a homicidal act; although one or two instances of suicidal throttling have been recorded in the insane.

Judicial Hanging.—In judicial hanging the prisoner is suspended by a rope with a running noose around the neck, after a sudden drop of from six to eight feet according to the weight of the body. The noose may be arranged with the knot or slip-ring fixed at the side below the ear, or in front so as to jerk the head backwards. The sudden and severe strain upon the neck produces fracture or dislocation of the spinal column at the second or third cervical vertebra, with rupture of the spinal cord. Other local injuries occur, such as rupture of cervical muscles, fracture of the larynx, and even lacerated wounds of the neck. The head has even been severed completely from the body, and the deep structures of the neck have even been so lacerated that the body has hung by skin only, stretched to the thickness of two or three fingers. Death is said to take place from shock, pressure on the vagi, and asphyxia, probably also cerebral apoplexy. When death is instantaneous, the body hangs motionless, the head fallen over the side opposite the knot, and the neck stretched.

The heart may, however, continue to beat for a varying period after apparent death—in some cases even as long as 14½ minutes. The following interesting series of pulse tracings were taken by Dr. Llewellyn Morgan, of Liverpool, and kindly placed at my disposal. In No. 1 the heart beats could be recorded at the wrist for 14½ minutes after the drop; in No. 2 for 12½ minutes; and in No. 3 for 12 minutes. The frequency and character of the beat is variable, but in each case shows a practically normal rate towards the end. (See Figs. 16, 17, 18.)

Apart from the local injuries to the neck, the external appearances in judicial hanging are similar to those in other forms.

CHAPTER IX DROWNING — Recapitulation of the Post-mortem Appearances in the Drowned — I. External — II. Internal

Death by drowning occurs when the breathing is arrested by watery or semi-fluid substances, blood, urine, or the muddy semi-fluid matter found in cesspools and marshes. It is not necessary for the whole body to be submerged. Death may result if the face alone be immersed, as in the case of a man in a fit of drunkenness being drowned in the water contained in the imprint of a horse‘s hoof left in the mud.

In addition to the changes in the internal organs, identical with those present in persons who have died from suffocation or hanging, water is found in the lungs or stomach.

Death may be due to—

• (a) Apoplexy.
• (b) Asphyxia.
• (c) A combination of the two.
• (d) Neuro-paralysis.

Death from pure apoplexy is rare; and it may be affirmed that death from syncope never occurs in the drowned without leaving some signs of asphyxia.

It is more difficult to restore the drowned than those dying from mere stoppage of air from entering the lungs. Few if any persons recover who have been submerged four minutes, and even in cases where this time has been exceeded, followed by recovery, this result is probably due to the person fainting before entering the water.

In death from drowning, the lungs are distended and overlap the heart, and have a peculiar spongy feeling. They also contain a quantity of frothy fluid, which cannot be produced in the dead body, as it is the result of the violent efforts made by the individual to breathe in the act of dying. This frothy condition of the fluid in the lungs is an important sign of death by drowning, especially if the fluid corresponds with that in which the individual is said to have perished. It is just possible, however, that the person may have been first suffocated, and then thrown into the water, froth in the trachea being found in those suffocated; but in this case the froth is small in quantity, and not watery. The froth in the drowned is like that made with soap and water, and is not viscid, thus differing from bronchitic exudation. Water in the stomach is an important indication of death from drowning, especially if the water contained in the stomach can be shown to possess the same characters as that in which the body was found. Water in the intestines is still more important. In a great number of cases this, however, must be next to impossible; when it can be identified, the value of this sign is enhanced by the fact that water does not enter the stomach in those submerged after death, unless putrefaction be far advanced, or the body has lain in very deep water. Casper concluded that a person had been drowned, by finding a small quantity of mud in the stomach after putrefaction had set in. Water, however, may be absent from the stomach if the person fall into the water in a state of syncope, and it may be present if the person has taken a draught of water before submersion.

The effect of season on putrefaction in water is shown in the following table:

Of the external signs, the presence of sand, gravel, or mud under the nails may or may not be an important sign, for sand or mud may collect under the nails during the efforts to drag the body from the water; but weeds, &c., grasped in the hands show that there has been a struggle, and point to death from drowning. The cutis anserina—goose skin—present generally on the anterior surface of the body, and not, however, peculiar to death from drowning, is important as a sign of recent vitality. The face of those who have been drowned, and then quickly removed from the water, is pale, and in most cases not swollen; the eyes may or may not be closed; and not infrequently round the mouth there is more or less froth, especially when death is due to apnœa. In summer, however, after two or three days, and longer in winter, the face assumes a reddish or bluish-red coloration, putrefaction taking place about the head and upper extremities earlier than in other forms of death. The contraction or retraction of the penis is a well-marked sign of death by drowning, and Casper asserts that he has “not observed anything similar so constantly after any other kind of death.” Ogston states that he has met with two cases of erection of the penis in the drowned.

The question as to how long a body may remain in the water before it floats has given rise to considerable discussion, without, however, arriving at any very definite conclusion. It may be stated in general terms that, as floating depends to some extent on the rapidity in which putrefaction supervenes on submersion, bodies float earlier in summer than in winter, in salt than fresh water, clothed than naked. In India bodies have floated in twenty-four hours after immersion. Females and children float more readily than males. A body from various causes may float within a few hours of its submersion, especially if the body be that of a female, fat and clothed. The old idea that the body of a person thrown into water during life sinks, but that a dead body under like conditions floats, is a fiction now exploded.

Suicide or Homicide?—Homicide by drowning is rare, except in children. Accidental and suicidal drowning are common enough.

The signs to be sought for in the drowned are—(1) Absence of any injury. (2) Cutis anserina and retracted penis. (3) Water and mud in the stomach. (4) Froth in the air-passages. (5) Distended lungs. (6) General signs of death by asphyxia.

It should be remembered that the fact of the hands being tied together, or to the feet, does not militate against suicide by drowning.

If wounds and other injuries be found on the body, the question arises as to whether the injuries were sufficient in themselves to cause death, and then as to whether they were caused during life. A person jumping from a height into the water may sustain severe injuries—dislocation of both arms, fracture of the skull and of the vertebræ, or even lacerated wounds of more or less severity. The absence of the signs proper to death by drowning, coupled with the presence of external injuries, would point to death by violence prior to immersion. The presence of signs of drowning, and injuries, sufficient to have caused death in themselves, would indicate that they had occurred after death.

The following considerations may assist in forming an opinion:

• 1. Previous history of person found in the water.
• (a) Any history of suicidal tendency.
• (b) Any motive that would render suicide probable.
• 2. Height from which the person fell.
• 3. Absence or presence of signs of death by drowning.
• 4. Absence of stakes or other objects in the water that might
• have caused injuries to anyone falling against them.

The time required to cause death by drowning is so short that persons seldom recover after submersion for three or four minutes; but the cessation of respiration is no guide to the extinction of life, and an attempt at resuscitation should always be made, for if the respiration be fairly restored the heart will soon act. Nay more, as pointed out before, in cases of so-called asphyxia, the heart may continue to act for several minutes after the entrance of air to the lungs has been arrested, and in judicial hanging it frequently happens that the pulse at the wrist can be felt for ten or twelve minutes after suspension. (See Figs. 16, 17, 18.)

1. In the Skin.—Rose-coloured patches may be present on the face and neck. The condition of goose skin—cutis anserina—is hardly ever absent even in summer. The cutis anserina is not, however, characteristic of drowning, as it may be present in other forms of violent death, and also in some persons during life. It is a vital act, the result of nervous shock, and does not depend upon the temperature of the water for its production; still, it points to recent vitality.

2. The Tongue.—The tongue is just as often found behind the jaws as between them (Casper).

3. The Hands and Feet.—The hands and feet acquire a greyish-blue colour when the body has lain in the water from twelve to twenty-four hours. The skin also becomes corrugated in longitudinal folds. The greyish-blue condition of the hand is known as the “cholera hand.” The nails may contain particles of sand and weeds. “No corrugation or discoloration of the skin of the hands or feet is ever observed on the body of anyone drowned who has been taken out of the water within half an hour, within two, six, or even eight hours” (Casper). The same authority states he has produced these effects by laying the hands after death in water, or wrapping them in cloths kept constantly wet for a few days.

4. The Genitals.—Contraction of the penis and dartos is an almost constant symptom, and Casper has “not observed anything similar so constantly after any other kind of death.” It is due, probably, to the same cause as the cutis anserina, which Brettner attributes to “bundles of unstriped muscular fibres, lying in the upper stratum of the true skin, surrounding the sebaceous glands, and forcing them forwards by their contraction, thus making the cutis anserina. Precisely similar unstriped muscles are found in the subcutaneous cellular tissue of the penis; they run principally parallel to the long axis of the member, but very often large bundles run across it.” The action of cold and fright is to induce contraction of these cutaneous muscles, with a resulting contraction of the penis.

1. The Brain.—Cerebral hyperæmia is most rare in the drowned, but cerebral hypostasis is not infrequently mistaken for it.

2. The Trachea.—The mucous membrane of the trachea and larynx is always more or less injected, and is of a cinnabar-red, which must not be mistaken for the dirty, brownish-red colour, the result of putrefaction. A white froth, but seldom bloody, is also found in varying quantity in the trachea, and is a most important sign of vital reaction, but its diagnostic value is destroyed by putrefaction. Sometimes a portion of the contents of the stomach may be found in the trachea. When this occurs it is due to the act of coughing, induced by the admission of water into the lungs. The contents of the stomach are forced into the mouth, and then drawn into the lungs during the next attempt at inspiration. This indicates that the person entered the water during life. In cases where death has taken place from syncope little or no froth may be found in the trachea.

3. The Lungs.—The lungs are completely distended, almost entirely overlapping the heart, and pressing close to the ribs. They are spongy to the feel, and when cut into, a considerable quantity of bloody froth escapes. The froth found in the lungs is the result of the powerful attempts to breathe, and cannot be produced by artificial means. It adheres not to the sides of the bronchial tubes, as does the exudation of bronchitis or pneumonia. The distension of the lungs is due partly to an actual hyperæmia, and partly to inhaled fluid. Water is present in the pleural cavities.

4. The Heart and Great Vessels.—As is common to other forms of asphyxia, the left side of the heart is entirely, or almost entirely, empty; the right, on the contrary, is engorged. This condition of the heart is, therefore, not a diagnostic sign of drowning, and is absent in the drowned when death takes place by neuro-paralysis; in fact, in some cases of undoubted drowning, both sides have been found empty, probably, however, the result of putrefaction (Ogston). The same may be said of the accompanying congestion of the pulmonary artery.

5. The Blood.—As is common in all forms of death where respiration has been arrested, the blood is found to be remarkably fluid, and of a cherry-juice colour. M. Faure in his monograph on asphyxia states that he has found large and firm clots in the right side of the heart in the drowned who have not remained long under water. The blood is diluted with water, most marked in the left side of the heart. The amount of dilution is greater in slow drowning.

6. The Stomach.—Casper considers that the presence of fluid in the stomach, corresponding to that in which the body is found, is “an irrefragable proof of the actual occurrence of death from drowning,” and that the swallowing of it must have been a vital act of the individual dying in the water. The absence of water from the stomach does not negative death from drowning. Water is not always present. It is possible for it to reach the stomach of a submerged body after death.

Water in the intestines is a more reliable sign of death from drowning, and indicates submersion during life. It is only after very long submersion and under great pressure that water finds its way into the intestines after death.

CHAPTER X DEATH FROM STARVATION, COLD, HEAT, BY LIGHTNING AND ELECTRICITY — DEATH FROM STARVATION — DEATH FROM COLD — DEATH FROM EXPOSURE TO HEAT — DEATH BY LIGHTNING AND ELECTRICITY — LIGHTNING — Industrial Electricity

Death from starvation may be due to the total withdrawal of food, to prolonged insufficiency, defective quality, inability to swallow it, and inability to retain it.

Death from starvation may occur during famines, amongst ship-wrecked sailors, and persons entombed in mines or pits, and is due to sheer privation. It may follow criminal starvation, wilful refusal to take food as a form of suicide, and it has been noted in cases of hysteria and lunacy.

It may result from mechanical hindrance to the entrance of food into the body from ankylosis of the jaws, or its passage through the alimentary tract from stricture of the œsophagus or stomach, from cancer or cicatrisation after injury from swallowing corrosive substances. Amongst other diseases, tuberculosis, malignant disease, and diabetes mellitus are the chief which produce external appearances of starvation.

In the withdrawal or deprivation of food for criminal purposes the victims are usually old, helpless, or feeble-minded persons, or young children.

Symptoms.—These depend on the previous state of nutrition. Starvation may be regarded as acute when death occurs within fourteen days from the withdrawal of food, chronic when at a longer period.

The symptoms of hunger vary: they are said to pass off in forty-eight hours, but may last for several days acutely.

The body temperature falls below normal, and the fall may be two or three degrees before death. The pulse gradually increases in frequency day by day. The chief sign is loss of body weight. Chossat‘s experiments on pigeons showed that when they were totally deprived of food, the surplus fat of the body was lost first, then the fatty coverings of internal organs, the interstitial fat of muscles last of all; the muscles themselves also wasted. A peculiar odour like acetone emanates from those who have been starved, and towards and after death the odour is putrescent.

In addition to the above signs, there are anæmia, sunken, glistening eyes with dilated pupils, prominence of bony projections, pale and dry lips and tongue, parched mouth and throat, weakness of the voice, sunken abdomen, wasted limbs, constipated bowels, urine scanty and turbid. There are pains in the abdomen, relieved by pressure; great thirst, a dusky, dry skin, occasionally purpuric eruptions, exhaustion, ultimately delirium ending in death.

Post-mortem Appearances.—There is emaciation of the whole body, dry, wrinkled skin of a brown colour; the muscles are flabby and wasted, the abdomen sunken, the eyes red and open; this appearance is not common in death from other causes. The mouth and throat are dry even to aridity. The heart, lungs, and blood-vessels are collapsed, and contain but little blood. The abdominal viscera are shrunken and without enveloping fat. The omentum is devoid of fat, and clear; the gall bladder is full of dark bile; the urinary bladder may be quite empty. The stomach and intestines are collapsed, contracted, and empty, and the walls extremely thinned.

Diagnosis.—The absence of any other cause of death—such as cancer of the stomach, stricture of the œsophagus, &c.—and the previous history of the case will assist in forming an opinion, care being taken not to confound the results of wasting disease with those due to starvation.

Legal Relations.—The question of death from starvation may be raised in a case of infanticide by omission. Although rare as an act of homicide, it must be remembered that the law does not require the absolute deprivation of food to be proved, but only that the necessary quantity and quality of food has been withheld; but malice at the same time must be proved. In cases of infanticide by starvation, the mother and not the father is responsible for the proper feeding of the child; but in the case of an apprentice, the master and not his wife is bound to supply proper food to such apprentice.

In questions of survivorship, and in criminal cases, the medical witness may be asked how long a person may survive after complete withdrawal of food. Little is known as to the length of time required to cause death by starvation, but it is certain that life may be prolonged for some time without food, if water be allowed. Starvation is less rapid in its effects if the body be kept warm. In a case recorded in the Lancet, a man who had been shut up in a coal-mine for twenty-three days, with only a little dirty water to drink, lived three days after his liberation, and then died of exhaustion. In adults the average is from seven to ten days without water. Tidy (Legal Medicine, vol. i. p. 392) is of the opinion that the young die first, then adults, and the aged last. Taking into account the enfeebled vitality of the aged, it is more probable that the young or middle-aged adult would survive the longest. Where water is freely obtainable, life may be prolonged to the fifty-eighth day (Foderé, vol. ii. p. 276) or even more.

Apart from age, account must be taken of the condition of the person in reference to bodily health prior to the withdrawal of food.

The following tables, showing the average weight and height of children up to twelve years of age, are from the Report of the British Anthropometric Committee (1883):

Male Children

Table of Ages, Heights, and Weights
of Males and Females from
13 to 30-35 Years of Age

Recapitulation of the Post-mortem Appearances
of Death by Starvation

1. In the Body generally.—Marked general emaciation of the body. The skin is dry and shrivelled, sometimes more or less covered with unhealthy-looking pimples, the muscles soft, reduced in size, and free from fat. A peculiar fœtid acrid odour is given off from the body.

2. In the Solid Viscera of the Thorax and Abdomen.—The liver is small, the gall-bladder distended with bile, and the heart and kidneys deprived of any surrounding fat. All the internal organs are shrivelled and bloodless.

3. In the Stomach and Intestines.—The stomach in some cases is quite healthy, but more or less stained with bile; in others it is found collapsed, contracted, empty, and the mucous membrane more or less ulcerated. The intestines are thin, contracted, empty, and so shrunken that the canal is almost obliterated. According to the late Dr. Duncan, the intestines are frequently found inflamed and ulcerated.

This form of death is rare in England, but is more common in countries where the winters are severe. Anything that depresses the vital powers renders the individual more or less susceptible to cold; such, for instance, as drunkenness, previous illness, or deficiency in the amount of food. The following post-mortem appearances are given by Ogston, who holds that they point, in the absence of any other obvious cause of death, “if not with absolute certainty, yet with high probability,” to death caused by cold:

These signs are not so well marked in children as in adults. The late Sir Benjamin Brodie considered that the effect of cold is to destroy the principle of vitality equally in every part, and that it does not exclusively disturb the functions of any particular organ. The fact of a body being found frozen is no proof that death has been brought about by cold.

Symptoms.—Exposure to severe cold produces loss of energy, lethargy, followed by drowsiness, with an intense desire to sleep, which, if gratified, passes on to stupor and coma. There may be delusions before the coma. The primary cause of death is attributed to the lessened dissociation of oxygen from the hæmoglobin to the tissues, and a lessened power of the latter to utilise it.

Diagnosis.—The general appearance of the deceased, and the absence of any other cause of death, together with the appearances just mentioned, will assist in forming an opinion on this difficult subject. The body lies as if in a deep and calm, sleep, without any external appearance to guide us as to the cause of death, except perhaps a swelling of the extremities, which has come on prior to death. If a body be found buried in snow, and putrefaction present, death did not in all probability take place from cold, provided that the cold has been severe and continuous. Death from cold is generally accidental, except in newly-born children, when it may be either accidental or homicidal, according to circumstances.

When freezing of the body has taken place prior to the onset of rigor mortis, the latter comes on after the body thaws. This, combined with the other post-mortem signs given above, affords evidence of the strong probability that death had resulted from exposure to cold. In view of the red colour of the skin being similar to that caused by poisoning with CO, a spectroscopic examination of the blood should be made.

The results from exposure to excessive heat manifest themselves in various ways. Any condition which may lessen the resistance of the body to external heat predisposes to heat-stroke; such as privation, fatigue, mental emotions, alcohol, over-eating, and especially previous attacks of the disease.

Sunstroke occurs in those who work under the direct rays of the sun, when the air is hot, still, and humid.

Heat-stroke or thermic fever affects those working in places which are excessively hot and confined, as in glass-works, foundries, stoke-holds, boiler-houses, sugar-refineries, paper-mills, &c.

Heat exhaustion and prostration are brought about in a similar manner, but the effects are not the same, and usually transient and less severe.

Sunstroke or heat-stroke may occur in two forms, the asphyxial or apoplectic, and the hyperpyrexial; it is also classified as sthenic or asphyxial, and asthenic or syncopal.

Asphyxial sunstroke or heat apoplexy is probably the least frequent; prodromal symptoms are headache, vertigo, disturbances of vision, dyspnœa, and dry skin. In some cases sudden unconsciousness, with or without convulsions, may occur, and death rapidly follows.

The coma may not be profound; there may be nausea and vomiting of dark material, bounding pulse, stertorous breathing, contracted pupils, and frequent micturition. The body exhales a “mousey odour.” There may be involuntary dejection, with the same pungent odour, and very watery. Delirium is present in some cases. The temperature may be subnormal, or rise to 102° F., occasionally even to 106° F. When fatal, the coma deepens, the pulse becomes rapid and feeble, and there is Cheyne-Stokes respiration.

In Hyperpyrexial cases the symptoms are similar to the asphyxial, but the temperature may reach 110-115° F., and in profound coma death takes place from asphyxia. A subconscious or automatic state, in which the person may go on working, may precede the “stroke.”

In cases which are not so rapid, pneumonia, meningitis, cardiac and respiratory paralysis may occur and prove fatal.

Heat exhaustion may be more gradual in its onset, or come on suddenly. Prodromal dizziness, faintness, nausea, headache, drowsiness, epigastric and lumbar pains may precede the prostration and muscular weakness. Fever supervenes, a rapid pulse, and in severe cases collapse. Consciousness is seldom completely lost, and in favourable cases is quickly regained. When there is marked prostration the heart may fail.

The condition known as heat prostration is a milder form, in which there is little or no fever, and the circulation remains good.

After suffering from an attack of heat-stroke certain sequelæ have been noted. The patients are rendered sensitive to slight elevations of temperature, and, during warm weather, experience chromatopsia, headaches, irritability, irascibility, and even delirium. Epilepsy and insanity may persist during life. Fiske from his investigations concludes that the habits of those working in hot atmospheres, and the degree of temperature, are not nearly so important as the absence of thorough ventilation as causative factors in the disease.

Post-mortem Appearances.—Rigor mortis comes on early, and is pronounced and disappears quickly. Putrefaction is early in onset. The brain and cord, the lungs and spleen and splanchnic area exhibit venous engorgement.

The blood is fluid, and the red corpuscles crenated. Extravasations of blood may be present in the skin, the serous membranes, and cavities, the superior sympathetic ganglia, and the vagi and phrenics. The left ventricle is markedly contracted, the right dilated and filled with blood.

Van Gieson records acute parenchymatous degeneration of the whole of the cerebro-spinal nervous system, with chromatolysis of the cells. Parenchymatous changes may be present in the liver and kidneys.

Death is not always immediate. Sometimes the clothes have been torn off the body with scarcely any personal injury. Metallic articles, especially steel, worn or carried about the person become magnetic and may be fused. The lesions which may be met with after lightning-stroke are varied, and may comprise wounds of almost any description; simple, compound, or comminuted fractures of bones; burns in the form of streaks, patches, lines, or arborescent markings; ecchymoses; singeing of the hair; impressions of metallic articles on the skin. Apart from the lesions noted above, the following symptoms may be present: deafness, blindness, paralysis, loss of memory, delirium, and convulsions. Not infrequently those killed by lightning are found in the same position that they occupied during life. The question may arise as to whether the deceased died by lightning or violence. The presence of a storm at the time when death is stated to have occurred, and other attendant circumstances, will in most cases point to the true cause of death. Metallic articles should be examined with regard to their electric state. Dr. Honiball tenders this caution: “Be not too sure that in every body found dead after a thunderstorm, and where no marks upon it are found, that death was due to lightning-stroke, for it may happen that death was due solely to cardiac syncope owing to sudden and startling fright.”

Post-mortem Appearances.—Apart from the external injuries, when present, post-mortem rigidity comes on early. The head and neck may be purplish in colour, the eyes partially open and suffused, with variable pupils. The internal signs are not characteristic. The membranes and vessels of the brain may be hyperæmic. The blood has been said to be very fluid, but it may be coagulated. The internal organs may be torn, bones may be fractured, and blood-vessels ruptured.

With the increased use of electricity for motive power and illumination instances of injury and even death have occurred, and probably will become more frequent. One of the most important safeguards of the body against the effects of electricity is its high degree of resistance, especially if the body surface be dry. Moisture of the body surface lessens the resistance and increases the liability to injurious effects.

The body is a bad conductor; it is said to be three million times less than mercury, and fifteen million times less than copper; the nerves conduct like metals. The danger of electric shocks depends upon the amount of current passing through the body, the kind of contact, and the insulation of the body at the time. Moisture of the body or clothes will increase the effects of the shock. Much depends upon the quality, duration, strength, and density of the current, and the direction in which it passes.

The continuous current is less severe than the interrupted, and the alternating is the most powerful in its effects. An alternating current of 300 volts has caused death, and one of 1500 volts would certainly prove fatal, whereas for the continuous current it would take 3000 volts to prove fatal.[13] Cases are recorded when with good contact even so low as 65 volts has proved fatal. The Board of Trade forbids the introduction into dwelling-houses of currents of more than 250 volts, unless for special purposes and with special permission.

As the current enters or leaves the body it may cause local injury. Tetanic muscular contractions with pain, and pain from stimulation of nerve endings in the skin with erythema may occur. Burns produced by electricity may be accompanied by much local destruction of tissue and slow healing.

There may be ascending neuritis from injury to nerves.

The shock may cause insensibility with pallor and stertorous breathing; the skin is moist, the eyes suffused, and the pupils dilated.

Death is due to (1) inhibition of the medulla oblongata, or (2) direct action on the heart muscle. According to the researches of Cunningham, currents which traverse the whole body transversely or longitudinally produce fibrillary contraction of the heart muscle. When the current passes through the brain, medulla, and upper cord it may cause death by respiratory paralysis. Those who have recovered from severe shock describe the sensation as peculiar rather than painful.

Post-mortem Appearances.—These include the local injury, if any, at the point or points of contact, some hyperæmia of the internal organs, œdema of the lungs, and fluidity of the blood. The general appearances are those of asphyxia. Kratter considers that external burns in association with subpericardial and subpleural ecchymoses, and especially subendocardial petechiæ, also the presence of congestion of the bronchi, strongly indicate death from electricity.

Minute hæmorrhages may occur in the meninges, and in the fourth and other ventricles. Changes have also been described in the cells of the central nervous system in experiments upon animals.

Treatment.—The current should be switched off at once; the patient should be removed from the conductor, the rescuer being protected with some insulating material, the attempt should not be made bare-handed.

Stimulation, warmth, and artificial respiration should be resorted to. After respiration has been re-established, friction should be applied to the body. The treatment should be persevered in for several hours. Signs of life may not be seen for two hours. Venesection may be desirable.

CHAPTER XI OFFENCES AGAINST CHASTITY — RAPE — VIRGINITY

According to the Statute 24 and 25 Vict. c. 100, sec. 48, rape in England is defined as the “carnal knowledge of a woman against her will.” In Scotland rape is held to be “the carnal knowledge of a woman forcibly, and against her will, or of a girl below twelve years of age, whether by force or not” (Hume, i. 303). An Act passed in 1885 (48 and 49 Vict. c. 69) has materially affected the law on this subject as regards the age of females. To constitute the offence of rape, there must be penetration, but proof of the actual emission of semen is not now necessary. Before the Statute 9 Geo. IV. c. 31, sec. 18, it was also necessary to prove emission, which might be proved either positively by the evidence of the woman that she felt it, or it might be presumed from circumstances; as, for instance, that the defendant, after connection with the prosecutrix, arose from her voluntarily without being interrupted in the act. The slightest penetration of the male organ within the vulva will be sufficient, and the hymen need not be ruptured (R. v. Russen, 1 East P.C. 438, 439). The resistance of the woman must be to the utmost of her power. If, however, the woman yield through fear or duress, it is still rape; but of course much will depend upon the previous character of the woman, and her conduct subsequent to the alleged outrage. The party ravished is a competent witness to prove this and every other part of the case; but the credibility of her testimony must be left to the jury. The defendant may produce evidence of the woman‘s notoriously bad character for want of chastity or common decency, or that she had before been connected with the prisoner himself; but he cannot give evidence of any other particular facts to impeach her chastity (R. v. Hodgson, R. & R. 211). She may be asked if she has had connection with other men, but she need not answer (R. v. Cockcroft, 11 Cox, 410, per Willis, J.). If she deny connection with the men named to her, they cannot be called to contradict her (R. v. Holmes, L.R. 1 C.C.R. 334).

A rape, according to Scottish law, may be committed on a common strumpet; and in England the law goes even further, and admits the possibility of rape on the concubine of the ravisher (1 Hale, 729), “although such circumstances should certainly operate strongly with the jury as to the probability of the fact that connection was had with a woman against her will.” A husband may be guilty of rape on his wife if he hold her while another violates her, as in the case of the Earl of Castlehaven, tried in 1637. Carnal knowledge of a woman by fraud, which induces her to suppose it is her husband, now constitutes a rape by the 48 and 49 Vict c. 69, which enacts that “whereas doubts have been entertained whether a man who induces a married woman to permit him to have connection with her by personating her husband, is or is not guilty of rape, it is hereby enacted and declared that every such offender shall be deemed to be guilty of rape.” It has also been decided that if a man get into bed with a woman while she is asleep, and he know she is asleep, and he have connection with her while in that state, he is guilty of rape (R. v. Mayers, 12 Cox, 311, per Lush, J.). The offence of rape is not triable at quarter sessions.

Upon an indictment for rape, there must be some evidence that the act was without the consent of the woman, even when she is an idiot. In such a case, where there was no appearance of force having been used to the woman, and the only evidence of the connection was the prisoner‘s own admission, coupled with the statement that it was done with her consent, the Court held that there was no evidence for the jury (R. v. Fletcher, L.R. 1 C.C.R. 39).

In another case, where the prisoner was caught in the act by the father of an idiot girl, the learned judge told the jury that if the prisoner had connection with the prosecutrix by force, and if she was in such an idiotic state that she did not know what the prisoner was doing, and if the prisoner was aware of her being in that state, they might find him guilty of rape; but if, from animal instinct, she yielded to the prisoner without resistance, or if the prisoner, from her state and condition, had reason to believe she was consenting, they ought to acquit him. The jury found that he was guilty of an attempt at rape (R. v. Barrat, L.R. 2 C.C. 81).

Where the prosecutrix, an apparent idiot, proved that the prisoner had had connection with her, but it appeared from her examination that though she knew he was doing wrong, she made no resistance, and the prisoner, on being apprehended and charged with committing a rape upon the prosecutrix “against her will,” said “Yes, I did, and I‘m very sorry for it,” it was held that there was evidence to go to the jury of a rape (R. v. Pressy, 10 Cox, 635).

In Scotland, in the case of Hugh M‘Namara (H.C. July 24, 1848, Ark. 521), where the woman was only one degree removed from idiocy, it was laid down that “if she had shown any physical resistance, to however small an extent, the offence would be complete, in consequence of her inability to give a mental consent.”

In future cases the above decisions will probably be set aside in the light of the present enactment.

In the case also of a quack doctor, who, under the pretext of performing a surgical operation on a young girl of nineteen years of age, had connection with her, she at the time resisting, but believing that she was undergoing an operation, it was held, on appeal, that he was guilty of the crime of rape, and the former conviction confirmed (R. v. Hattery, C.C.).

In England, and in Ireland, and also in Scotland, unlawfully and carnally knowing a girl under thirteen years of age constitutes a felony—the attempt in the former countries constitutes a misdemeanour; in Scotland, a “crime and offence.” The child may be a witness if she understands the nature of an oath or understands the duty of speaking the truth, but her evidence must be corroborated by some other material evidence in support thereof, implicating the accused. The carnal knowledge of a girl above thirteen and under sixteen, or of any female idiot or imbecile woman or girl, under circumstances which do not amount to rape, but which prove that the offender knew at the time of the commission of the offence that the woman or girl was an idiot or imbecile, constitutes a misdemeanour. Above sixteen consent does away with the crime; and it shall be a sufficient defence for the accused to show that he had reasonable cause to believe that the girl was of or above the age of sixteen years. This defence does not apply to female idiots or imbeciles.

A boy under the age of fourteen was formerly in England presumed by law incapable of committing a rape (R. v. Groombridge, 7 C. & P. 582); but in Scotland there was no such provision, and a boy thirteen and a half years of age was committed for rape (Rob. Fulton, jun., Ayr, Sept. 20, 1841).

The recent Act before quoted provides that, instead of imprisonment, the offender, if under sixteen, may be whipped and sent to a reformatory school for not less than two or more than five years. Evidently age cannot now be pleaded as an incapability.

The crime of rape appears to be most frequently perpetrated against children, probably due to the popular idea that an attack of gonorrhœa may be cured by connection being had with a virgin or healthy female.

The following Table from Casper gives the result of his examination of one hundred and thirty-six cases of rape:

In examination of a case of alleged rape, several points of interest will have to be considered, which, for the sake of convenience, will be placed in a tabular form:

• 1. An examination of the parts of generation.
• (a) Inflammatory redness and abrasion of the parts.
• (b) A muco-purulent secretion.
• (c) Hæmorrhage or dried blood about the genital organs.
• (d) Destruction of the hymen.
• (e) Dilatation of the vagina.
• (f) General signs of rape.
• 2. An examination of the body and limbs of the female.
• 3. Examination of the linen worn by the female and the male for
• (a) Marks of semen.
• (b) Marks of blood.
• (c) Marks of other discharges, gonorrhœa, &c.

1. An Examination of the Parts of Generation.

(a) More or less inflammatory redness and abrasion of the mucous membrane lining the parts, which is never absent in children, and may last for some weeks. “In adults, virgins up to the time of the commission of the crime, this appearance is either not found at all or only faint traces of it. In those previously deflowered it is never observed.” In the case of young children the genitals may be so injured as to cause death in a few hours. The parts may therefore present all varieties of injury, from slight bruising and redness to the most fearful lacerations.

Caution.—Inflammatory irritation due to catarrh may occur, and be apt to mislead.

(b) A muco-purulent secretion, from the mucous membrane lining the vagina, of a greenish-yellow colour, more or less viscid, and soiling the linen of the girl. This secretion, in colour and consistence, cannot be distinguished from that the result of gonorrhœa. The usual period of incubation of gonorrhœa is from three to eight days; among young girls, however, this period may be shortened. The incubatory stage of soft chancre is from three to five days (Diday); that of hard chancre somewhat longer, varying from fifteen to twenty days. Enlargement of the inguinal glands and the persistence of the discharge after the use of simple treatment will tend greatly to confirm the suspicion of venereal disease. The genital organs of the male may have to be examined as to the presence of gonorrhœa or syphilis. Syringing the urethra may remove for a time the gonorrhœal discharge; care must therefore be taken in forming an opinion.

(c) Hæmorrhage or Dried Blood about the Genital Organs.—(1) Frequently absent in young children. (2) Always found in adults, virgins at the time the rape was committed, when the vessels of the hymen are ruptured.

(d) Destruction of the Hymen.—Most frequently, and especially in young girls, one or more lacerations of the hymen may be seen. These lacerations must be looked for within five or six days of the alleged rape, as they soon heal up, and then no certain opinion can be given as to the date of their infliction. They may also be produced by any foreign body to substantiate a charge of rape.

(e) Dilatation of the Vagina.—This condition may be produced by the passage of hard bodies in order to substantiate a false charge of rape. Casper once examined a girl, only ten years of age, whose mother had gradually dilated her vagina with her fingers, in order to fit her for sexual intercourse with men.

(f) General Signs of Rape.—To the above are added certain general signs, as a difficulty in walking, attended with an involuntary separation of the thighs, common to both children and adults; pain is also not infrequently present in passing water, and when the bowels are relieved. In determining the truthfulness of the statements made as to an alleged rape, the character of the woman, and the obvious inconsistencies of her statements must be taken into consideration. Moreover, if, in addition to the injuries found on the external genitals, spermatozoa be detected in the vagina, a presumption in favour of the injuries being due to sexual intercourse will be clearly made out, but the presence of spermatozoa in the vagina of a woman is no evidence of rape. Care, however, must be taken not to confound with spermatozoa an animalcule—Trichomonas vaginæ—described by M. Donné as being sometimes found in the vaginal mucus. The head of the animalcule is larger than that of a spermatozoon, and is surrounded by a row of cilia.

Fig. 19.—Hymen of child of
four years—annular type.
The illustration also shows the prominence of the
urinary portion of
the genitals.

(Glaister.)

In the case of young children, the anxiety on the part of the parents of the child to push the charge, and the story of the child and that of the parent heard apart, may assist in guiding the opinion. The lesson-like way in which the child tells her story, even to the minutest details, is always suspicious. The proof of a previous defloration negatives the pretended loss of virginity at the time of the commission of the deed for which the accused is being tried. In most cases, it is best to let the patient tell her own tale, and then cross-examine. An injudicious question may put her on her guard.

2. Examination of the Limbs and Body of the Female for Bruises, &c.—Little value is to be placed on injuries said to be inflicted on the person of a female the result of a struggle, as these may be produced by the woman on herself in order to substantiate her story. In children, for obvious reasons, they do not occur.

Fig. 20.—Virgin hymen,
with central slit.

(Glaister.)

3. Examination of the Linen.—In all cases a careful examination of the body linen of both parties should be made. With regard to the position of the stains on the chemise of the woman, M. Devergie insists that the stains on the front of the chemise are seminal, those on the back are due to blood. This distinction is too arbitrary to meet all the facts of these cases, for the position of the spots necessarily depends on the respective positions of the parties at the moment of ejaculation; and, moreover, the woman is more likely to wipe the parts with the front than the back of her chemise. Mistakes may arise from—

The identification of blood-stains is not difficult when the stain occurs on pieces of white linen; but when, as it not infrequently happens, they have to be detected on the coarse, dirty, often stinking linen of the poor, the task becomes somewhat more difficult. The same may be said with regard to seminal spots. As a means of diagnosis in stains due to semen, the appearance and smell of the stains are of no assistance whatever. The microscope will alone give any trustworthy evidence as to the nature of the stain; and even here a caution must be added—for the fact is beyond doubt that the semen even of a healthy young man varies much, and is scarcely ever twice alike, so that the absence of spermatozoa is no proof that the spot is not seminal in its origin.

The following are the tests used for the detection of semen:

Can a Rape be committed by one man on a healthy, vigorous woman?—The answer to the question will, to a great extent, depend on the relative strength of the conflicting parties. Every case of rape has to be judged on its own merits. In any case, the medical jurist has simply to state, from the examination of the parties, that sexual intercourse has taken place, leaving the jury to decide whether a rape or not has been perpetrated. A case is mentioned by Casper where a healthy, strong adult of twenty-five years old was violated by a single man.

Can a Woman be Violated during Sleep?—By this is intended natural healthy sleep, and not that induced by narcotics. In natural sleep, rape is scarcely possible in a virgin, especially if the hymen be found recently ruptured, though it may be possible in a woman accustomed to sexual intercourse.

Fig. 21.—Photo-micrograph of human spermatozoa, × 1000.
(R. J. M. Buchanan.)

Can a Woman become Pregnant by an act of Rape?—The answer to this question is most decidedly in the affirmative. It is not necessary for a woman to experience any sexual pleasure during connection in order that she may conceive. A woman may become pregnant if fresh semen be injected into the vagina with a glass syringe.

Signs of Rape in the Dead.—In the case of a woman found dead, the question may arise as to her having been violated prior to death. The reply to the question is by no means easy. Severe injury to the genitals is a presumption in favour of rape, but cases are by no means rare in which men failing to accomplish coïtus have injured the parts with their fingers. The presence of spermatozoa in the vaginal mucus is good evidence of a recent coïtus, but is no direct evidence of a rape. Collateral evidence will in most cases decide the point.

Physical Signs of Rape
in Adult and in Child

Directions as to manner of making a Medico-Legal
Examination in a Case of Alleged Rape.

1. Be careful to note everything, for it is in such cases as the one under discussion where apparently unimportant signs may become of the greatest moment.

2. Give the female no time for preparation, but make your visit, and at once proceed to an examination. The visit to be of any practical service should not be delayed beyond the third or fourth day after the alleged offence, “by which time the lacerations will have healed, the cicatrices disappeared, and the torn hymen be in such a state as to make it difficult to say whether it had been divided recently or at an earlier period.” But remember that you are not justified in using force; and in this, as in cases of suspected pregnancy, if you examine a woman against her will you render yourself liable for an action for assault, and may have to pay heavily for your enthusiasm.

• (a) Note time of a visit.
• (b) Note time of alleged offence.
• Why? May prove the accused party innocent by an alibi.
• (c) Avoid leading questions.

3. Age, strength, and condition of the health of the complainant. Examine the wounds asserted to have been inflicted, and see if they correspond with the history given of their infliction.

4. Examine organs of generation.

• (a) Any recent signs of violence—blood, abrasions, ulcerations, &c.
• (b) Condition of hymen, and of the carunculæ myrtiformes.
• (c) Was the woman menstruating at the time? Signs
• modified or obliterated by menstruation.

5. Preserve any spots on linen, &c., for future examination.

6. In case of death after violence—

• (a) Examine mouth for foreign bodies, &c.
• (b) Fractures or bruises on the body.

7. Examine spot where the crime is stated to have taken place.

8. Examine person of the accused.

• (a) Muscular development and strength.
• (b) Any abrasion about the penis, size of penis,
• rupture of the frænum, &c.
• (c) On linen, blood-stains, seminal spots, &c.
• (d) Marks on his body, scratches, &c., as evidence
• of resistance.

N.B.—The lapse of a few days may be sufficient to remove all traces of the violence done to the parts; and in most cases days, weeks, and even months may elapse before an examination is made of the alleged victim.

Fig. 22.—Deflorated hymen, after parturition, in adult woman.

(Glaister.)

There is no one sign which may be considered as an absolute test for virginity. The presence or absence of the hymen is of no probative value one way or the other. Its very existence has been denied by Paré, Buffon, and others. It may be absent as the result of disease, or as the result of a surgical operation to allow of the free discharge of the menstrual flow. Its presence is no bar to conception; and cases are on record where it has been found necessary to incise it, to allow of the passage of the fœtus into the world. In fact, women who have been prostitutes for years have possessed to the last uninjured hymens. The changes in the breasts which proceed from impregnation do not occur where only defloration has taken place. The rugose condition of the vagina is only affected by the first birth, and not by sexual intercourse.

What has been said of the above signs as tests for virginity may be said of a host of others which from time to time have, with varying success, been advanced as aids to the diagnosis. Casper, however, considers “that where a forensic physician FINDS A HYMEN STILL PRESERVED, EVEN ITS EDGES NOT BEING TORN, AND ALONG WITH IT—in young persons—A VIRGIN CONDITION OF THE BREASTS AND EXTERNAL GENITALS, HE IS THEN JUSTIFIED IN GIVING A POSITIVE OPINION AS TO THE EXISTENCE OF VIRGINITY, and vice versa.”

CHAPTER XII PREGNANCY — Signs of Pregnancy — Uncertain Signs — Certain Signs — Diagnosis of Pregnancy — DELIVERY — 1. Signs of Recent Delivery in the Living — 2. Signs of Recent Delivery in the Dead — 3. Signs of a Previous Delivery

It not infrequently happens that a medical man is called upon to make an examination of a woman for legal purposes, in order to decide—(a) The existence of an alleged pregnancy. (b) The possibility of a previous pregnancy. (c) As to the existence of concealed pregnancy.

The following are some of the reasons why pregnancy may be feigned:

Pregnancy may be concealed—(a) In order to procure abortion. (b) In order to commit infanticide. (c) In the married and the unmarried, to avoid disgrace.

Besides the above, other important questions may arise with regard to this state:

1. Is pregnancy possible as the result of coïtus in a state of unconsciousness?—There appears no reason for doubting the possibility of this occurrence.

2. Can pregnancy occur before the appearance of the catamenia?—That pregnancy may occur before menstruation is undoubted; and it appears probable that the changes in the ovaries and uterus may go on at the regular monthly periods, and yet there may be no discharge of blood from the uterus, which, as pointed out by Bischoff, is only a symptomatic though usual occurrence. Hence, pregnancy is possible prior to menstruation.

3. What is the earliest and latest age at which pregnancy is possible?—In our climate (Britain), the earliest age at which pregnancy may occur is about the eleventh or twelfth year; but the youngest age at which this condition is reported to have occurred is nine years (Meyer). In hot climates—as in Bengal—mothers under twelve years of age are by no means rare. Cohabitation in marriage takes place much earlier in India than in Europe, but Chevers doubts if menstruation naturally occurs much sooner there than elsewhere, and Baboo Modusoodun Gupta believes that the catamenia appear sooner or later, according to the mode of living of the females, and the sexual excitement to which they may be subjected. Thomas mentions the case of a girl who menstruated regularly from the age of twenty-one months, and also of another at eight months. The limit to child-bearing appears to be between the fiftieth and fifty-second years; but even here considerable variation has been recorded, and women have been delivered of children at the age of sixty. Haller even reports one at seventy. As long as menstruation continues a woman may become pregnant; but even the cessation of this flow for some months is no bar to conception.

4. Is it possible for a woman to become pregnant eight weeks after her last confinement?—This is undoubtedly possible, but it is of rare occurrence. It is also probable that a woman may abort at the end of the time above mentioned. Husband knew a woman, who for several years bore a child every ten months.

At common law, in cases of disputed inheritance, the following may occur, and give rise to the necessity for medical evidence on the subject: A woman who has just lost her husband may disappoint the expectant heirs to an estate by alleging that she is pregnant.

At criminal law, pregnancy may be used as a stay to the infliction of capital punishment.

In the first case, a jury of matrons is impanelled by a writ de ventre inspiciendo, to decide the existence of pregnancy, and if the fact be proved, to watch till such time as she be delivered.

In the second case, in England, the pregnancy must be proved, and also whether she be quick with child. In Scotland the pregnancy must be proved, but without reference to quickening, and the jury of matrons is unknown in that country. In the same country, if it can be shown that a woman is pregnant, and that her life or that of the child is endangered by her imprisonment, she may be admitted to bail till after delivery. A pregnant female also cannot be compelled to appear and give evidence, if on competent authority it be shown that her delivery will probably take place at the time fixed for the trial.

The diagnosis of early pregnancy in ordinary cases is by no means easy, especially before the third or fourth month of gestation; but to the medical jurist it is still more difficult, as he has to deal with cases where he can scarcely expect much candour. No opinion should, however, be given without taking into consideration the collective value of the signs, as no one sign will afford sufficient data on which to base an opinion. The signs furnished by auscultation are the most reliable, but the position of the fœtus may render the sounds of the fœtal heart and placental souffle difficult to detect.

The following may be taken as among the most important signs of pregnancy, given in the usual order of their occurrence:

1. Cessation of Menstruation.—The non-appearance of the catamenia, though a most valuable sign, is by no means a conclusive one, as menstruation may be arrested by diseases of various kinds; while, on the other hand, there are many well-recorded cases of women who have menstruated regularly during the whole period of their pregnancy. There have been also cases in which the menses only occurred during pregnancy; and in a few still more curious cases, women who have never menstruated have been known to have borne several children. In cases of concealed pregnancy, the woman may smear her linen with blood to imitate the menstrual flow.

2. Morning Sickness.—Nausea, often ending in vomiting, generally occurs soon after rising in the morning, and may commence almost immediately, but more frequently not till the expiration of the fifth or sixth week after conception. It is not a reliable sign, and is often very irregular in its occurrence. When present, it varies in degree, from a feeling of nausea to the most violent vomiting, very distressing to the patient.

3. Salivation.—The excessive secretion of the salivary glands, due to the irritation caused by pregnancy, was first mentioned by Hippocrates as a sign of this condition. “It is to be distinguished from ptyalism induced by mercury, by the absence of sponginess and soreness of the gums, and of the peculiar fœtor, and by the presence of pregnancy.” It is oftener absent than present.

4. Mammary Sympathies.—As the breasts may enlarge from various causes—such, for instance, as the distension of the uterus from hydatids, or, as is the case with some women at each menstrual period, when the catamenia are suspended, or after they have ceased—this is by no means a sign on which much reliance should be placed. The change in the colour of the nipple and areola, more apparent in women of dark complexions, is more to be relied on as a diagnostic sign of pregnancy. The first observable alteration, which occurs about two months after conception, is “a soft and moist state of the integument, which appears raised, and in a state of turgescence, giving one the idea that, if touched by the point of the finger, it would be found emphysematous. This state appears, however, to be caused by infiltration of the subjacent cellular tissue, which, together with its altered colour, gives us the idea of a part in which there is going forward a greater degree of vital action than is in operation around it; and we not infrequently find that the little glandular follicles, or tubercles as they are called by Morgagni, are bedewed with a secretion sufficient to damp and colour the woman‘s dress.”

During the progress of the next two months, the changes in the areola are in general perfected, or nearly so, and then it presents the following characteristics: “A circle round the nipple, whose colour varies in intensity according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light-coloured eyes, and delicate complexion. The extent of the circle varies in diameter from an inch to an inch and a half, and increases in most persons as pregnancy advances, as does also the depth of colour. In the centre of the coloured circle, the nipple is observed partaking of the altered colour of the part, and appearing turgid and prominent, while the surface of the areola, especially that part which lies more immediately around the base of the nipple, is studded over and rendered unequal by the prominence of the glandicular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch; and, lastly, the integument covering the part appears turgescent, softer, and more moist than that which surrounds it; while on both there are to be observed at this period, especially in women with dark hair and eyes, numerous round spots or small mottled patches of a whitish colour, scattered over the outer part of the areola, and for about an inch or more all around, presenting an appearance as if the colour had been discharged by a shower of drops falling on the part.” The value of the above changes in the nipple and areola as a diagnostic sign of pregnancy is greatly lessened by a previous pregnancy. It should also be remembered that milk may occur in the breasts of women who are not pregnant.

5. Enlargement of the Abdomen.—For the first four months of pregnancy the entire uterus is contained in the cavity of the pelvis; it then gradually rises, so that at about the fifth month it is midway between the pubes and umbilicus, which latter it reaches at the end of the sixth month; during the seventh month it may be felt half-way between the umbilicus and ensiform cartilage; at the end of the eighth month it is level with the cartilage, now quite filling the abdomen. Still increasing in size during the ninth month it does not ascend higher, the abdominal walls yielding to its increased weight, allowing it to fall somewhat forward. A caution is necessary with regard to this sign. The abdomen may enlarge from causes other than pregnancy. Pregnancy and ascites, or ovarian dropsy, may coexist in the same patient, and the diagnosis be rendered anything but easy. The enlargement of the abdomen may lead to unfounded suspicions detrimental to the happiness and health of the unfortunate object of them.

6. Condition of the Cervix Uteri.—The cervix softens during pregnancy, and the softening is present as early as the second or third week. It is an important sign. Hejar‘s sign or the softening at the junction of cervix and body and the lower uterine segment is valuable, but not always easily elicited. It is of most value from the second to the fifth months. At the sixth month it loses one-fourth of its length; at the seventh it is only half of its original length; at the eighth it loses another quarter; and at the ninth the neck is entirely obliterated. This shortening is more apparent than real, and its occurrence is denied by the late Dr. J. M. Duncan, except during the last few days of pregnancy.

7. Quickening.—The period at which quickening occurs varies from the fourth to the fifth month; and the term is understood to imply the first perception of the movements of the fœtus experienced by the mother. Nervous women, anxious to have children, sometimes complain of sensations which they ascribe to quickening, pregnancy being absent. Pregnancy may occur without quickening.

8. Kiesteine.—This is no test of pregnancy, as it may be found in women not pregnant.

9. Jacquemier‘s Test.—A violet or port-wine colour of the vagina and inner surface of the vulva, due to venous congestion of the parts from pressure of the gravid uterus.

A flattening of the upper wall of the vagina, produced by the enlargement and anteversion of the uterus, which, forcing the os towards the sacrum, makes the anterior wall of the vagina tense, has been added by Dr. Barnes as a sign of pregnancy.

1. Ballottement.—This test of pregnancy is applied by causing the patient to stand upright; the finger of the right hand is then passed into the vagina and placed in the anterior fornix, the other hand being placed lightly over the abdomen in order to steady the uterine tumour. If the finger be now jerked upwards against the head of the child, it will be felt to float upwards in the liquor amnii, and then by its own weight gradually to return to its former position. Tumours in the uterus, attached to its walls by a pedicle, may give the same sensation. Scanty supply of liquor amnii, or malposition of the child, may sometimes prevent the adoption of the test.

2. Uterine Souffle.—Under this head are included the placental bruit, and the pulsations of the umbilical cord. Both these sounds require a skilled auscultator to detect them. The uterine murmur, or bruit placentaire, is heard best at the lower and lateral portions of the uterus, just above Poupart‘s ligament. It is isochronous with the pulse of the mother, and is heard most distinctly about the fourth or fifth month of utero-gestation; in some cases, however, it may be heard as early as the tenth week. The sound is intermittent, and varies in character, being sometimes hissing, whirring, or cooing, at others rasping.

3. Pulsation of the Fœtal Heart.—The sounds of the fœtal heart were first noticed by Mayar in 1818, and those of the placenta, or placental souffle, by Kergaradec in 1822. The sound of the fœtal heart is composed of a rapid succession of short, regular double pulsations, differing from that of the adult heart in rhythm and frequency. It can be heard more or less over the whole of the abdomen about the middle of the fourth month, and is not unlike the muffled ticking of a watch. In frequency it varies from 100 to 140. The auscultator should be careful not to hang his head down, or he may be apt to mistake the throbbing of his own arteries for sounds communicated from the patient.

4. Intermittent Contraction of the Uterus.—From the fourth to the tenth month of pregnancy, the uterus may be felt by the palpating hand to alternately contract and relax; the period of contraction and relaxation varies. It is present in pregnancy whether the fœtus be alive or dead.

Pregnancy may be simulated by ascites, by fibrous tumours of the uterus, by ovarian dropsy, and by enlargement of the uterus from retention of the catamenia due to an imperforate hymen, &c. The breasts may also become affected by uterine tumours.

1. Pseudo-Pregnancy.—In the examination of cases of alleged pregnancy, the medical jurist should bear in mind the possibility of enlargement of the uterus and abdomen from the presence of tumours. The probable occurrence of pseudo-pregnancy should also be considered. Tumours and pseudo-pregnancy may occur in the married and unmarried; and as the latter is not infrequently accompanied with many of the signs and symptoms of pregnancy, an early diagnosis is of the utmost importance.

The diagnosis will consist in—

2. Dropsy.—Use of the stethoscope; examination of the breasts for milk, and the urine for albumen.

3. Fibrous Tumours.—Absence of fœtal movements and other signs of pregnancy.

4. Ovarian Dropsy.—Tumour on one side of the abdomen; breasts unaffected, and auscultation giving negative results.

5. Retention of the Catamenia.—On examination, the hymen found perfect and bulging. This condition cured by a crucial incision.

This subject is best discussed under three heads: (1) Signs of Recent Delivery in the Living. (2) Signs of Recent Delivery in the Dead. (3) Signs of Previous Delivery.

(a) Transitory Signs; (b) Persistent Signs of Delivery

(a) Transitory Signs of Delivery

1. General Indisposition.—The face is pale or flushed; the eyes sunken, and surrounded by a dark areola; there is considerable debility, and a tendency to faint; the skin is warm and moist, and the pulse quick. It must be borne in mind that a woman who is anxious to conceal her recent delivery may, by an effort of the will, to a great extent hide her real condition.

2. The Breasts.—The breasts feel firm and “knotty,” and on pressure yield a small quantity of colostrum or milk, which may be distinguished by the aid of a microscope.

3. The Abdomen.—The skin of the abdomen shows signs of recent distension; it is relaxed, and more or less thrown into folds, the lower part marked by irregular broken streaks of a pinkish tint, becoming white and silvery as time goes on.

4. The Lochia, or the “Cleansings.”—These consist in a discharge from the uterus, which, for the first three or four days after delivery, is more or less bloody. During the succeeding four or five days it acquires a dirty-greenish colour—“green waters,” with a peculiar sour, rancid odour. In a few days this is succeeded by a yellowish, milky-looking mucous discharge, which may continue for four or five weeks.

5. External Parts of Generation.—The labia and vagina bear distinct marks of injury and distension.

6. The Uterus.—The uterus is enlarged, and may be felt by the hand for two or three days after delivery, as a round ball, just above the pubes. The orifice of the uterus, if examined a few hours after delivery, appears as a continuation of the vagina. This condition completely disappears in about a week after delivery.

7. After-pains.—These are of no use from a diagnostic point of view, as we have no means of testing their presence or absence.

(b) Persistent Signs of Delivery

1. Entire obliteration of the hymen.—This is no proof of actual delivery.

2. Destruction of the fourchette.

3. The vagina dilated, and free from rugæ.

4. Dark colour of the areola round the nipples.—This varies among women; and cases are known where there was no areola either during pregnancy or after delivery.

5. Skin of Abdomen.—Due to the great distension of the abdomen, the skin appears streaked with silvery lines varying in breadth. These markings in some cases may be scarcely perceptible, especially if the female has worn a tight abdominal belt during her pregnancy. The same appearance may be produced by dropsy, or the prolonged distension of the abdominal walls, the result of other causes. Attention to the other signs present will assist the diagnosis. After the lapse of seven to ten days the recent delivery of a woman cannot be certainly proved by an examination of the living woman, especially if it be known that she had previously borne children. In primiparæ the pink-coloured streaks on the abdomen, and the transverse condition of the os uteri, may strongly point to recent delivery.

Should the woman die immediately after delivery, the external parts will present the same appearance as just described in the living. On opening the abdomen, the uterus will be found fat and flabby, between nine and twelve inches long, and with the os uteri wide open. The cavity of the uterus may contain large bloody coagula, and its inner surface be lined by the decidua. The attachment of the placenta is easily detected by its dark colour, and by the semi-lunar openings of the arteries and veins on the surface of the uterus.

Of course all the appearances just described will be greatly modified by the time that has elapsed between delivery and death.

Delivery after Death.—The fœtus has been known to have been expelled from the uterus by the force of the gases generated by putrefaction. Dr. Aveling, in a paper published in the Obstetric Transactions, 1873, arrives at the conclusion that post-mortem delivery is possible even where no symptoms of parturition were noticed before death. He also thinks that the child may live in utero for some hours after the death of the mother.

Table showing the Size of the Uterus at
Different Periods after Delivery

Table giving Weight of the Uterus
after Delivery

1. Marks on the abdomen, consisting in shining silvery lines, due to the distension of the skin. These may result from distension other than that the result of pregnancy—tumours, dropsy, &c.

2. Marks on the breasts, similar to those appearing on the abdomen. These, in conjunction with the above, are important.

3. Peculiar jagged condition of the os uteri, felt by the finger. The condition may be the result of disease.

4. Marks of rupture of the fourchette or perinæum.

5. Dark colour of the areola round the nipple.

6. Negative evidence, from absence of any of the above.

Can a Woman be delivered unconsciously?—This question may arise in cases of infanticide. Setting aside cases of epilepsy (in a fit of which disease Husband once attended a woman who was confined during the fit without being aware that she had been delivered), cases of apoplexy, coma, and narcosis from chloroform, opium, &c., it may be stated that delivery is possible during profound sleep. Husband once attended a woman who informed him that “she always had her pains during her sleep,” and only woke up just as the head came into the world. When it is borne in mind how easily some women pass through labour, it is quite possible that, after a busy day, sleep may be so profound as not to be disturbed by the pains of labour. In primiparæ the occurrence is more problematical. Women have often declared that they have been unconsciously delivered whilst at stool. This is also possible, but the circumstances of the case must be severely sifted.

CHAPTER XIII FŒTICIDE, OR CRIMINAL ABORTION — 1. Natural or Accidental — 2. Violent

[“Every woman, being with child, who, with intent to procure her own miscarriage, shall unlawfully administer to herself any poison or other noxious thing, or shall unlawfully use any instrument, or other means whatsoever, with the like intent: and whosoever, with intent to procure the miscarriage of any woman, whether she be or be not with child, shall unlawfully administer to her, or cause to be taken by her, any poison or other noxious thing, or shall unlawfully use any instrument, or other means whatsoever, with the like intent, shall be guilty of felony, and being convicted thereof shall be liable, at the discretion of the Court, to be kept in penal servitude for life, or for any term not less than five years, or to be imprisoned for any term not exceeding two years, with or without hard labour, and with or without solitary confinement.”—Statute 24 and 25 Vict. c. 100, sec. 58.]

The 59th section of the same Statute also takes into consideration the unlawfully supplying or procuring any poison, or other noxious thing, or instrument, or thing whatsoever for a woman, for the purpose of inducing abortion. The person so doing shall be guilty of a misdemeanour, and be kept in penal servitude for a term of five years, or be imprisoned for any term not exceeding two years, with or without hard labour.

It will be seen from the passages above quoted that there is no distinction between a woman quick or not quick with child. “The offence is to procure the miscarriage of any woman, whether she be or be not with child” (R. v. Goodhall, 1 Din. 187; 2 C. & K. 293). But although the law does not regard “quickening” in cases of abortion, yet the fact of having “quickened” may be pleaded as a bar to immediate capital punishment.

Fig. 23.—Abortion at fourth week.
(Glaister.)

It has been decided in Scotland that drugging or operating to procure abortion is criminal, though unsuccessful, but it is not certain whether the woman alone can be charged with taking drugs to procure abortion. Both in England and in Scotland, to make the procuring of abortion criminal, “there must be felonious intent,” for it may be necessary to cause abortion. It must be borne in mind that the law allows no discretionary power on the part of medical practitioners who, to save the life of the mother, may deem it advisable to induce premature delivery. This being the case, no medical man should attempt to induce premature labour without the consent of the relatives of the woman, and the sanction of a medical colleague after consultation. This precaution is the more necessary as several medical men have been prosecuted, an event which would not have taken place had the precaution above suggested been observed. A medical man should also be very careful never to give any medicine “to bring on the courses” if he has the slightest suspicion of pregnancy, even as a “placebo” to satisfy an importunate patient, for should abortion be otherwise procured, his really harmless medicine may be accused with the result, and a grave suspicion be raised against him, to say the least.

The term abortion is understood in medicine to mean the expulsion of the contents of the fœcundated uterus before the sixth month of pregnancy, that is, before the child is considered viable. After this period it is said to be a premature labour.

In law, however, no distinction is made and the expulsion of the contents of the uterus at any period before the full time of pregnancy is considered an abortion; in popular language, a miscarriage.

Fig. 24.—Abortion between
sixth and eighth week.
(Glaister.)

 

Fig. 25.—Abortion at tenth week.
(Glaister.)

Abortion, when not produced by criminal means, generally occurs at or a little before the third month of utero-gestation, and then usually in first pregnancies, or during the latter part of the period of child-bearing. It is also more frequent among the rich than among the poor. Of the two thousand cases of pregnant women examined by Dr. Whitehead of Manchester, the sum of whose pregnancies was 8681, or 4.38 for each, rather less than 1 in 7 had aborted.

When abortion is criminally induced, it generally takes place between the fourth and fifth months, that is, about the time the woman becomes certain of her condition.

The Causes of Abortion are—

• 1. Natural or Accidental.—
• (a) Maternal—belonging to the mother;
• (b) Fœtal—belonging to the ovum.
• 2. Violent.—
• (a) Mechanical;
• (b) Medicinal.

(a) Maternal.—Among the maternal causes may be mentioned excessive lactation; any irritation of the rectum or bladder; loss of blood, which, by increasing the amount of carbonic acid in the blood, acts as an excitant to the spinal cord; excessive irritability and excitability of the uterus, &c. Certain states of the system conduce to abortion—albuminuria, syphilis, certain fevers, scarlet fever, smallpox, &c. Abortion may become habitual in some women. Great joy or sudden sorrow have not infrequently been the cause of abortion. The tendency to abortion is greatest at the menstrual periods, that is, at the time when, had not the woman become pregnant, menstruation would have taken place. Slight causes acting at these times are very liable to produce abortion.

(b) Fœtal.—The death of the ovum, or a diseased condition of its uterine coverings, or of the placenta, probably of an inflammatory nature.

(a) Mechanical.—Under this head may be mentioned the passage of certain instruments into the cavity of the womb, and the rupture by violence of the membranes which surround the fœtus; also the injection of fluids into the uterus. A medical man practising in Yorkshire informed Husband that so great was the dread of large families, that he knew of several ladies who, if they went a day over their monthly period, passed a catheter into the uterus, with the desired result. “It was wonderful,” he added, “how clever they were.” In India a twig of the Euphorbium nivulia, anointed with assafœtida, is used for the same purpose. “The fœtus is never delivered alive, but there is said to be no great danger to the woman” (Chevers). Women may use hairpins, knitting-needles, and the idea is to pass the instrument “until blood comes,” which is accepted as a sign that abortion will be sure to follow. In some cases it is by no means easy to procure abortion, and women have been known to undergo a considerable amount of violence without abortion taking place. In some women, however, on the other hand, the slightest violence—such, for instance, as slipping from a step or low chair—will cause them to abort.

(b) Medicinal.—Certain drugs, among which may be mentioned ergot, savin, pennyroyal, rue, tansy, saffron, perchloride of iron, diachylon which contains lead, and others, have been used for the induction of abortion. In India unripe pineapple has a great reputation as an abortive (Medical Jurisprudence for India, Chevers). It is scarcely necessary to mention each drug individually, but it must be remembered that there is not one single internal medicament of which it can be consistently with experience asserted that, even when an abortion has followed its use, it must have produced this abortion, and that cause and effect are in such a case “indirect and necessary connection.” All the so-called abortives are most uncertain in their action, and their use is attended with considerable risk to the woman. In the case of diachylon profound lead poisoning may be the result. Be this as it may, they are more frequently used to induce abortion than mechanical procedure, from the fact that the latter requires some amount of anatomical knowledge and manipulative skill.

The dangers of abortion from any cause are hæmorrhage, sepsis, and peritonitis. In mechanical interference, especially where proper precautions have not been taken to prevent them, sepsis and peritonitis from local injury and perforation are prone to occur.

A medical man may be required to—(1) Examine into the nature and characters of the substances expelled from the womb; (2) Examine the woman stated to have aborted.

1. Examination of the Substances expelled from the Womb.—The substances expelled from the womb often become the subject of judicial inquiry, and the medical man may be required to give his opinion as to their probable nature.

Dr. Gallard has called attention to the following:

1. During the last six months of pregnancy, abortion, even when it occurs spontaneously, goes through the two stages as at full time, i.e. the expulsion of the products of conception is, as a rule, preceded by rupture of the membranes, followed after a time by the expulsion of the placenta.

2. In the first three months this order of things is absent, for it is the rule to see the fœtus expelled entire en bloc without rupture of the membranes.

3. If, then, we find during the first three months of pregnancy the products of an abortion in which the membranes have been ruptured and the embryo expelled alone, we must look for a pathological cause for this infraction of a general rule; and if no disease of the embryo or of the mother is found, we are justified in attributing the abortion to mechanical means used directly against the products of conception. Charpentier has shown that this rupture of the membranes is not an absolute proof of criminal abortion; but in eighteen cases of spontaneous abortion M. Leblond only found rupture of the membranes in one, and in this the membranes presented an abnormal friability.

The questions may be asked—(1) Is it a fœtus?—(2) Is it a mole? If so, is a mole also a fœtus?—(3) Is it merely the coats of the uterus, and unconnected with pregnancy?

1. Is it a Fœtus?—The development of the fœtus is given on pp. 35, 36 et seq.

2. Is it a Mole?—This question gives rise to another: Is a mole a fœtus? To this the answer must be in the affirmative. Moles, being the diseased appendages of the fœtus, vary in character, and have been described by obstetrical writers under the following heads: (a) Hydatiginous; (b) Carneous; (c) Fatty Moles.

3. Is it merely the Coats of the Uterus, and unconnected with Pregnancy?—Fleshy masses may be expelled from the womb, which may not be the result of sexual intercourse. The description just given of true moles will, it is hoped, assist in forming a correct diagnosis. Considerable care will be required, for the honour of the woman accused depends upon the opinion given as to the nature of the substances submitted for examination. It must also not be forgotten that moles may be retained for many months in the uterus and be then expelled. The knowledge of this fact may rebut an accusation of infidelity against a wife. Polypi may be discharged from the womb; the presence of a pedicle will point to their true character. All substances expelled from the uterus should be carefully washed in water, and all clots removed. The examination of the woman may also help in the formation of the diagnosis. The absence of the signs of defloration or of recent delivery will be in her favour.

2. Examination of a Woman stated to have aborted.—This subject may be divided under two heads—(1) Has the woman been recently delivered? (2) What were the means used to procure the abortion?

It is by no means easy to answer the question whether an alleged abortion has really taken place or not. The signs of recent delivery are in most cases absent, for the woman can better hide her condition during the earlier than during the later months of utero-gestation; consequently suspicion may not have been aroused against her for some weeks or months after the event. The history of the case, with other attendant circumstances—milk in the breasts, change in the colour of the areola round the nipples, severe flooding, absence of the hymen, injuries to the os uteri, transverse condition of the os uteri in contradistinction to its circular form after delivery, &c.—will, in most cases, assist in forming a correct diagnosis; but it must be again repeated that few of the signs applicable to delivery at the full time are here available.

In all doubtful cases—

Where death is supposed to have followed the use of abortives, the alimentary canal must be examined for the signs of the action of irritants, or the presence of disease in the internal organs; but when death has resulted from an attempt to procure abortion by instrumental means, the neck of the womb is most frequently found covered by a number of small more or less irregular wounds, which may penetrate into the womb or lose themselves in the walls of the organ. Their course is indicated by infiltration, or a small extravasation of coagulated blood, the exact condition of which must, if possible, be ascertained, so as to decide when the wound was inflicted.

The examiner must not forget that the wounds may extend to the fundus of the uterus, and in this case the autopsy shows that a blunt instrument, as a catheter or uterine sound, introduced through the os uteri into the retroverted uterus, glides by its own weight into the rent. The seat of the tear leads one to think that pregnancy was not far advanced when the attempt was made, and in fact the accident most frequently occurs in cases of suspected pregnancy. It must be remembered that the uterus is often punctured by the injudicious use of the uterine sound, but without any immediate dangerous symptoms. Wounds in the walls of the vagina indicate the use of instruments by an inexperienced hand; in the fundus of the uterus, to one at least accustomed to the introduction of instruments. Spontaneous rupture of the uterus is impossible during the early periods of pregnancy, just when the attempts at abortion are usually made. Rupture due to external violence is, as a rule, accompanied with outward signs of the violence used.

In all cases a careful examination of the structure of the uterus should be made. An examination of the ovaries for false or true corpora lutea should be made. The opinions on the character and differences of these bodies are so discordant as to destroy all confidence in their value as proof of conception or the reverse.

Taylor says: “The discovery of the ovum in the uterus in process of development could alone, in the present state of our knowledge, warrant an affirmative opinion on this point in a Court of Law, and this I believe to be the safest view at present of this much-contested question. On the other hand, the absence of a corpus luteum from the ovary would not in all cases warrant an opinion that conception had not taken place.”

Examine carefully for local sepsis and signs of inflammation of the uterus and its surrounding structures.

Recapitulation

In Medicine, Abortion occurs before the sixth month of pregnancy—premature labour after that period.

In Law, Abortion may take place any time before the full period of utero-gestation.

Abortion may be due to—

• 1. Natural or Unavoidable Causes.
• (a) Maternal. (b) Fœtal.
• 2. Violence, with Criminal Intent.
• (a) Mechanical. (b) Medicinal.

CHAPTER XIV INFANTICIDE — DEFINITION OF THE TERM “LIVE BIRTH” IN CRIMINAL CASES — DEFINITION OF THE TERM “LIVE BIRTH” IN CIVIL CASES — CAUSE OF DEATH TO THE FŒTUS — 1. In Favour of Precipitate Birth and Accidental Injury — 2. In Favour of Criminal Violence

According to the present state of English law, infanticide—murder of a new-born child—is not regarded as a specific crime, but is treated and tried by those rules of evidence which are applicable in cases of felonious homicide, but with this difference, that the law requires proof that the child was born alive. An old Statute (21 Jac. I. c. 27) made the concealment of the birth of a bastard child conclusive evidence of murder. As far as the legal estimation of the crime is concerned, it matters not whether the child was killed immediately on its entrance into the world, or within a few days afterwards. A fœtus not bigger than a man‘s finger, but having the shape of a child, is a child within the Statute (R. v. Colmer, 9 Cox, 506; R. v. Hewitt, 4 F. & F. 1101). An English judge, at a late trial, stated that if the jury were of the opinion that the prisoner had strangled her child before being wholly born, she must be acquitted of murder. The law also, on the score of humanity, presumes that every child is born dead until direct evidence to the contrary, from medical or other sources, is given. The onus of the proof of live birth, therefore, devolves on the prosecution. It may also be difficult to decide as to the maternity, and the woman accused will have to be examined as to the possibility of her recent delivery.

Here let me repeat the advice given on page 148 as to the examination of a woman. Your duty is to request the woman to allow of the necessary examination, giving her the warning which every magistrate or coroner is bound to give to any person charged with a crime, before requiring an answer to a question which may be used in evidence against her at the subsequent trial. The innocent and the guilty may alike object to an examination, but the presumption is against the party declining, if several have voluntarily submitted. A young lady committed suicide rather than submit to an examination by two medical men under an order from the coroner. The medical men were guilty of a grave indiscretion, and both they and the coroner were acting ultra vires in attempting to force a woman to obtain evidence against herself (Taylor, vol. ii. p. 431).

The decision as to recent delivery will, to a great extent, rest on the condition of the mother, and the apparent age of the child found dead. The discovery of the body of the child is not necessary to conviction, but the medical evidence as to the signs of respiration, of course, depends on the body being found and examined. In most cases of alleged infanticide tried in England, juries appear more inclined to fall back on the minor offence—concealment of birth—than to convict of the capital offence; and this appears to be the only alternative if the body cannot be found, for, as we have just said, in law every child is held to be born dead. It must of course be shown that the woman has been recently delivered. In case of failure to prove the murder of the child, the Act (24 and 25 Vict. c. 100, sec. 60) enacts that “if any woman shall be delivered of a child, every person who shall, by any secret disposition of the dead body of the said child, whether such child died before, at, or after its birth, endeavour to conceal the birth thereof, shall be guilty of a misdemeanour.” The mere avowal of the birth is not sufficient to convict her; she must be proved to have done some act of disposal of the body after the child was dead (R. v. Turner, 8 C. & P. 755).

In Scotland, concealment of pregnancy is a statutory crime, chargeable when the child born is found dead or is not found at all, and there is no proof of its having been murdered. Pregnancy, up to a period when a child might be born alive, must be proved, and the words “during the whole period of her pregnancy” do not imply that the pregnancy must have continued for the full period of nine months. All that is necessary is that there should be such proof of duration of pregnancy as made a living birth possible. If the accused can bring forward a witness to whom she communicated her pregnancy, or called for assistance at the birth, or (it is believed) can prove that the child was born dead, she is entitled to an acquittal.

It has also been said that a woman ought not to be convicted of “concealment of pregnancy,” if at the time of delivery the fœtus do not appear to have reached the seventh month of intra-uterine existence. The birth of a “child,” whether dead or alive, is essential; therefore, if the woman accused “can prove that that which she brought forth was not a ‘child,’ but an abortion, or a fœtus, which, from some accident, was in such a condition that, though there had been assistance, it could not have been in a condition to be called ‘a child,’ then the case is out of the Statute.” The Scotch Statute differs from the English on the “concealment of birth” in this, that so long as the woman makes known her pregnancy, the motive for doing so is not considered. Thus, if she make arrangements with anyone to conceal the birth, “the Statute is eluded by that very circumstance” (Alison). The Statute applies to married as well as to single women; but, in the former case, the penalty is seldom enforced unless foul play is suspected.

“The entire delivery of a child.” There must be an independent circulation in the child before it can be accounted alive (R. v. Enoch, 5 C. & P. 539). The entire child must be actually born into the world in a living state (R. v. Poulton, 5 C. & P. 329). But the fact of the child being still connected with the mother by the umbilical cord will not prevent the killing from being murder (R. v. Reeves, 9 C. & P. 25). To kill a child in its mother‘s womb is no murder, because the person killed must be “a reasonable creature in being, and under the King‘s peace.” But if the child be injured in the womb, and yet be born alive, and then die as a result of such injuries, it may be murder in the person who inflicted them (R. v. Senior, 1 Mood. C. C. 346).

A distinction must be drawn between medical or physiological life and legal life. A child may have breathed, as it not infrequently does, before it is completely born into the world; and this might, in a medical point of view, be considered as a live child, but it is not one legally. The entire delivery of the child is necessary in law; and “it must also be proved that the entire child has actually been born into the world in a living state, and the fact of its having breathed is not a conclusive proof thereof.” The inference unfortunately follows from this ruling, that a mother may kill her child without fear of punishment, if she do so before the entire body has slipped from her.

The evidence of live birth in civil is somewhat different from that required in criminal cases. The viability of the child is determined in Scotland by its crying; in France, by its respiration; in Germany, “the LIVE BIRTH of a child is to be held proven when it has been heard to cry by witnesses of unimpeachable veracity present at its birth”; but in England, the pulsation of the child‘s heart, or any tremulous motion of the muscles, however slight, has been considered as satisfactory proof of live birth.[15]

According to Blackstone, “crying, indeed, is the strongest evidence, but it is not the only evidence”; and Coke remarks, “If it be born alive, it is sufficient though it be not heard to cry, for peradventure it may be born dumb.”

Signs of Live Birth prior to Respiration, and independent of it.—(1) Negative.—Signs of intra-uterine death, i.e. putrefaction, or “intra-uterine maceration,” or of such imperfect development that it could not have been born alive. (2) Positive.—Injuries to the child showing that it must have been born alive.

1. Negative.—Intra-uterine Putrefaction.—This condition differs in some remarkable points from putrefaction in air.

The body is extremely flaccid and flattened, the bones of the cranium moving easily on one another. The skin of the hands and other parts of the body bear the evidence of prolonged soaking in fluid. In parts, the skin is whitish, or of a reddish-brown or coppery-red colour, without any trace of green, which is always present when putrefaction takes place in the air. The cuticle may be raised in blisters, and be easily detached from the true skin. The denuded patches are moist and greasy, and exude a stinking, reddish-coloured serous fluid. The face is flattened, and the features distorted. In one case that Husband attended of intra-uterine death of the fœtus in a primipara, and where putrefaction was far advanced, the scalp burst during delivery, and the brain was poured out. Should, however, the child be exposed to the air, it may soon acquire the appearances proper to putrefaction in that medium. If the child, immediately after birth, be thrown into water, the putrefactive changes would be like those of intra-uterine decomposition. In this case the lungs must be examined for the evidence of death by drowning.

2. Positive.—Evidence that injuries found on the body could not have been inflicted during birth, or accidentally after birth. On this subject it is scarcely possible to give an opinion one way or the other. All the medical witness can fairly state is, that, from the condition of the lungs, respiration has or has not taken place; that, in the former case, it is not easy to state whether the injuries were the cause of death or inflicted after death.

Appearances showing that a New-Born Child has breathed.—1. Walls of the Chest.—“The vaulting of the thorax is not of the slightest diagnostic value.” Casper quotes from Elsässer the following remarks: “It is irrefutable that the variations in the circumference of the thorax (and, of course, in its diameters) are so considerable that no certain normal mean for a thorax that has breathed, and for one that has not breathed, can be laid down. In most cases the measurements of the thorax are incapable of determining whether the lungs contain air or not. The reasons for these variations is, without doubt, to be referred to the congenital differences in the volume of the osseous thorax; partly, also, to the thickness of the soft parts, particularly of the subcutaneous fat and the thoracic muscles; partly, also, to the differences in the degree and amount of the dilatation of the thorax by respiration, with which the distension of the lungs also corresponds,” &c.

2. Diaphragm.—The position of the diaphragm may be considered as a good diagnostic sign; for it is found that, in children born dead, the highest point of the concavity is between the fourth and fifth ribs, whereas in those born alive it is between the fifth and sixth. The position of the diaphragm may be affected by the gases produced during putrefaction, and also, in children who have breathed, from distension of the stomach and intestines with gas.

3. Stomach and Intestines.—With regard to the stomach, Tardieu has suggested that the presence of air-bubbles in the glairy mucus usually found in that organ is a sign of live birth, as it can only have arisen from the swallowing of saliva and mucus, aerated by repeated attempts at respiration, probably lasting from five to fifteen minutes. Air in the duodenum is strong evidence of live birth. Breslau of Prague, who has further investigated this subject, states that, in children born dead, or who have undergone prolonged intra-uterine putrefaction, there is never any accumulation of gas in the stomach or intestines, and that the presence of gas in these organs is contemporaneous with respiration, and is independent of the ingestion of food. The intestines of newly-born children do not float in water, but rapidly sink in that fluid. As respiration proceeds, the coils of the intestines become distended with gas.

4. Kidneys and Bladder.—The presence of crystals of uric acid in the pelvis of the kidneys and even in the bladder has been suggested as a sign of live birth. Uric acid infarction, as it has been called, usually occurs in from two to ten days after birth, at a period when there are more important signs of live birth than this, even if infarction did not occur, as it does, in still-born infants.

5. Lungs.

(a) Size.—In the fœtus, prior to respiration, the lungs do not fill the cavity of the chest, and the left lung is never found even partially covering the heart.

After respiration they fill the thorax more or less completely, the amount of distension depending, of course, upon the completeness of the respiratory acts on the part of the child.

(b) Consistence.—Before respiration has taken place, the lungs feel firm, compact, and resistant, and are of the consistency of liver.

After respiration they are spongy, crepitant, and yielding when pressed between the fingers. They also present a marbled appearance. These signs of respiration are more or less modified by disease, and the atelectasis pulmonum of Jörg, jun.

Casper denies the existence of atelectasis pulmonum as a distinct disease of newly-born children, and considers that “it is nothing else than the original fœtal condition, from which it differs in no anatomical respect”—an opinion supported by Meigs, who says “it, in fact, resembles exactly the fœtal lung.” It is simply the result of the child dying from some cause before respiration has had time to become fully established, and has possibly been confounded with hepatisation. It must also be remembered that cases are on record of infants having lived for some hours, and then died, yet the lungs sank as a whole, and when cut in pieces.

(c) Colour.—The colour of the fœtal lungs is “exceedingly various,” and it is by no means easy to convey the idea of colour by words. Speaking in general terms, the lungs of children who have not breathed are of a reddish-brown liver colour, this colour changing to a brighter red at their margins. In children who have breathed, the lungs are of a slaty-blue colour, more or less mottled with circumscribed red patches. This circumscribed mottling is never found in perfectly fœtal lungs. When the lungs are inflated artificially, they swell up and present a uniform cinnabar-red colour, destitute of insular marbling. The insular marbling of the lungs is characteristic of lungs that have breathed, and is due to the presence of blood in the arteries and veins surrounding the inflated lung tissue.

(d) Buoyancy in Water.—Lungs which have respired float in water.

But the objection may be raised that lungs that have not respired may yet float from—

• 1. The result of artificial respiration.
• 2. The result of putrefaction.

The value of these objections will be discussed in the following pages.

The following table is given by Tidy:

Hydrostatic Lung Test

(Docimasia pulmonum hydrostatica)

The value of this test, which is a test of respiration and not of live birth, is founded on the supposition that a lung in which respiration has taken place will float if placed in water, and that when this has not occurred it will sink. Admitting that a lung floats as a result of respiration, it has been objected that this is no proof of live birth, for respiration may take place in:

• 1. The womb, vagitus uterinus.
• 2. The maternal passages, vagitus vaginalis.
• 3. Cases when the head protrudes, the body not yet being born.

With regard to the two first objections, it will be sufficient to say that, in all the cases of so-called intra-uterine respiration, the respiratory acts have occurred in difficult or instrumental labours, where it is justifiable to suppose that, in the endeavour to remove the child, a certain amount of air may have been unavoidably admitted into the maternal passages. But the cases with which the medical jurist has to deal cannot be classed with these, for in all those brought under his notice delivery has been more or less rapid and unassisted.

To the last objection the same reply may be given, that rapid delivery in doubtful cases must be considered as the rule, and that the time which elapses between the birth of the head of the child and its complete delivery is so short as not to lead to any great error in diagnosis. It is true that the woman may faint with the child half born, and that respiration may thus take place; and it has not yet been decided how many inspirations a child must make to entirely inflate its lungs, or the length of time required to do so.

N.B.—Any pressure exerted on the umbilical cord during the process of delivery gives rise to respiratory acts on the part of the fœtus. The presence of what Casper calls petechial ecchymoses beneath the pleuræ, upon the aorta, and even on the heart, are, as a rule, a proof that attempts at respiration have been made. These petechial ecchymoses are sometimes found on the same parts in the drowned. (See “Drowning.”)

How is the Hydrostatic Lung Test performed?
and What are the Objections to its Use?

As this test was first used, it consisted in placing the lungs, with or without the heart, in water, and then noting whether they sank or floated. A glass vessel, eighteen inches high and twelve in diameter, half filled with distilled water at 60° F., should be used. In summer, water at the ordinary temperature of the room will answer the purpose. To this rough test pressure is now added; the lung, or portions of it, are greatly compressed in a linen cloth, and then thrown into water as before. If the lungs thus compressed float, respiration is held to have taken place; should they sink, the contrary is presumed.

Pressure is used for the following reason: The air generated by putrefaction, and which may cause the lungs to float, is removed by pressure, but no amount of pressure, short of entirely destroying the lung tissue, will remove that which is the result of respiration or inflation; and between these the medical expert must decide from collateral evidence.

In performing the test: (1) Try if the lungs will float with the heart and thymus gland attached to them. (2) If they will float without the heart, &c. (3) Try if portions will float with or without pressure.

The following are the Objections to this Test:

• 1. The lungs may sink as a result of disease.
• 2. Respiration, even in healthy lungs, may be so imperfect
• that they may sink.
• 3. Emphysema pulmonum neonatorum.
• 4. Putrefaction.
• 5. Artificial inflation.

1. That in consequence of disease the entire lungs, or portions of them, may sink, and yet respiration may have taken place. Disease of the lung may occur previously to birth or soon afterwards, but it is scarcely probable that the disease would attack every portion of the lung. Parts, doubtless, small in proportion to the diseased part, may yet have been sufficiently inflated to float. The presence of disease is also not difficult of detection.

2. That respiration, even in healthy lungs, may be so imperfect that they may sink. This objection can scarcely be considered valid against the general application of the test, for in these cases there is no known test by which respiration or its absence can be determined. They are, therefore, out of the pale of the test, as they are out of every other mode of investigation.

3. Emphysema pulmonum neonatorum.—Emphysema is generally the result of excessive dilatation of the air cells of the lung, rupture of the cell walls, and infiltration of the intra-lobular areola tissue. This condition may be brought about by:

(a) Respiration.  (b) Inflation.

The fact of the matter is simply this, that the so-called emphysema pulmonum neonatorum, or emphysema of new-born children, is nothing more or less than incipient putrefaction, induced by certain unascertained conditions.

Casper sums up his conclusions on this subject in the following words:

4. Putrefaction.—It must be admitted as proved that the lungs of new-born children in a state of decomposition will float in water. But this admission does not render the test valueless, for it must be remembered:

5. Inflation.—In the first place, it is to be remarked that to inflate the lungs is by no means an easy task. Elsässer states “that in forty-five experiments performed on children born dead, without opening their thorax and abdomen, only one was attended with complete success, thirty-four with partial success, and ten with none whatever; and it must also be remembered that these experiments were conducted without disturbance, and with the greatest care.” Professor Gross states his opinion on this subject thus: “We are decidedly of opinion that artificial inflation of the lungs is a very difficult matter; and we believe that the complete distension of these organs can only be effected where a tube is introduced into the mouth of the larynx.” In the cases that come before the medical expert, the question naturally arises, Who would inflate the lungs? Surely not the mother. If not the mother, who else? It has been suggested that some malicious person might inflate them to sustain a charge of infanticide. Is this probable?

The following points may be noticed on this subject:

It may be further noted that natural respiration is accompanied with, first, the distension of the air cells of the lungs with air; and, second, with an increased flow of blood into the organs, beyond that necessary for their nourishment and growth. They thus increase in absolute weight, while their specific gravity is lessened.

The objections just mentioned apply to the hydrostatic test as originally employed. It will now be necessary to notice those against the same test when modified by pressure. These are two in number:

1. That no amount of pressure, short of entirely destroying the lung tissue, can expel the air from a lung that has been inflated, or from one in which respiration has taken place.

2. Pressure is, therefore, no test of natural respiration or of artificial inflation.

In answer to the above, it will only be necessary to refer to what has been already said with regard to the difficulty of inflation, and the more probable event of the condition of the lungs being the result of respiration.

Casper thus sums up the result of his views with regard to the probative value of the docimasia pulmonaris:

“That a child has certainly lived
during and after its birth—

“1. When the diaphragm stands between the fifth and sixth ribs.

“2. When the lungs more or less completely occupy the thorax, or at least do not require to be sought for by artificial separation of the walls when cut through.

“3. When the ground colour of the lungs is broken by insular marblings.

“4. When the lungs are found by careful experiment to be capable of floating.

“5. When a bloody froth flows from the cut surface of the lung on slight pressure.”

The Lung Test is unnecessary when—

1. The umbilical cord has dropped off, and cicatrisation has followed.

2. Where food is found in the stomach.

3. Where there are evident signs of putrefaction in utero.

4. Also in the case of the birth of monsters, or where, from congenital malformation, the possibility of live birth is excluded.

Besides the hydrostatic test, the following have been proposed:

Ploucquet‘s Test.—This test is based on the relative weight of the lungs, before and after respiration, to that of the entire body of the child. The variations found in practice between the relative weights render the test worse than useless.

Absolute Weight of the Lungs.—This test consists in a comparison of the weight of the lungs before and after respiration, and it may be stated here that the lungs, prior to respiration, vary in weight from about 400 to 650 grains; but so much depends on the maturity or immaturity of the child, and degree of respiration, that, like the last, the test is unworthy of confidence.

Wredin‘s Test.—Dr. Wredin, of Petrograd, states that the gelatinous substance found in the middle ear of infants before birth, gradually disappears, to be replaced by air on the subsequent establishment of respiration. Wendt, of Leipzig, from an examination of 300 cases, declares that the gelatinous substance can only be expelled by the establishment of full respiration. The value of this test has been questioned, as some observers have found that in different cases intervals of from a few hours to five weeks have occurred, before the replacement of the gelatinous material by air.

Table Showing the Signs of
Maturity of Child At Birth

As regards:

1. Average Length of Body.—Nineteen inches.

2. Average Weight of Body.—About seven pounds.

3. Eyes.—The pupillary membrane is not found in the mature child.

4. Navel.—Said to be exactly midway between the pubes and the ensiform cartilage.

5. External Genitals.—Testicles found in the scrotum, and the labia majora cover the vagina and clitoris.

6. Os Femoris.—Ossification of the inferior femoral epiphysis. The osseous nucleus measures from three-quarters of a line to three lines in diameter.

Death may be due to—

•  I. Immaturity on the part of the fœtus.
•   II. Complications occurring during or immediately after birth.
•  III. Congenital disease in one or more of the fœtal organs.
• IV. Neglect or exposure, constituting “Infanticide by Omission.”

I. Immaturity on the part of Fœtus.-From some cause or another, the child may die immediately after birth, in spite of every attempt to save it. In many of these cases no disease adequate to account for death can be detected.

II. Complications occurring during or immediately after Birth.—(1) Unavoidable or inherent in the process of parturition. (2) Induced with criminal intent, constituting “infanticide by commission.”

1. Unavoidable or Inherent in the Process of Parturition.—The immediate cause of death may be either maternal or fœtal. In the former, the presence of tumours in the pelvic passages, or disease of the bones, causing a narrowing of the canal, may lead to fatal compression of the head of the child. Death may also be due to protracted labour from debility on the part of the mother, or she may suddenly faint after delivery. A congested state of the brain may be present in these cases. In the latter (fœtal), pressure on the umbilical cord from malposition of the child during labour, or an abnormal increase in the size of the head, may cause death. There is also a greater mortality, both during and after delivery, among male than female children. The child may be also accidentally suffocated in the fæces of the mother, or in the fold of her dress; or it may be born while the woman is straining at stool, and be drowned in the contents of the pan. Husband once met with a case of accidental death of a child from suffocation in the drawers of the mother, who persisted, from motives of delicacy, in wearing those articles of dress during her confinement. Death may also result from strangulation, occasioned by the pressure of the funis round the child‘s neck. The death in this case can scarcely be considered as due to strangulation, as the child had never breathed, but it is probably the result of the arrest of the flow of blood along the cord, from the tightness of the folds round the neck. Some congestion of the brain may, however, be found resulting from the pressure on the vessels of the neck. Lastly, death may ensue from a fall on the floor in cases of sudden and quick labours, especially if the woman be in the erect posture at the time of delivery.

2. Induced with Criminal Intent.—Infanticide by commission: was the death due to violence? The answer to this question is by no means easy. In all doubtful cases the attendant circumstances must be taken into consideration. A woman may unintentionally injure her child in her efforts to drag it from her. The presence of respiration, more or less complete, is strongly presumptive against the death being the result of accident. But even here considerable caution is necessary, for the injury may not be immediately fatal, although accidentally inflicted, sufficient time elapsing between its infliction and the death of the child to allow of respiration. Foreign bodies found in the mouth and fauces are also corroborative of death by violence. A case is recorded in which the child‘s fauces, upper portion of the œsophagus, the larynx, and the trachea were closely packed with a coarse green sand, and yet the lungs sank when the hydrostatic test was applied to them. There was nothing to show when the packing of the fauces was effected.

Strangulation may be produced by the constriction of the umbilical cord round the neck, and for this reason marks round the child‘s neck cannot always be ascribed to intentional violence. Of 327 cases collected by Elsässer, in which the cord was from one to four times round the children‘s necks, there was not in a single instance any mark of the cord perceptible, even though in some cases the cord had to be cut to permit the completion of labour. With regard to marks round the neck of a new-born child, Casper remarks that it is possible “to mistake the folds of the skin, produced by the movements of the head, and which remain strongly marked in the solidified fat, and are very prominent, particularly in short necks, for the marks of the cord.” The mark left by the funis is broad, corresponds with the breadth of the cord, runs without interruption round the neck, and is everywhere quite soft, and never excoriated. Ecchymoses may be present, irregularly following the line made by the cord. On the other hand, “a mummified, parchment-like, unecchymosed depression points in every case to strangulation by a hard, rough body,” and this more especially if there be any abrasion of the cuticle or laceration of the skin. Death, sometimes ascribed to strangulation, is probably the result of suffocation, and happens thus: any pressure exerted on the cord cuts off the blood from the placenta to the fœtus, and gives rise to respiratory attempts on the part of the child, the child dying from suffocation, or from the engorgement of the lungs with liquor amnii drawn into them at every effort to breathe. An infant may be poisoned. This cause of death is very rare, but deaths have resulted from the use of poisonous gases. While on this subject it may be advisable to state here that ulcerations have been found in the stomach and intestines more or less accompanied with a collection of dark brown or black bloody fluid, which have given rise to suspicions of poisoning in infants to all outward appearances quite healthy. An infant may be thrown into water and drowned. No traces of this mode of death would be discoverable in the infant unless respiration had taken place prior to its immersion. The plea of accidental drowning in a cesspool or water-closet pan may be put forward; it is therefore well to examine the cord. Has a ligature been placed upon it? Has it been cut by a sharp instrument? The nature and character of the fluid found in the stomach should be noted.

Fractures of the skull may happen—

1. In the Womb.—The parturient female may fall from a considerable height, and thus cause injury to her child. These cases are of no judicial importance, as the presence of intra-uterine putrefaction or an examination of the lungs will at once show that the child has not breathed. It must be borne in mind, however, that dislocations may take place in the womb, and this fact may be brought forward in defence. The history of the case, and the absence of any other signs of violence, will decide the truth or falsity of the plea.

2. During Labour.—Fracture of the cranial bones during labour generally occurs in difficult and protracted labours, which, from this very cause, seldom become the subject of judicial inquiry. In some cases the defective ossification of the bones of the skull may give rise to fractures, which may lead to dangerous mistakes. This deficiency, in the process of ossification is thus described by Casper: “If the bone in question is held up to the light, this is seen to shine through the opening, which is closed only by the pericranium. When the periosteal membrane is removed, the deficiency in the ossification is seen in the form of a round or irregularly circular opening, not often more than three lines in diameter, though frequently less; its edges are irregular and serrated: these edges are never depressed, as is the case in fractures; and neither they nor the parts in their neighbourhood are ever observed to be ecchymosed.” The child in these cases may breathe for a short time, and then die without any apparent cause.

Fig. 26.—Photo-micrograph
of human milk, × 250.
(R. J. M. Buchanan.)

3. By Falls.—It is beyond doubt possible for a child to be born so precipitately as to fall on the floor and be severely injured, and that even fatally. In cases of alleged precipitate birth, to account for injuries found on the child, the following points should be remembered, and will assist in forming a diagnosis:

(a) Rupture of the umbilical cord. In all cases it would be advisable to measure the length of the cord, and then the distance of the vulva from the ground, allowing of course for the woman not being quite erect at the time of delivery owing to a separation of the legs. A disproportion between the two measurements may or may not account for the rupture of the cord. The following measurements may be taken: usual length of cord, eighteen to twenty inches; distance of vulva from the ground, twenty-six inches, but allowing for stooping, two-thirds of the above. To the length of the cord must be added about nine inches, the distance from the navel to the top of the head of the child. Thus, a fall of about thirty inches will put no strain on the cord. A case is on record of a rupture of the cord taking place while the woman was in a recumbent position, but in that case the labour was precipitate, and the cord very short and small.

(b) Placenta not detached from the child.

(c) Fracture of the parietal bones; the fracture radiating into the frontal and squamous portion of the temporal bone. In experiments on twenty-five children dropped from a height of thirty inches, one parietal bone was found fractured in sixteen of the cases; both parietals, in six cases. The fractures in most cases occurred about the parietal protuberances. It must be remembered that the children were dead, and that it is easier to fracture the skull of a live infant than that of a dead one.

(d) Imperfect ossification of the bones of the skull.

(e) Absence of other injuries.

(a) The fact of the umbilical cord being divided by some sharp instrument and not torn. A caution must be here inserted, for Taylor mentions a case where rupture of the cord occurred in such a manner that it could not be decided whether it had been intentionally cut or torn.

(b) Extensive fracture of one or more of the bones of the cranium.

(c) Fracture and dislocation of the neck.

(d) Presence of incised wounds, and other evidence of violence.

N.B.—In all doubtful cases, a guarded opinion should be given, stating simply that the dissection does not reveal anything contrary to the statements offered as to the cause of death.

III. Congenital Disease in one or more of the Fœtal Organs.—In all cases the presence of congenital disease must be sought for.

IV. Neglect or Exposure, constituting “Infanticide by Omission.”—Under this head may be mentioned the following:

(a) Neglecting to place the child in such a position that it may breathe freely.

(b) Neglecting to protect the child from extremes of cold or heat.

(c) Neglecting to feed it with the food appropriate to its age. (See Signs of Death from Starvation, pp. 132 et seq.)

(d) Neglecting to tie the umbilical cord.

To give answers to these questions will in many cases be impossible, and each must be decided by such circumstances as present themselves in each individual case. For instance, if the body be found stiff, blanched, naked or nearly so, lying on the ground, the vessels of the interior gorged with blood, whilst the superficial vessels are contracted and can be seen only with difficulty; at the same time, the hydrostatic test shows that respiration has taken place, and in the absence of all external or internal causes—the probability is in favour of death by cold. In close relation with the present subject is the question—

Has the Infant bled to Death?—Fatal hæmorrhage from the cord may occur, especially if it be divided by a sharp instrument close to the body of the child. As a rule, hæmorrhage does not occur from a ruptured cord. (The signs of death from hæmorrhage have been noticed, page 81.)

How Long did the Child survive its Birth?—The answer to this question is by no means easy, and the data on which a decision can be based are not very reliable. The presence or absence of the vernix caseosa should be noticed. In still-born children the closed eyelids, when raised, do not remain open; in the live-born, on the other hand, the eyes remain half open even after repeated attempts to close them. Another guide to the determination of the length of time the child survived its birth may be found in the absence or presence of the meconium in the intestines. The meconium—so-called from its resemblance to inspissated poppy juice—is found in the large intestine as a dark-greenish pasty mass, more or less filling that portion of the bowel. In the upper portions of the intestines it varies from a light-yellowish or greyish to a greenish-brown colour, till in the large intestine it assumes the colour and consistence above mentioned. It is generally discharged by the infant in from four or five to forty-eight hours after birth. In breech presentations it may be passed during the process of delivery, although the child be still-born; but its entire absence from the intestines is presumptive of existence for some days after birth.

Fig. 27.—Photo-micrograph of
starch granules, × 250 (potato).
(R. J. M. Buchanan.)

The following are some of the points to be considered in forming a diagnosis: (1) Changes in the skin. (2) Changes in the umbilical cord. (3) Changes in the circulatory system.

Table showing how long a
New-born Child has Lived.

1. Changes in the Skin.—Exfoliation of the cuticle. The time at which this occurs is so variable as to be of little value in a medico-legal inquiry.

2. Changes in the Umbilical Cord.—Mummification of the cord is not of the slightest value as a proof of extra-uterine life; but the separation of the cord which occurs between the fourth and seventh day, especially when cicatrisation has taken place, is a sure sign that the child must have lived four or five days at least. Two other appearances of some value may also be noted, namely:

(a) In fresh bodies, the appearance of a bright red ring about a line in breadth, which surrounds the insertion of the cord, and which is formed within the uterus.

(b) A similar red ring, about two lines broad, around the insertion of the cord, accompanied with “thickening, inflammatory swelling of the portion of the skin affected, and slight purulent secretion from the umbilical ring itself.” This latter condition Casper considers as affording “irrefragable proof of the extra-uterine life of the child.”

3. Changes in the Circulatory System.

(a) Ductus Arteriosus.—Arterial duct. A contracted condition of this duct is of no value as a proof that a child has survived its birth; for the duct is liable to become contracted, and even obliterated, before the birth of the child.

(b) Ductus Venosus.—Nothing certain is known as to the exact time when this duct closes; the condition of the vessel is, therefore, of no assistance in determining the possibility of the child having survived its birth. The duct has been found closed in a still-born child; and in one child, which lived for a quarter of an hour, both the ductus arteriosus and the foramen ovale were found closed. Cases are also on record in which these fœtal channels were found open after thirty days of extra-uterine life.

(c) Foramen Ovale.—What has been said of the preceding may be said with regard to the foramen ovale.

N.B.—To sum up, therefore, in the fewest words, any attempt at forming an opinion on the docimasia circulationis may result in a fatal error on the part of the medical witness, as it is impossible to determine with any accuracy by days the period of their closure. As a general statement, however, the following, according to Bernt and Orfila, is the order in which obliteration of the fœtal vessels takes place: (1) The umbilical arteries. (2) Ductus venosus. (3) Ductus arteriosus. (4) Foramen ovale.

Synopsis

1. Infanticide is not regarded as a specific crime.

2. To be tried by the same rules of evidence as apply to murder.

3. The law presumes that every child is born dead, till proof to the contrary is given.

4. Onus of proving live birth devolves on the prosecution.

5. The body need not be found in order to obtain conviction of the suspected party, if not of infanticide, at least of concealment of birth.

6. In absence of proof of infanticide, the woman, in England, may be tried for concealment of birth, that is, disposing secretly of the body, whether the child be born dead or alive.

7. In Scotland, a woman may be tried for concealment of pregnancy when the child is dead or missing, if she do not call for or make use of help or assistance in the birth; but the case is quashed, if the child be shown alive by the mother to others.

CHAPTER XV INHERITANCE—LEGITIMACY—IMPOTENCE AND STERILITY —SURVIVORSHIP—MALPRAXIS AND NEGLECT OF DUTY —FEIGNED DISEASES—EXEMPTION FROM PUBLIC DUTIES—WILLS — INHERITANCE — LEGITIMACY — IMPOTENCE AND STERILITY — SURVIVORSHIP — MALPRAXIS AND NEGLECT OF DUTY — FEIGNED DISEASES—MALINGERING — EXEMPTION FROM PUBLIC DUTIES — WILLS

This subject will be discussed under the following heads: (1) The child must be born alive. (2) The child must be born during the lifetime of the mother. (3) The child must be born capable of inheriting. (4) Tenancy by courtesy, and possessio patris.

1. The Child must be born alive.—This has been discussed in the preceding section.

2. The Child must be born during the lifetime of the Mother.—Death terminates the marriage contract. Would a child born after the death of the mother, and therefore not during marriage, be entitled to inherit?

On this point Lord Coke writes:—“If a woman, seised of lands in fee, taketh husband, and by him is bigge with childe, and in her travell dyeth, and the childe is ripped out of her body alive, yet shall he not be tenant by the curtesie, because the child was not born during the marriage nor in the life of the wife; but in the meantime her land descended.”

It appears from this that the husband is not entitled to the life-rent.

3. The Child must be born capable of inheriting.—Monsters cannot inherit according to law. Blackstone says: “A monster which hath not the shape of mankind hath no inheritable blood,” and cannot, therefore, inherit; but, “if it hath human shape, it may be an heir.”

Buffon classes monsters under three divisions: (a) Monsters by excess of organs. (b) Monsters by defect of organs. (c) Monsters by alteration or wrong position of parts.

A hermaphrodite inherits, or not, property according to the prevailing sex.

4. Tenancy by Courtesy and Possessio Patris.—“When a man marries a woman seised of an estate of inheritance, and has by her issue born alive, which was capable of inheriting her estate; in this case he shall, on the death of his wife, hold the lands for his life as tenant by the courtesy of England.”

There is yet another case bearing closely on this subject, known in law as possessio fratris. On this subject Mr. Amos writes: “In the event of a man twice married dying, and leaving a daughter by each marriage, his estate would be equally shared by the daughters of the two marriages; but if we suppose that there is also a son by the second marriage, born in a doubtful state, the legal effect of his momentarily surviving birth would be to disinherit the daughter of the first marriage entirely, and transfer the whole of the estate to the daughter of the second marriage, she being sister to the male heir, while the daughter of the first marriage is only half-blood.”

In both of these cases proof of live birth, as before mentioned, is of the slenderest kind.

A fœtus in the womb (en ventre sa mère) may—(a) Have a legacy or estate made over to it. (b) A guardian assigned to it. That these conditions may take effect, it must be born alive. (c) Be an executor. To exercise this post partum function, the child must in England have attained the age of twenty-one.

Every child born in wedlock is presumed to have the husband of the woman as its father; but this presumption may be denied for the following reasons:

In Scotland, a child is held to be legitimate if born ten lunar months after the death or absence of its alleged father; and the absence of the supposed father must continue till within six lunar months of the birth of the child, to prove its illegitimacy.

In the same country, a child born before marriage is rendered legitimate by the subsequent marriage of the parents. This is not the case in England.

A child born during wedlock is legitimate, although the date of conception may be before marriage. A child born after the death of its mother is held to be legitimate. A child may, as Taylor remarks, be conceived before marriage, and born after the death of the mother, and yet be legitimate, though neither conceived nor born in wedlock.

The Code Napoleon prohibits the contraction of a second marriage until ten months after the death of the first husband; and this is also the case in Germany. The Anglo-Saxon law prohibits remarriage for twelve months. In Britain no time is fixed by law.

Duration of Pregnancy.—The consideration of this subject is of importance in its relation to the legitimacy of a child.

The natural period of human gestation is usually stated at forty weeks, ten lunar or nine calendar months, or 280 days. In Prussia, the period is extended to 302 days, and in the Code Napoleon to 300; in Scotland, ten months is held as the limit.

The duration of human gestation is subject to considerable variation; in some females it is always protracted; in others, always premature. Several modes of calculation are adopted by women:

Whichever may be the mode of calculation adopted, it may be stated that, as a rule, the period of human gestation is from 275 to 280 days, and that cases of alleged pregnancy beyond 300 days must be received with considerable caution.

The pregnancy of the Countess of Gloucester was held, in the reign of Edward II., to be legitimate, although her husband had been dead one year and seven months at the date of the application.

Premature Births.—The question may be asked, At what period of gestation may a child be born viable—that is, capable of living and attaining to maturity? Seven months, or 210 days, is considered as the limit; but cases have been recorded of children born at six months being reared. The Roman law admitted the legitimacy of seven-months’ children. (For the Signs of Immaturity, see “Table of the Development of the Embryo,” pp. 35, 36.)

Superfœtation.—The term is used to imply the conception of a second embryo in a woman already pregnant, and the birth of two children at one time, differing considerably in their maturity, or of two births, a considerable period of time elapsing between each. The possibility of this occurrence has been doubted.

Churchill, in his work on Midwifery, writing on this subject says: “In conclusion, I would say—(1) That the theory of superfœtation is unnecessary to explain the birth of a mature fœtus and a blighted ovum, of a mature and immature fœtus born together or within a month of each other, or of fœtuses of different colours, as they may reasonably be supposed to be the product of one act of generation, or of two nearly contemporaneous. (2) That, in cases of double uterus, it is possible for a second conception to take place, and—judging from the subsequent birth of the second child in the only case on record—at a later period than the first. (3) That, in the remaining cases, where one mature child succeeded the birth of another after a considerable interval, we have no proof of a double uterus in any, and positive proof that in one case it was single; and that to the explanation of these cases no theory as yet advanced is adequate, that of superfœtation being opposed by physical difficulties which are unsurmountable in the present state of our knowledge.”

The late Dr. Matthews Duncan has, however, shown that the mouth of the womb is not completely closed by conception, and the communication between the vagina and ovary is not destroyed for some months after impregnation, and that there is no impediment to the ascent of the spermatozoa. Galabin[16] records an instance of extra-uterine and uterine pregnancy occurring at the same time, the extra-uterine fœtus being advanced in development as compared with that in the uterus, and regards the condition as one of superfœtation.

The late Dr. Milne, while admitting this form of pregnancy as possible, though very rare, remarks: “This variety we should not think due so much to mechanical hindrances as to the absence of proper ovules. It would imply extraordinary vigour were perfect ovulation to be achieved for any length of time after impregnation.”

Evidence in relation to the above subjects may be required in actions for nullity of marriage, divorce, legitimacy, inheritance, pregnancy, and criminal assault.

Impotence.—By impotence is meant the incapacity for sexual intercourse, and applies both to the male and female; but the term is more especially used in reference to the former.

Sterility.—Sterility denotes the incapacity for procreation of children; is also applicable to both sexes, but more usually in reference to the female. A person may be impotent without being sterile, although the former is usually regarded as implying the latter. On the other hand, a person may be sterile without being impotent, the former not necessarily denoting the latter. In reference to nullity of marriage, if natural sexual relations are not and cannot be consummated, the marriage will be declared null and void, provided that such inability of consummation was unknown to the person bringing the action for nullity before marriage. Impotence is sufficient ground for bringing an action for nullity, provided it was present at the date of the marriage, that it is irremediable, and that the person bringing the action was not informed of it previously. Should, however, the marriage have been consummated and impotence develop later, there will be no grounds for such an action.

Impotence and Sterility in the Male.—This may arise from some organic defect of the organs or functional disorder. In reference to the former there are certain abnormalities of the male organs which have to be considered. Monorchids, men in whom one testis is absent from the scrotum, are not necessarily impotent or sterile; nor are cryptorchids, where both testes are undescended. In many of these cases spermatozoa are absent from the seminal fluid with consequent sterility; on the other hand, procreation has taken place, proving that cryptorchids are not necessarily sterile.

Absence of the penis may be the result of want of development, injury, disease, or operation. The penis may be present but attached in its whole length to the scrotum; this may be remedied by operation.

Epispadias, so often associated with ectopion vesicæ, as a rule renders an individual impotent and sterile. On the other hand, hypospadias does not necessarily bar procreation; it will depend largely upon the position of the urethral opening, and the possibility of its being remedied by operation.

Removal or destruction of both testes renders a man sterile eventually, but not necessarily impotent.

Functional disorder due to disease may give rise to impotence, although the organs may remain anatomically perfect. Diseases such as diabetes and influenza, neurasthenia, tabes dorsalis, myelitis, mumps, and orchitis, and injuries to the head may be causative factors in impotence.

The capacity for sexual intercourse is influenced to a varying degree by age. Sexual capacity is regarded as coincident with puberty. In judging the sexual capacity of a youth, age is of less moment than the degree of physical development. I have seen a male child of five years of age with as complete development of the sexual organs as an adult, and with a deep voice. At the other extreme of life it is impossible to lay down any definite limit to sexual capacity. Although it is regarded as diminishing with age, yet there are many instances of procreative power in men of an advanced age.

The principal points for consideration in reference to impotence and sterility in the male are: (a) Does the condition prevent the secretion of semen? (b) Does it prevent the conveyance of semen to the vagina?

Impotence and Sterility in the Female.—As in the male, these may be associated with organic defect or functional disorder. The external organs may be absent, with or without the internal. The vagina may be wanting through lack of development, or it may be obstructed by mal-development or the result of disease. Again, the external organs may be present, but the internal absent in whole or part. The hymen may be imperforate, or unusually tough. Diseases of the uterus often give rise to sterility. Vaginismus, in which attempts at coïtus cause painful spasm, may prevent intercourse. In reference to functional disorders are to be noted extreme debility, constant leucorrhœa, dysmenorrhœa, menorrhagia, and amenorrhœa, all of which may be associated with or causative factors in sterility. Emotional psychical conditions may prevent sexual intercourse in women. General diseases, however, do not necessarily prevent intercourse, as the woman may remain a passive agent, neither is bodily deformity always a barrier to the act.

The advent of sexual capacity in women is regarded as coincident with the onset of the menses, about fourteen years of age, but pregnancy has been known to take place prior to the first menstrual period. The age at which the menses first appear varies in no small degree. It has been known to occur during the first year of life, and pregnancy has been known to occur as early as the eighth year. The menopause in women is regarded as coincident with loss of procreative power. Women as a rule cease to menstruate at forty-five years of age, but in not a few the function persists until fifty, in exceptional cases to a more advanced age. It is rare for a woman to bear children after the menopause, but exceptions have been known to take place.

In the case of a husband seeking a nullity of marriage on the grounds of impotence or sterility in his wife, the question at issue is not whether she can bear children, but can she permit sexual intercourse? Many conditions which cause sterility in the woman need not render her impotent, and unless the latter obtains a nullity of marriage would not be allowed. Further, the conditions which render the woman impotent must be permanent and irremediable.

The question of survivorship is not infrequently raised when a mother and her new-born infant are found dead, or where several persons have perished by a common accident. In the first case the mother is generally presumed to have lived longest; and this presumption may be borne out by the fact of the delivery being premature, or if there be considerable disproportion between the size of the child and the maternal passages. As pointed out before, important civil rights may depend upon the question as to the live birth of an infant; and the husband‘s rights to be tenant to the courtesy will, of course, depend upon the view taken as to the probable survivorship or not of the child.

With regard to the second question, much will depend upon the relative ages and strength of the individuals. Sex will also have to be taken into consideration. In the case of one or more persons found dead, either from wounds or other causes, the fact of some being warm and others cold, the presence of the rigor mortis in one and absence in the other, will point to the probable survivorship. The severity of the wounds and injuries to large arterial trunks must also be considered. (See test case, Underwood v. Wing, 1 Jur. N.S. 169.) In this case a man, his wife, and three children were washed overboard and drowned, one child, however, being seen alive a few minutes after the others were submerged. The question at issue was, Did the husband survive the wife, or the wife the husband? and on this Wightman, J., in summing up, said: “We may guess, or imagine, or fancy, but the law of England requires evidence, and we are of opinion that there is no evidence upon which we can give a judicial opinion that either survived the other; in fact, we think it unlikely that both did die at the same moment of time, but there is no evidence to show who was the survivor.” Verdict for the plaintiff.

A medical man is liable to a civil action for damages who, by a culpable want of care and attention, or by the absence of a competent degree of skill and knowledge, causes injury to a patient. And it is not necessary that the patient should have employed or was to have paid him, provided always that there be no negligence or carelessness on the part of the patient. Lord Chief-Justice Tindall remarks: “Every person who enters into a learned profession undertakes to bring to the exercise of it a reasonably fair and competent degree of skill.” It has also been decided that if the defendant acted honestly, and used his best skill to cure, and it does not appear that he thrust himself in the place of a competent person, it makes no difference whether he was at the time a regular physician or surgeon or not (R. v. Van Butchell; R. v. Williamson, &c.). A surgeon does not undertake to perform a cure, nor does he profess to bring the highest professional skill into the consideration of the case; but he does undertake to bring a fair and reasonable amount. The degree of skill required by law is good common sense, or such knowledge as the operator had, joined with a good purpose to help the afflicted, even if such interference rendered the patient a cripple for life. “It would be dreadful,” says Hullock, B., “if every time an operation was performed an individual was liable to have his practice questioned.” “So, if a physician or surgeon give his patient a potion or plaster to cure him, which, contrary to expectation, kills him, this also is neither murder nor manslaughter, but misadventure.” A medical man is only liable for gross negligence, not for every slip he may make; but the distinction between criminal and actionable negligence cannot be defined; but it appears that the negligence must be so gross as to come under the legal meaning of the word “felonious.” (See p. 82.)

Human ingenuity is not wanting among those who, for private ends, pretend to be suffering from disease. The soldier or sailor, anxious to escape the dangers of active service, finds a ready means of evading his duties by shamming; the prisoner, in order to lighten the burden of his punishment, does the same. A man declares himself impotent to save the expense of keeping an alleged bastard child, or to avoid punishment for rape. Beggars appeal to the public by feigning some painful disease, and incautious benevolence becomes the dupe of the clever impostor.

Any attempt at classification is here out of the question, nor does it appear necessary to give a long list of diseases which have been feigned, or the means that have been employed by artists in deception. To give some general hints for guidance is all that will be attempted here, leaving matters of detail to the acumen of the medical examiner, who, if in active practice, will have many opportunities of testing his powers of discernment:

The existence of certain diseases may be claimed as a bar to active service, both in a civil and in a military capacity; and the opinion of a medical man may be required as to the fitness or unfitness of the individual for the service from which he claims exemption. In giving certificates of this nature, the medical practitioner cannot be too guarded in wording them; and each case must be treated on its merits, so that strict justice may be done.

Among the diseases which may incapacitate a man for active employment may be mentioned—syphilis; hernia; phthisis; affections of the eyes, attended with dimness of vision, or colour blindness; varicose veins; and some other diseases.

Although a medical man, as a rule, should refuse to draw up a will, still there are occasions when his doing so may save much litigation and expense. The following directions may therefore be of use:

CHAPTER XVI MENTAL UNSOUNDNESS — DEFECTIVE DEVELOPMENT OF THE FACULTIES — CARE OF MENTALLY DEFECTIVE PERSONS — GENERAL SYMPTOMS OF INSANITY — MANIA — MORAL MANIA — MELANCHOLIA — DEMENTIA OR FATUITY — DELIRIUM TREMENS. SIMPLE DELIRIUM. SOMNAMBULISM. SLEEP-DRUNKENNESS. — THE RESTRAINT OF THE INSANE AND DIRECTIONS FOR SIGNING MEDICAL CERTIFICATES. — LIABILITIES OF PERSONS SIGNING LUNACY CERTIFICATES — LIABILITIES OF PERSONS RECEIVING INSANE PATIENTS — TESTAMENTARY CAPACITY — RESTRAINT OF HABITUAL DRUNKARDS

In the whole range of medical jurisprudence there is no subject more interesting, more difficult, or more important than the diagnosis of insanity, and its relation to the criminal responsibility of individuals. It is impossible, in the short space at our disposal, to do more than to offer a few remarks which may assist the student in the elucidation of some of the most important cases which may engage his attention.

Legal Definitions.—Three forms of mental disorder are recognised in law:

Under the term lunacy are included the mania, monomania, and dementia of medical writers. Another term frequently used in legal proceedings, the meaning of which it is not easy to give, is “non compos mentis,” unsoundness of mind. According to the late Forbes Winslow, “unsoundness of mind is not lunacy” in the legal acceptance of the phrase. This term was first used in a Statute passed in the reign of Henry VIII., relating to the punishment of treasonable offences, and is defined by the early law text-books to be strictly one who gaudet lucidis intervallis—a definition not psychologically exact. The phrase “unsoundness of mind” was first used by the late Lord Eldon to designate a state of mind not exactly idiotic, and not lunatic with delusions, but a condition of intellect occupying a place between the two extremes, and unfitting the person for the government of himself and the management of his affairs.

The above definition has been acted upon by other judges—Lyndhurst, Brougham, &c. As a rule, a medical witness will consult his own interest in not attempting to define insanity, bearing in mind the philosophic caution of Polonius, who, when addressing Hamlet‘s mother, says—

• “Your noble son is mad:
• Mad call I it; for, to define true madness,
• What is‘t but to be nothing else but mad?”

Since the trial and acquittal of MacNaughton on the ground of insanity, the doctrine of the knowledge of abstract right and wrong has been changed to a knowledge of right and wrong in relation to the particular act of which the person is accused, and also at the time of committing it.

It has also been held that, on the assumption that a person labours under partial delusion only, and is not in other respects insane, he must be considered in the same situation as to responsibility as if the facts, with respect to which the delusion exists, were real. For example, if, under the influence of delusion, he supposes another man to be in the act of attempting to take his life, and he kills that man, as he supposes, in self-defence, he would be exempt from punishment. If his delusion were that the deceased had inflicted a serious injury on his character and fortune, and he killed him in revenge for such supposed injury, he would be liable to punishment. “Here,” says Maudsley, “is an unhesitating assumption that a man, having an insane delusion, has the power to think and act in regard to it reasonably, ... that he is, in fact, bound to be reasonable in his unreason, sane in his insanity.” Yet this was the doctrine laid down by the judges in answer to certain questions propounded by the House of Lords after the acquittal of MacNaughton (see Maudsley‘s Responsibility in Mental Disease, pp. 88 et seq.).

As laid down by English lawyers, madness absolves from all guilt in criminal cases. Where the deprivation of the understanding and memory is total, fixed, and permanent, it excuses all acts; so, likewise, a man labouring under adventitious insanity is, during the frenzy, entitled to the same indulgence, in the same degree, as one whose disorder is fixed and permanent (Beverley‘s Case, Co. 125, Co. Litt. 247, 1 Hale 31). “But the difficulty in these cases is to distinguish between a total aberration of intellect and a partial or temporary delusion merely, notwithstanding which the patient may be capable of discerning right from wrong; in which case he will be guilty in the eye of the law, and amenable to punishment.”[17]

Lord Hale, who first pointed out the distinction to be drawn between total and partial insanity, offered the following as the best test he could suggest: “Such a person, as labouring under melancholy distempers, hath yet as great understanding as ordinarily a child of fourteen years hath, is such a person as can be guilty of felony.” (On this subject, see R. v. Ld. Ferrers, 19 St. Tr. 333; R. v. Arnold, 16 St. Tr. 764, &c.)

To excuse a man from punishment on the ground of insanity, it appears that it must be distinctly proved that he was not capable of distinguishing right from wrong, and that he did not know, at the time of committing the crime, that the offence was against the laws of God and nature (R. v. Offord, 5 C. & P. 186).

I shall here quote from Macdonald‘s Criminal Law of Scotland: “Insanity or idiocy exempts from prosecution. But there must be an alienation of reason such as misleads the judgment, so that the person does not know ‘the nature of the quality of the act’ he is doing, or if he does know it, that he does not know he is doing what is wrong. If there be this alienation, as connected with the act committed, he is not liable to punishment, though his conduct may be otherwise rational. For example, if he kill another when under an insane delusion as to the conduct and character of the person—e.g. believing that he is about to murder him, or is an evil spirit,—then it matters not that he has a general notion of right and wrong. For, in such a case, ‘as well might he be utterly ignorant of the quality of murder.’ He does the deed, knowing murder to be wrong, but his delusion makes him believe he is acting in self-defence, or against a spirit. Nor does it alter the effect of the fact of insanity at the time, that the person afterwards recovers.... But the alienation of reason must be substantial. Oddness or eccentricity, however marked, or even weakness of mind, will not avail as a defence. Even monomania may be insufficient as a defence, where the delusion and the crime committed have no connection, or where the person, though having delusions, was yet aware that what he did was illegal.”

Mere moral insanity—where the intellectual faculties are sound, and the person knows what he is doing, and that he is doing wrong, but has no control over himself, and acts under an uncontrollable impulse—does not render him irresponsible (R. v. Burton, 3 F. & F. 772). Some medical writers contend that there are two forms of insanity—moral and intellectual. The law only recognises the latter, owing probably to the difficulty of distinguishing between so-called moral insanity and moral depravity. Taylor says: “Further, until medical men can produce a clear and well-defined distinction between moral depravity and moral insanity, such a doctrine, employed as it has been for the exculpation of persons charged with crime, should be rejected as inadmissible.”

The day may not be far distant when the term “moral depravity” will be unknown, and future generations, ceasing to believe in absurd superstitions, will come to look on crime as the result of disease of the brain, and learn to treat, instead of to punish, the morally diseased. (For a full discussion of this subject the reader is referred to the works of Dr. Henry Maudsley.)

The fact of the sanity or insanity of the prisoner at the time the crime was committed is left to the jury to decide, guided by the previous and contemporaneous acts of the party; and it has been laid down by Lord Moncreiff in Scotland, and Lord Westbury in England, that the mental soundness or unsoundness of any individual is to be decided by the jury on the ordinary rules of every-day life, and that on these principles they are as good judges as medical men. The whole tendency of legal practice, when dealing with the plea of insanity, is to entirely ignore the medical evidence. On the question of medical evidence in cases of insanity, Doe J., of New Hampshire, remarks: “At present, precedents require the jury to be instructed by experts in new medical theories, and by judges in old medical theories,” and that in this “the legal profession were invading the province of medicine, and attempting to install old exploded medical theories in the place of facts established in the progress of scientific knowledge. If the tests of insanity are matters of law, the practice of allowing experts to testify what they are should be discontinued; if they are matters of fact, the judge should no longer testify without being sworn as a witness, and showing himself qualified to testify as an expert.”

Lunacy—What Constitutes? (8 and 9 Vict. c. 100, secs. 90 and 114).—Imbecility and loss of mental power, whether arising from natural decay, or from paralysis, softening of the brain, or other natural cause, and although unaccompanied with frenzy or delusion of any kind, constitute unsoundness of mind, amounting to lunacy within the meaning of 8 and 9 Vict. c. 100 (R. v. Shaw, 1 C.C. 145).

The above is the last definition of lunacy up to 1875; but as the law on this subject is so constantly changing, the student will find it best to consult the Law Reports from time to time. (See the account in the case of R. v. Treadaway, Law Reports. Also the Lancet, on the same case, vol. i. 1877.)

For some valuable remarks on the subject of the irresponsibility of madmen, the student is referred to the works of Maudsley, Pritchard, Ray, Hoffbauer, Georget, and others.

The following suggestions are offered for consideration on this subject:

1. Was the act an isolated event in the life of the culprit? Has it the appearance of spontaneity, or was it the culminating point of a life spent in so-called criminal acts?

2. Absence of a motive for the committal of the deed.—The absence of an apparent motive is no proof of an unsound mind; the moving principle may be “the conscious impulse to the illegal gratification of a selfish desire.”

3. The presence or absence of a well-concerted plan of action is a diagnostic sign of little value.—Casper remarks that “only in one case can the examination of the systematic planning of the deed afford any information, and that is when these plans and preparations themselves evince the stamp of a confused intellect, and betray the hazy consciousness, the mental darkness, in which the culprit was involved.”

4. A dominant delusion may be so concealed as to be for a time undiscoverable.—The case of the man who gave no indication of his madness till he was asked to sign the order for his release, when he signed Christ, is an example how carefully a delusion may be concealed even during a most careful examination. Questions directed to this point showed that he laboured under all the errors which such a delusion might suggest.

5. It may “easily be conceived that insane persons, whose unreason affects only one train of thought more or less restricted, yet labour in other respects under disorders of feeling which influence their conduct and their actions and behaviour without materially affecting their judgment: and that many of such deranged persons, who often conduct themselves tolerably well in a lunatic asylum, and while living among strangers with whom they have no relations, and against whom they have no prejudices or imaginary reason of complaint; subjected, besides, to the rules of the house and to an authority that nobody attempts to dispute; would, nevertheless, if restored to liberty and residing in the midst of their families, become insupportable, irritable at the slightest contradiction, abusive, impatient of the least remark on their conduct, and liable to be provoked by trifles to the most dangerous acts of violence. If, under such circumstances, a lunatic should commit any act of injury or serious damage to another, would it be just to punish him; because it cannot be made apparent that the action has any reference to, or connection with, the principal delusion which is known to cloud his judgment, it being apparent that his moral faculties have undergone a total morbid perversion?”

6. Insanity with Lucid Intervals.—Haslam, Ray, and others appear to deny the possibility of lucid intervals; but M. Esquirol, on the other hand, fully recognises the existence of this form of insanity. In a legal sense, a temporary cessation of the insanity constitutes a lucid interval, but the cessation must be complete, and not merely a remission of the symptoms. The interval must be of some duration; and when continuous insanity has been proved, the onus of proving a lucid interval in civil cases rests with the party trying to support the validity of a deed executed during the alleged interval. “If you can establish,” says Sir W. Wynne, “that the party afflicted habitually by a malady of the mind has intermissions, and if there was an intermission of the disorder at the time of the act, that being proved is sufficient, and the general habitual insanity will not affect it, but the effect of it is this—it inverts the order of proof and presumption; for, until proof of habitual insanity, the presumption is that the party agent, like all human creatures, was rational; but when an habitual insanity in the mind of the person who does the act is established, then the party who would take advantage of the fact of an interval of reason must prove it.” In civil cases the law recognises the validity of wills made during lucid intervals, and has even taken the reasonableness of a will as a proof of a lucid interval.

7. Have measures been taken by the culprit to escape punishment?

The classification of insanity adopted here is that given by Ray, and is sufficient for all practical purposes:

Under this heading may be included idiocy, cretinism, imbecility, feeble-mindedness, and moral imbecility.

Idiocy is congenital, and was defined by Esquirol thus: Idiocy is not a disease, but a condition in which the intellectual faculties are never manifested, or have never been developed sufficiently to enable the idiot to acquire such an amount of knowledge as persons of his own age, and placed in similar circumstances with himself, are capable of receiving. Idiocy commences with life, or at an age which precedes the development of the intellectual and affective faculties, which are from the first what they are doomed to be during the whole period of existence. Since the days of Esquirol, much improvement has been made in the care and treatment of the idiot; and it appears that he is capable of some, though in most cases slight, mental culture. The cases in which improvement takes place probably belong to imbecility, leaving the idiot in the same condition as described by Esquirol.

Cretinism differs from idiocy in being endemic; it is also more curable, or at least more susceptible of improvement, than the latter. In the idiot the malady is congenital; the cretin, on the other hand, may to all appearances be free from disease for a time. “Every cretin is an idiot, but every idiot is not a cretin; idiocy is the more comprehensive term, cretinism is a special kind of it.” The enlarged thyroid gland, high-arched palate, and brown or yellow colour of the skin, are characteristic of the cretin. Local causes are at work in the production of cretinism; e.g. defective function of the thyroid gland.

The idiot is usually cunning, mischievous, and dirty in his habits.

The derivation of the word idiot, from the Greek, ίδιώτης— a private person, or an ill-informed ordinary fellow—is peculiar. A person suffering from any form of mental unsoundness, and thereby rendered incapable of taking care of himself or of his property, was formerly called by English law “an idiot,” and this word was not infrequently joined with “fatuus” in old writs.

Imbecility.—This is a minor form of idiocy, and may or may not be congenital. It admits of considerable degrees of intensity. Imbeciles exhibit mental defection, rendering them incapable of managing themselves or their affairs, and imbecile children are incapable of being taught to do so.

Feeble-mindedness is a lesser degree of mental defection than imbecility. It may exist from birth or an early age. Such persons require care and control for the protection of themselves and others. They may be incapacitated from acquiring the knowledge imparted in ordinary schools.

Moral imbeciles exhibit moral defects which render them vicious in behaviour, and they often exhibit criminal tendencies, which are not affected by punishment.

The Mental Deficiency Act of 1913 provides for their care. Such a person may be either sent to an institution or placed under special guardianship by the parent or guardian, if an idiot or imbecile; or by the parent when, though not an idiot or imbecile, the person affected be under the age of twenty-one years. If in addition to being a defective, the person is neglected, abandoned, or without means of support; or cruelly treated, guilty of a criminal offence, or liable to be sent to an industrial school, or under imprisonment, detained in an industrial school, inebriate reformatory, or institution for lunatics, or habitual drunkard within the meaning of the Inebriates Act; or in whose case proper notice has been given by the Local Education Authority; or who is in receipt of relief at the time of giving birth to an illegitimate child, or pregnant of such child.

Certificates required.—In the case of a parent or guardian who desires to place a mentally defective person under guardianship, two medical certificates are necessary, one of which must be from a medical man approved by the Local Authority or Board. If the person be not an idiot or imbecile, the certificates must be signed by a Judicial Authority, after such inquiry as he thinks fit. A defective to be dealt with otherwise than by parent or guardian, is so under an order by a Judicial Authority on a petition presented under the Act, an order of a Court if guilty of a criminal offence, or an order of the Secretary of State if detained in prison, a criminal lunatic asylum, or reformatory.

The order of a Judicial Authority may be obtained by petition of any relative or friend, or an officer of the Local Authority authorised under the Act for the purpose. Two medical certificates must accompany the petitions, one of which must be signed by a medical man approved by the Local Authority or Board; or, when a medical examination cannot be carried out, a certificate to that effect must be presented, and a statutory declaration made by the petitioner and one other person, who may be one of the medical certifiers, stating the class to which the defective belongs. Upon receiving the certificates the Judicial Authority interviews the defective. When the petition is presented by a parent or guardian, the Judicial Authority, if satisfied, may issue an order for the defective to be placed in an institution or appoint a guardian. If the petitioner be not parent or guardian, consent in writing of one or other must be obtained, without which the order must not be made, unless the parent or guardian withhold their consent unreasonably or are not to be found. If the Judicial Authority be not satisfied, he may postpone the order, or refuse it.

When the order is made by a Court, the Court must be satisfied, on medical evidence, that the person is a defective.

Two medical certificates are necessary when the Secretary of State makes an order.

The order remains in force for a year, may be renewed for a second year, and then for periods of five years.

The onset of insanity may be gradual or sudden. More commonly the onset is gradual, and manifested by alterations of emotion and conduct, which may for a considerable period precede any impairment of intelligence. Periods of depression may alternate with periods of excitement. Irritability and instability of temper manifest themselves, and lead relatives and friends to become suspicious of the change that is the herald of serious mental impairment. Lack of interest in environment, business, or the usual pleasurable pursuits, also a tendency to personal seclusion manifest themselves, and changeability of the affections, more often to those nearly related, are not uncommon. Sooner or later the capacity to conduct business and allied pursuits becomes enfeebled, and the power of judgment lessened; depression begets apprehension and a dread of impending ruin in this world or in the world to come. Marked indecision and vacillation of action is quite common. Delusions follow, mostly of persecution, in the form of attempts to cause ruin or poisoning. Delusions associated with the special senses are common, particularly of hearing, supposed voices urging the committal of certain actions, or expressive of derision; of vision, by which objects are seen which are non-existent; of taste, imparting the idea of poisoning; of touch and pain, invoking peculiar sensations; of smell, conveying the idea that food, the body, &c., exhale disgusting odours.

Associated with the onset of insanity, and remaining permanently, are three special distortions of perceptions—viz. illusions, hallucinations, and delusions. So long as the first two can be reasoned upon and rejected, judgment remains. At one or other time the afflicted person becomes so affected by them that they become realities, and are accepted as true and existent; then the judgment is perverted, and the person is said to suffer from a delusion.

Illusions.—An illusion is a false perception, a perversion of the senses, a mockery, false show, counterfeit appearance. The false perception is, however, invoked by some external appearance.

Hallucinations.—Hallucinations are perverted sensations and perceptions, for the production of which no external impulse is present. The person may complain of seeing horrible reptiles around, which are not present. So long as the reasoning faculties are capable of dispelling the alleged reality of the hallucination and rejecting it, it remains but an hallucination.

If, however, it becomes accepted as a reality and the person becomes obsessed thereby, it becomes a delusion.

Delusions.—A delusion is a chimerical thought, an affection of the mind. It implies a disordered intellect. Delusions generally concern the insane person, his power, soul, &c. A delusion is a perverted idea of the mind in which there is belief in non-existent things or occurrences. Delusions may be based upon previous hallucinations, or arise out of erroneous conceptions.

Mania is the result of a morbid condition of the brain, and to express which “the term raving madness may be used with propriety, as an English synonym for mania. All maniacs display this symptom occasionally, if not constantly, and in greater or less degree.” Like other diseases, mania observes the same pathological laws. There is a period of incubation, during which the true state of the patient is in most cases misunderstood, or not appreciated. Mental exaltation may exist from the first onset of the disease, or the attack may be ushered in by a stage of gloom or despondency. The general health shows signs of impairment, the liver becoming sluggish, and the bowels confined or relaxed. In some cases a febrile condition of the system is among the premonitory symptoms of an attack of mania. The physical health is not usually much affected during the paroxysm.

Dr. Conolly remarks that “even acute mania is not always accompanied by the ordinary external signs of excitement. It would seem as if we had yet to learn the real symptoms of cerebral irritation. Certainly, in recent cases of mania—cases which have lasted more than six weeks, and in young persons in whom I have seen the maniacal attack pass into dementia—I have known the most acute paroxysms of mania exist, rapid and violent talking, continual motion, inability to recognise surrounding persons and objects, a disposition to tear and destroy clothes and bedding, without any heat of the scalp or of the surface, without either flushing or paleness of the face, with a clean and natural appearance of the tongue, and a pulse no more than eighty or eighty-five.”

This may occur in some cases, but in the majority there is always some amount of physical derangement; the system, however, gradually becoming tolerant of the undue excitement to which it is subjected.

Following the classification adopted, Intellectual Mania will now be briefly considered under its two divisions—General and Partial.

General Intellectual Mania.—By many medical writers general intellectual mania is divided into mania and melancholia. The mind in the former type of the disease is involved in the most chaotic confusion possible, and there is also considerable bodily derangement. The moral faculties become more or less affected, and the patient‘s social and domestic relations are greatly altered. At one time he is subject to violent fits of immoderate laughter, at another he is gloomy and taciturn; sometimes quiet and tractable, at others wild and excited, necessitating close confinement. He is haunted by wild delusions, which at times take entire possession of him, and under the influence of which he acts in the most extraordinary manner. In the latter—melancholia, or mania with depression—delusion may be absent, or, rather, for a time undetectable. The sufferer is gloomy, and troubled with unhappy thoughts, which sometimes lead him to self-destruction. He is sleepless, and rejects his food as unnecessary. He may be aroused for a short time by questions addressed to him, his replies to which are usually given correctly, most frequently in monosyllables; but the moment his questioner leaves him he relapses into his former gloomy state.

Partial Intellectual Mania.—The term monomania, first suggested by Esquirol, is now generally given to this variety of insanity. The patient, in the simplest form of this disorder, becomes possessed of some single notion, which is alike contradictory to common sense and to his own experience. Thus, he may fancy himself made of glass; and influenced by this idea, he walks with care, and in dread of being broken by contact with other bodies. In the case of an inmate at the City of London Asylum, the presence of a weasel in the stomach was stated by one woman. Esquirol mentions the case of a woman with hydatids in her womb, who believed that she was pregnant with the devil. Most of these strange fancies appear to be dependent on errors of sensation.

Monomaniacs are ready enough to declare their predominant idea; yet at times, and that without the occurrence of a lucid interval, they will as carefully conceal it. “In the simplest form of monomania, the understanding appears to be, and probably is, perfectly sound on all subjects but those connected with the hallucination. When, however, the disorder is more complicated, involving a longer train of morbid ideas, we have the high authority of Georget for believing that, though the patient may reason on many subjects unconnected with the particular illusion on which the insanity turns, the understanding is more extensively deranged than is generally suspected.”

Pinel first drew attention to this form of madness. Pritchard defines it as “consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, and moral dispositions, without any notable lesion of the intellect or knowing and reasoning faculties, and particularly without any maniacal hallucinations.”

It is divided into—General Moral Mania. Partial Moral Mania.

General Moral Mania.—“There are many individuals,” says Pritchard, “living at large, and not entirely separated from society, who are affected in a certain degree with this modification of insanity. They are reputed persons of a singular, wayward, and eccentric character. An attentive observer will often recognise something remarkable in their manners and habits, which may lead him to entertain doubts as to their entire sanity; while circumstances are sometimes discovered on inquiry which add strength to this suspicion. In many instances it has been found that a hereditary tendency to madness has existed in the family, or that several relatives of the person affected have laboured under other diseases of the brain. The individual himself has been discovered to have suffered, in a former period of life, an attack of madness of a decided character. His temper and disposition are found to have undergone a change, or to be not what they were previously to a certain time; he has become an altered man, and the difference has perhaps been noted from the period when he sustained some reverse of fortune which deeply affected him, or the loss of some beloved relative. In other instances, an alteration in the character of the individual has ensued immediately on some severe shock which his bodily constitution has undergone. This has been either a disorder affecting the head, a slight attack of paralysis, or some febrile or inflammatory complaint, which has produced a perceptible change in the habitual state of his constitution. In some cases, the alteration in temper and habits has been gradual and imperceptible; and it seems only to have consisted in an exaltation and increase of peculiarities which were always more or less natural and habitual. Persons labouring under this disorder are capable of reasoning, or supporting an argument upon any subject within their sphere of knowledge that may be presented to them; and they often display great ingenuity in giving reasons for the eccentricities of their conduct, and in accounting for, and justifying, the state of moral feeling under which they appear to exist. In one sense, indeed, their intellectual faculties may be termed unsound—they think and act under the influence of strongly excited feelings; and persons accounted sane are, under such circumstances, proverbially liable to error, both in judgment and conduct.” (For interesting cases of this form of madness, see Ray‘s Jurisprudence of Insanity.)

Partial Moral Mania.—In the case of the unfortunate sufferers from this malady, one or two only of the moral powers are perverted.

This division admits of several subdivisions:—

Kleptomania.—A marked propensity to theft. “There are persons,” says Rush, “who are moral to the highest degree as to certain duties, but who, nevertheless, lie under the influence of some vice. In one instance, a woman was exemplary in her obedience to every command of the moral law except one—she could not refrain from stealing. What made this vice more remarkable was, that she was in easy circumstances, and not addicted to extravagance in anything. Such was the propensity to this vice that, when she could lay her hands on nothing more valuable, she would often, at the table of a friend, fill her pockets secretly with bread. She both confessed and lamented her crime.”

Pyromania.—This consists in an insane impulse to set fire to everything—houses, churches, and property of every kind and description.

Erotomania and Nymphomania.—This is known as amorous madness, and consists in an inordinate and uncontrollable desire for sexual intercourse. The unfortunate victims of this disease often express the greatest disgust and repugnance for their conduct.

Homicidal Mania—In this form of madness the propensity to homicide is very great, and in most cases uncontrollable. In the case of the notorious Deeming, hanged in Australia in 1892 for the murder of his wife, an appeal was made from the finding of the Colonial Court by which he was tried to the Privy Council, on the ground of his being affected with homicidal mania. The plea was not sustained. (See the case of Henrietta Cornier, given by Pritchard, Ray, and others.)

The following suggestions may be of assistance in forming a diagnosis as to the existence or non-existence of this form of madness:—

Suicidal Monomania, or the Propensity to Suicide.—Much discussion has arisen on this subject. Suicide is not always the result of unsoundness of mind. Some, like M. Esquirol, are inclined to consider suicide as always a manifestation of insanity. In the present day, the dislike of coroners‘ juries to bring in any other verdict but that of “suicide whilst in a state of unsound mind” is proverbial.

This condition is associated with mental depression and delusions. In its simple form, marked depression of spirits, apprehension of evil, sleeplessness, loss of appetite, and impaired alimentation with constipation are evident.

Delusions of ruin, of the committal of acts contrary to the laws of God and man—“the unpardonable sin”—a marked inaptitude to carry on the ordinary duties of life, indecision, and often unutterable misery, are commonly exhibited. The delusions are fixed and may be multiple. They may comprise persecution, by friends or others; that things are happening which powerfully influence the person‘s life and body, or, as is often the case, concern religious matters, and everlasting punishment.

Suicidal tendencies are often present, and depend largely upon the misery associated with the condition. Melancholics often conceal this tendency, or may exhibit it in varied ways so as to hide the method which has been definitely decided upon. Thus a person so afflicted may be found in possession of poison at one time, a pistol at another, a knife at another, when the real intention is that of drowning. Thus it is necessary to keep an extremely careful watch on melancholics. Homicidal tendencies are not common. In some cases the melancholia is combined with marked agitation. The face depicts misery, the eyebrows raised, and the person moves about incessantly, picking up objects and replacing them, moaning and uttering the same phrases expressive of misery and hopelessness, wringing the hands, and rocking the body to and fro.

In other cases stupor is predominant, and the person sits in silence and in the same attitude. Some resent interference, others are easily persuaded by their attendants to do certain acts, but when done relapse again into stupor. They manifest extreme apathy. Suicidal tendencies are a pronounced feature of such cases.

Melancholia and mania may alternate periodically, with lucid intervals intervening. The term circular insanity has been applied to this alternate character of the disease.

Dementia consists in a failure of the mental faculties, not congenital, but coming on during life. “A man,” says Esquirol, “in a state of dementia is deprived of advantages which he formerly enjoyed. He was a rich man who has become poor. The idiot, on the contrary, has always been in a state of want and misery.” In this state there is always more or less coherence, and maniacal paroxysms are not infrequent. In mania, incoherence may be present, but then it is characterised by sustained and violent excitement. In dementia, on the other hand, there is apparent torpor and exhaustion of the mental faculties. Closely allied to this form of mental unsoundness is that interesting disease known as “general paralysis of the insane,” or perhaps a better term, progressive paralysis of the insane. It is considered by some to precede the psychical derangement, a contrary opinion being held by others. General paralysis may accompany any of the forms of mental derangement, but it is generally preceded by a stage of melancholy. As the paralytic affection becomes more marked, there is a concurrent loss of memory and incapability of mental association, and all sense of duty is lost; the patient becomes careless as to his person, and dirty in his habits. He expresses himself as possessed of great property, and boasts of the wonderful deeds that he can or has accomplished. Gradually he sinks into a state of complete mental and physical decay. He cannot give expression to his thoughts, and has to be fed, the food being pushed into his mouth. The symptom which first attracts the attention, and which is perhaps the first order of sequence, is a modification in the articulation. “This is neither stammering nor hesitation of speech. It more closely resembles the thickness of speech observable in a drunken man. It depends upon loss of power over the co-ordinate action of the muscles of vocal articulation.” If the tongue be now examined, it will be found that when it is protruded it is not inclined to one side, but that it is tremulous, and is protruded and withdrawn in a convulsive manner. Griesinger was the first to call attention to the fact, and his statement has since been confirmed, “that this motory disorder is at the commencement not so much paralytic as convulsive in its nature.” The gait becomes unsteady, the patient walks stiffly, and stumbles over the slightest unevenness in the floor. Step by step the paralysis progresses, till at last the unfortunate sufferer takes to his bed, on which he may lie for months. Sometimes, especially during the earlier stages, he may suffer from terrible delusions, from maniacal paroxysms, or from epileptic fits, the latter possessing certain peculiarities. The tongue during the fit is seldom bitten, which is so commonly the case in epilepsy; and the convulsions are not so general, being limited more to one side than to the other. It is also remarkable that each fit is in most cases followed by an increase of the mental derangement.

Pritchard recognises four stages of dementia or fatuity:—

First Stage.—Forgetfulness and impaired memory. This is common to old age. In most cases passing events produce little, if any, impression, whilst the past is remembered with tolerable freshness.

Second Stage.—Incoherence and unreason, characterised by a total loss of the reasoning faculty.

Third Stage.—Incomprehension. The person so affected is quite incapable of comprehending the meaning of the simplest question; and should he attempt to reply, his answer is generally remote from the subject.

Fourth Stage.—Inappetency. The animal instincts are lost. The unfortunate sufferer lives, and that is all, being scarcely conscious of life. Organic life is all that is left.

Delirium Tremens.—A temporary form of insanity, the result of excessive indulgence in spirituous liquors. The drunkard, under the effects of intoxication, “can derive no privilege from a madness voluntarily contracted, but is answerable to the law equally as if he had been in full possession of his faculties at the time” (1 Hale 32; Co. Litt. 247). The intoxication of the defendant may be taken as a mitigating circumstance, showing that the deed was unpremeditated. A person rendered incapable of using his reason by intoxication brought about by others, is not liable for his actions.

Simple Delirium.—Acts performed during attacks of certain diseases—fever, sunstroke, &c.—accompanied with delirium, do not render the individual liable to punishment; and wills made during the continuance of the disorder, if they contain no statement inconsistent with the known wishes and desires of the party during health, are valid, the law looking more to the good sense of the will as a proof of a lucid interval, than to the proved existence of such lucid interval.

Somnambulist, &c.—This is an abnormal mental state, closely allied to that artificially produced and known under the names of mesmerism, hypnotism, electro-biology, &c. It is commonly known as “sleep-walking.” In this condition the mind appears to become enslaved by one train of ideas to the exclusion of all others; the somnambulist, thus deeply bent on the accomplishment of a definite end, takes no heed of those objects which are in no way connected with the dominant ideas in his mind. Hence, he walks safely past dangers which, when awake, would disconcert his judgment and weaken his will. Somnambulism appears also to be closely connected with epilepsy. In 1878, a man named Fraser was tried in Glasgow for the murder of his child by beating it against the wall. He was acquitted on the ground of being unconscious of the nature of his act by reason of somnambulism. He had sprung from an epileptic and insane stock; his mother died in an epileptic fit, and some of his other relatives were insane. Thus it appears, if the somnambulism be proved, the accused is exonerated from any responsibility connected with the act for which he is being tried. So also, if a person be suddenly aroused from a deep sleep—somnolentia or sleep-drunkenness—the question may be raised as to his responsibility for an act committed at the moment of awakening (R. v. Milligan). There cannot be a doubt but that if a person be suddenly aroused whilst dreaming, he may unconsciously commit acts, the outcome of his dream, which, unless the possibility of this condition be recognised, may entail severe punishment on him. This state is closely allied to that mental condition which sometimes occurs in epileptics immediately after a fit. But in this, as in cases of somnambulism, the facts of the case would have to be most carefully scrutinised.

The following hints may be of use as a guide in determining the responsibility or not of the accused:—

No person can be put under restraint unless the conditions required by the Lunacy Acts are fulfilled. The Acts of Parliament for this purpose are the Lunacy Act of 1890 (53 Vict. c. 53) and that of 1891 (54 and 55 Vict. c. 65). Lunatics may be put under restraint by the following procedures, according to the particular case:—

• Reception Order on Petition.
• Urgency Order.
• Order after Inquisition.
• Summary Reception Order.
• Order for Lunatics Wandering at Large, and for Pauper Lunatics.
• Reception Order by Two Commissioners.

Reception Order on Petition.—This is usually the procedure for private patients. The order for petition may be obtained from a specially appointed Justice of the Peace, Judge of County Courts, or Magistrate. A petition for the order must be presented to the Judicial Authority by the husband, wife, or relative of the alleged lunatic; if any other person apply, the reasons for this must be given. A petitioner must be twenty-one years of age or over, and must have seen the alleged lunatic within fourteen days before its presentation. A statement of particulars and two medical certificates must accompany the petition. The proceedings are private, and no one except the petitioner, the alleged lunatic, and any one person appointed by him, and the two medical men who have signed the certificates, may be present, unless by permission of the Judicial Authority. If the Judicial Authority be satisfied, he may make the order at once, even without seeing the patient, or he may appoint a time within seven days for inquiries and consideration. He may visit the alleged lunatic.

At the time of consideration of the petition he may adjourn it for not more than fourteen days, or he may make the order at the time. He may summon further witnesses, or dismiss the petition, giving his reasons for so doing in writing.

A reception order is valid for seven days from its date, unless the lunatic is certified by a medical man to be unfit for removal, when the order is extended until a medical certificate of fitness for removal is obtained, which is valid for three days.

The medical men signing the certificates must not be in partnership, as principal and assistant, or have any direct or indirect interest in the patient or his keeping (16 and 17 Vict. c. 96, sec. 4). They must make separate visits at different times for the purpose of examination. Each medical man must have examined the person within seven clear days before the presentation of the petition.

Each medical man must write clearly and in the proper place on the certificate: (1) The facts observed by himself as evidence of insanity, and (2) the facts observed by others as evidence of insanity. The name of his informant must be given.

One of the certificates should, whenever practicable, be under the hand of the usual medical attendant (if any) of the alleged lunatic. If not practicable, the reason must be given by the petitioner to the Judicial Authority.

Neither of the certifying medical practitioners may be the father or father-in-law, brother or brother-in-law, sister or sister-in-law, partner or assistant of the other of them.

Great care should be taken to follow carefully the marginal directions on the certificate form. The most trivial omission will invalidate the certificate. The omission of the name of the street and number of the house is sufficient to set it aside. A medical man should remember that, although his certificate may have passed the scrutiny of the Commissioners, it is liable to be made the subject of discussion in a Court of law, and in cross-examination he will have to support the statements therein made.

The following certificate properly filled up by Dr. Millar of Bethnal House Asylum, is given in his book on Hints on Insanity, and may be taken as an example of a correct certificate at that time, the present form being slightly different:—

MEDICAL CERTIFICATE
PROPERLY FILLED UP

Table relating to “Facts” of Insanity,

(compiled from Millar.)

The following are examples of “Facts” sent back to be amended by the Commissioners—the emendations in italics:—

Form 2.

STATEMENT OF PARTICULARS REFERRED
TO IN THE ANNEXED PETITION

If any particulars are not known the fact is to be so stated.

[Where the patient is in the petition or order described
as an idiot, omit the particulars marked ►]

The following is a Statement of Particulars		__________________
relating to the said		__________________
Name of patient, with Christian name at		__________________
length		__________________
Sex and Age		__________________
► Married, single, or widowed		__________________
► Rank, profession, or previous occupation		__________________
(if any)		__________________
► Religious persuasion		__________________
Residence at or immediately previous to		__________________
the date hereof		__________________
► Whether first attack		__________________
Age on first attack		__________________
When and where previously under care		__________________
and treatment as a lunatic, idiot, or		__________________
person of unsound mind		__________________
► Duration of existing attack		__________________
Supposed cause		__________________
Whether subject to epilepsy		__________________
Whether suicidal		__________________
Whether dangerous to others, and in		__________________
what way		__________________
Whether any near relative has been		__________________
afflicted with insanity		__________________
Names, Christian names, and full postal		__________________
addresses, of one or more relatives		__________________
of the patient		__________________
Name of the person to whom notice of		__________________
death to be sent, and full postal		__________________
address, if not already given		__________________
‡Name and full Postal Address of the		__________________
usual Medical Attendant of the Patient		__________________
‡When the Certificate is not signed by the usual Medical Attendant,  the Certificate on the other side must be filled out.

(a) When the
petitioner
or person
signing an
urgency order
is not the
person who
signs the
statement, add
the following
particulars
concerning
the person who
signs the
statement.

Signed (a)
Name, with Christian
Name at length	____________________________________
Rank, Profession or
Occupation (if any)	____________________________________
How related to, or
otherwise connected
with the Patient	____________________________________

An Order for Reception of a Lunatic is to be obtained upon a private application by Petition to a Judge of County Courts, or Stipendiary Magistrate, or Metropolitan Police Magistrate, or specially appointed Justice of the Peace. The petition is to be presented, if possible, by the husband or wife, or by a relative (i.e. a lineal ancestor or lineal descendant, or lineal descendant of an ancestor not more remote than great-grandfather or great-grandmother) of the Lunatic, and is to be accompanied by a Statement of Particulars and two Medical Certificates on separate sheets of paper. One of the Medical Certificates accompanying the Petition must, if practicable, be by the usual Medical Attendant of the Lunatic; if not by him, the reason must be stated (see Form above). If a previous Petition has at any time been dismissed, the facts relating to its dismissal are to be stated in the fresh Petition (see Form above); and the Petitioner must obtain from the Commissioners in Lunacy a Copy of the Statement sent to them of the reasons for its dismissal, and present this copy with his Petition. The Reception Order (which will not remain in force for more than seven days after its date), the Petition, the Statement of Particulars, and the Medical Certificates must be sent to the Superintendent or Proprietor of the Asylum, Hospital, or House where the Patient is to be received.

Urgency Orders.—Where it is urgent that an alleged lunatic (not a pauper) must be put under restraint as soon as possible, he may be received upon an urgency order, without petitioning a Judicial Authority, accompanied by a statement of particulars and one medical certificate. The order should be made by the husband, wife, or a relative of the alleged lunatic; if this be not possible, the reasons must be stated. It may be signed before or after the medical certificate, and before or after a petition order has been made. If before, it must be noted in the petition; if after, a copy must accompany the petition. No person may sign an urgency order if under twenty-one years of age, and must have seen the alleged lunatic within two days before the date of the order.

The urgency order remains in force seven days from its date, during which period the procedure for a “Judicial Order on Petition” is carried out. If the petition has been presented and the order is for some reason or other deferred, then the urgency order remains in force. The medical examination for certification must have been made not more than two days before reception, and reasons must be given why “it is expedient” that the alleged lunatic should be put under control “forthwith.”

Form 2.

STATEMENT OF PARTICULARS REFERRED
TO IN THE ANNEXED ORDER

If any particulars are not known the fact is to be so stated.

[Where the patient is in the petition or order described
as an idiot, omit the particulars marked ►]

The following is a Statement of Particulars		__________________
relating to the said		__________________
Name of patient, with Christian name at		__________________
length		__________________
Sex and Age		__________________
Married, single, or widowed		__________________
► Rank, profession, or previous occupation		__________________
(if any)		__________________
► Religious persuasion		__________________
Residence at or immediately previous to		__________________
the date hereof		__________________
► Whether first attack		__________________
Age on first attack		__________________
When and where previously under care		__________________
and treatment as a lunatic, idiot, or		__________________
person of unsound mind		__________________
► Duration of existing attack		__________________
Supposed cause		__________________
Whether subject to epilepsy		__________________
Whether suicidal		__________________
Whether dangerous to others, and in		__________________
what way		__________________
Whether any near relative has been		__________________
afflicted with insanity		__________________
Names, Christian names, and full postal		__________________
addresses, of one or more relatives		__________________
of the patient		__________________
Name of the person to whom notice of		__________________
death to be sent, and full postal		__________________
address, if not already given		__________________
Name and full Postal Address of the		__________________
usual Medical Attendant of the Patient		__________________
Signed (a)	____________________

When the Petitioner or person signing an Urgency Order is NOT
the person who signs the Statement, add the following particulars
concerning the person who signs the Statement.

Name, with Christian
Name at length	____________________________________
Rank, Profession or
Occupation (if any)	____________________________________
How related to, or
otherwise connected
with the Patient	____________________________________

Orders after Inquisition.—This constitutes a legal investigation as to whether or not a person is capable of managing his or her own affairs, and whether restraint is necessary. It is conducted before a judge, with a jury if the alleged lunatic demand one, unless the judge is satisfied by personal examination that the lunatic is not mentally competent to understand the demand for a jury. In such a case the medical man is only concerned as a witness.

According to circumstances the alleged lunatic may be kept under restraint, or remain at liberty with the control of his or her affairs under a “Committee of Estate”; or, if declared sane, set free and with control of his estate.

Summary Reception Orders.—When a lunatic is not under proper control, and if without relations or friends, and there be no one who will sign a petition for detention, or when a lunatic is uncared for, cruelly treated, and is found so by a medical practitioner, his duty is to inform a constable, relieving officer, or overseer of the parish of the fact. The official will then make a statement on oath to a Judicial Authority, who will direct two medical practitioners to make the necessary examinations, and if satisfied he will issue an order for the removal of the individual to an asylum. The procedure followed will then be the same as for a “petition for reception.” Under a summary reception order the Judicial Authority may place the person under the care of a relation or friend, or the visitors of the asylum in which the person is intended to be, or is placed.

Lunatics Wandering at Large.—Every constable, relieving officer, or overseer of a parish who knows of a person, whether pauper or not, who is deemed to be a lunatic and wandering at large, shall apprehend and take such person before a Justice, or if the Justice receive information on oath, he may have the person apprehended and brought before him. The Justice has the person medically examined, and if certified a lunatic to the satisfaction of the Justice, he may issue an order for detention; if the medical man certify that the person is not fit for removal, the removal is postponed until the person is certified fit for it.

The above proceedings are not necessary if it be considered a matter of public safety and for the good of the alleged lunatic that immediate detention be carried out. The constable, relieving officer, or overseer of the parish may remove such person to the workhouse of the union in which the person is, and detain him for not more than three days. Before the expiration of that time the necessary proceedings under the Lunacy Act must be taken.

Reception Order by two Commissioners.—Any two or more Commissioners in Lunacy may visit a pauper lunatic or an alleged lunatic not detained in a workhouse or lunatic asylum, and if satisfied after certification by a medical man that the person is a lunatic, order removal to an asylum.

Pauper Lunatics.—A medical officer of a Poor Law Union who has knowledge that a pauper within his district is alleged to be a lunatic, shall notify the relieving officer or overseer of the parish where the pauper resides of the fact, who within three days shall notify a Justice, who will interview the alleged lunatic and call in a medical practitioner to examine and certify. If the Justice be satisfied that the person be a lunatic, he makes an order for removal to an asylum. One medical certificate only is necessary.

Escape of Lunatics.—An escaped lunatic may be retaken at any time within fourteen days without a fresh order.

Discharge of Lunatics.—The reception order remains in force for periods of one, two, and three years, and then for periods of five years. At the end of any of these periods the Lunacy Commissioners may continue the detention of the lunatic, if satisfied by certification from the medical man of the institution, or the usual medical attendant of the lunatic, that the patient remains of unsound mind and further detention is necessary.

The petitioner of the reception order may request the discharge of a patient. The discharge may be refused if the medical man in charge certifies the lunatic dangerous and unfit to be at large, unless two of the visitors to the asylum or the Commissioners visiting the asylum or house give their consent in writing.

Two Commissioners—one medical, the other legal—may order the discharge of any patient.

When a patient recovers, the medical attendant of the institution notifies this to the petitioner or person responsible for the payment on account of the patient. Should the patient not be removed within seven days of such notice, the patient may be discharged “forthwith.”

PROCEDURE IN SCOTLAND

Idiots and imbeciles under eighteen years of age may be received into training schools without the legal procedure which obtains in England and Wales. They are sent to these institutions as lunatics, however, under the usual legalities, in order that the Government grant may be obtained. When over eighteen years of age, if sent to institutions other than training schools, they are classed as lunatics, and the necessary legal procedure is followed.

Insane persons whose malady is not confirmed may be cared for privately for a period not exceeding six months. The certificate of one medical practitioner only is required.

Insane persons, pauper or not, can be placed in an asylum by order of the Sheriff, by petition and two medical certificates. The inspector of the poor acts as petitioner for paupers.

In cases of urgency a certificate of emergency from one medical practitioner is required, along with a request from the petitioner, to the superintendent of the asylum.

A person who is prodigal or facile can be restrained from alienating his property by guardians appointed by the Court.

When a lunatic is found to be incapable of administering his or her estate, the Court appoints a Committee of Estate.

PROCEDURE IN IRELAND

The procedure differs in pauper and private cases.

Pauper patients, not dangerous.—In order to detain such a pauper there must be a declaration of insanity and destitution, with the names and addresses and descriptions of two relatives of the person, given before a magistrate. A magistrate and a clergyman or poor-law guardian must certify that they have personally inquired into the case. One medical certificate is necessary. The applicant must remove the patient when called upon.

Paying patients who are not dangerous, for admission to a district asylum, are under more stringent regulations. A declaration that they are unable to pay the expenses necessary for support in a licensed house must be made before a magistrate; further, that there is no friend who can undertake this; and a statement of the length of time the patient has resided in the country. A magistrate and clergyman must certify that they have investigated the case. One medical certificate must be signed by two practitioners. A guarantee for the payment must be given, and also to remove the patient when called upon. The sanction of an inspector of lunatics must be given.

For admission into licensed houses, charitable institutions, and single care, an order by a relative or connection of the lunatic is required with two medical certificates, unless urgent, when one is sufficient, but a second must follow within fourteen days.

A medical practitioner is bound to certify as to the sanity of a person. If, however, he undertakes to fill up the certificates necessary for the detention of an alleged lunatic, he becomes responsible to the authorities for the correctness of the certificates, and if he make a wilful misstatement of facts he is guilty of a misdemeanour. The medical practitioner may have an action brought against him by the lunatic when recovered or discharged. The most vindictive feelings may be entertained against the medical man. In such a case, if the medical man proves his “good faith” and the exercise of “reasonable care” in his examination and certification, he receives the protection of the Court.

In the case of Nottidge v. Ripley and Nottidge, the Lord Chief Baron having been understood to intimate an opinion that no person ought to be so confined unless he is dangerous to himself or others, the Commissioners pointed out that the scope of the Lunacy Acts is not thus limited. They said:

“The object of these Acts is not, as your Lordship is aware, so much to confine lunatics, as to restore to a healthy state of mind such of them as are curable, and to afford comfort and protection to the rest. Moreover, the difficulty of ascertaining whether one who is insane be dangerous or not is exceedingly great, and in some cases can only be determined after minute observation for a considerable time.

“It is of vital importance that no mistake or misconception should exist, and that every medical man who may be applied to for advice on the subject of lunacy, and every relative and friend of any lunatic, as well as every magistrate and parish officer (each of whom may be called upon to act in cases of this sort), should know and be well assured that, according to law, any person of unsound mind, whether he be pronounced dangerous or not, may legally and properly be placed in a county asylum, lunatic hospital, or licensed house, on the authority of the preliminary order and certificates prescribed by the Acts.

“Upon the whole, it appears that the power to restrain and confine a lunatic is limited at common law to cases in which it would be dangerous, either as regards others or himself, for the lunatic to be at large; but that the power to place and detain a lunatic in a registered hospital or licensed or other house, under an order and medical certificates duly made and obtained in accordance with the Lunacy Acts, is not so limited.”

The terms of the Lunacy Act, 1890, are as follows:

“Subject to the exceptions in this Act mentioned a person shall not be received or detained as a lunatic, as a single patient, unless under a reception order by a judicial authority.” “Every person who, except under the provisions of the Act, receives or detains a lunatic or an alleged lunatic in an institution for lunatics, or for payment takes charge of, receives to board or lodge, or detains a lunatic or alleged lunatic in an unlicensed house, shall be guilty of a misdemeanour, and in the latter case shall also be liable to a penalty not exceeding fifty pounds.” “Except under the provisions of this Act, it shall not be lawful for any person to receive or detain two or more lunatics in any house, unless the house is an institution for lunatics or a workhouse.” “Any person who receives or detains two or more lunatics in any house except as aforesaid shall be guilty of a misdemeanour.”

It is therefore unlawful to receive a lunatic or alleged lunatic except by reception order. Only one can be received into a private house, and a reception order is required. No medical man should receive a lunatic into residence without the necessary reception order. All the statutory regulations are demanded for a single case, and the private house is subject to visitation and inspection.

It is also important to remember that if any one receive a person not insane at the time, but who subsequently becomes insane, he renders himself liable to prosecution, unless he procure the necessary medical certificates and order (R. v. Wilkins).

Is a Lunatic a competent Witness?—Mr. Fitzjames Stephen maintains (Criminal Law) that madmen are competent witnesses in relation to testimony as in relation to crime. If they understand the nature of an oath, and the character of the proceedings in which they are engaged, they are competent witnesses whatever be the nature or degree of their mental disorder. An idiot shall not be allowed to give evidence (Co. Litt. 6 b; Gilb. Ev. 144); a lunatic during a lucid interval may do so (Id. Com. Dig. Testm. {A}). When a lunatic is tendered as a witness, it is for the judge to examine and ascertain whether he is of competent understanding to give evidence, and is aware of the nature and obligation of an oath; if satisfied that he is, the judge should allow him to be sworn and examined (R. v. Hill, 2 Den. 255; 20 L.J. [M.C.] 222).

The Civil Rights of Lunatics.—If an individual be suffering from such mental disease as to render him incompetent to manage his own affairs, the law steps in to protect him and his property from injury. But the power so used does not necessarily imply that he is deprived of his personal freedom, but merely such restraint as is necessary for his protection.

Many lunatics, under the protection of the Court, live in their own houses with large establishments. A person so protected by the law is said to be subject to an “interdiction.” In these cases a commission is usually granted by the Court of Chancery, and a writ known under the name of “de lunatico inquirendo” issued, after certain legal matters of detail are settled, and affidavits from medical men certifying to the insanity of the party have been filed.

The tests of insanity in these cases differ from those required in criminal cases, where the knowledge of right from wrong is imperatively demanded. The mental defect must not be the result of ignorance or want of education, and at one time commissions were only issued when it was shown that lunacy and idiocy alone existed, imbecility or mere weakness of mind not being deemed sufficient to deprive a man of his civil rights, or to place him under the protection of the Court.

To so great an absurdity did this lead, that the man suffering from a delusion sufficient to be comprehended under the legal term “lunacy” was protected, whereas the feeble-minded were left without interference, though needing it more. The cost of these commissions sometimes reached almost fabulous sums. The expense has been somewhat lessened by recent enactments, and the process simplified—the Lord Chancellor having it in his power to direct an inquiry before two Commissioners, thus dispensing with a jury. (See the 16 and 17 Vict. c. 70, and 25 and 26 Vict. c. 86.)

In Scotland, however, the law is far more simple. The cognition proceeds on a brieve or writ addressed to the Lord President of the Court of Session, and directs him to inquire “whether the person sought to be cognosced is insane, who is his nearest agnate, and whether such agnate is of lawful age.” “And such person shall be deemed insane if he be furious or fatuous, or labours under such unsoundness of mind as to render him incapable of managing his affairs.” “The trial is before a judge of the Supreme Court and a special jury. If the insanity be proved, the nearest agnate—relation by the father‘s side—is by law entitled to the guardianship.” No one not a near relative can institute these proceedings.

In Scotland also, the trial by jury may be avoided by applying by petition to the Court of Session for the appointment of a judicial factor or curator bonis. Of this appointment the alleged lunatic is informed, which, if he please, he may oppose; medical evidence is received, and on this the Court rests its decision—the usual course being to remit the case to some competent person to make inquiry, take evidence, and report. The Commissioner is usually the Sheriff.

Examination of the Insane.—A few words of caution need here be said. Medical men will consult their own dignity and that of their profession by remembering that in cases of alleged insanity, as in fact in all other cases when their opinion is sought, they are not justified in taking sides. Their evidence will be the more valuable in proportion to the care they take in examining into the facts of the case, and the good sense and judgment shown in their examination of the patient. To distinguish between the mistakes, the result of ignorance and want of education, and those the result of a feeble mind, is of primary importance. It is no sign of insanity in an uneducated farmer that he knows not the pons asinorum. All cases should be tested by considering the surroundings and possible degree of culture of a person placed under like conditions as the party under examination. Has he shown himself capable of an average amount of culture? or is his mental condition inferior to what one might legitimately expect under the influences to which he has been subjected? The medical examiner should also direct his attention to this important point, setting aside all legal and medical theories of insanity, viz.—“Is the case of such mental disorder as to create an incapacity for managing affairs.”

A medical practitioner may be called upon to give evidence as to the capacity of a testator to make a valid will. An ordinary person witnessing a will does so to fact only, but if a medical man do so it implies that he was of the opinion that the testator was fit to make a will and of a sound and disposing mind. In making an examination of a person for fitness to make a will, the medical man must endeavour to find out if the testator understands the nature of his action, and all the details associated with it; also if he knows the nature and amount of his property, and the claims or otherwise of those who may become beneficiaries under it. Further, has he such a delusion as may influence his will in disposing of his property, and bring about a disposal of it which, if the mind had been sound, would not have been made.

A person may have a delusion or delusions without interfering with the making of a will. If the “disposing mind” be left intact, testamentary capacity is upheld. In severe illness and old age the mind may be so disturbed, without true insanity being present, that a person is rendered incapable of making a will. In all such cases the medical man should be sure of his ground before granting, if requested, that the patient is capable or otherwise. It is a good plan, when examining a patient as to testamentary capacity, to have the will produced, and privately read it out to the person and ask if it be correct, then to have the person repeat the dispositions of the will, and see if they coincide with the contents of the document.

People who are aphasic may make wills which are valid. Difficulties arise in cases of sensory aphasia.

An habitual drunkard, as defined by law, is “a person who, not being amenable to any jurisdiction in lunacy, is notwithstanding, by reason of habitual intemperate drinking of intoxicating liquor, at times dangerous to himself or herself, or to others, or incapable of managing himself or herself or his or her own affairs.”

Before placing such a person under restraint in a licensed retreat the person‘s consent must be obtained. The patient must make an application to a Justice of the Peace, and supported by a declaration from two persons stating that the applicant is an habitual drunkard within the meaning of the Act. If the justice be satisfied, he can make out an order for detention. The order is valid for any time mentioned in the application not exceeding two years. The patient can be detained, forcibly if necessary, and if escaped may be arrested and taken back.

CHAPTER I — GENERAL EVIDENCE AND DIAGNOSIS OF POISONING — GENERAL TREATMENT OF CASES OF POISONING — EXAMINATION OF THE CONTENTS OF THE STOMACH, VISCERA, ETC., FOR POISON

Toxicology is that division of Forensic Medicine which takes into consideration the modes and actions of poisons upon the living body, the treatment of their effects upon the body, and the methods of detecting them when occasion requires.

Definition of a Poison.—Neither the law nor medicine defines a poison. The popular definition is to be avoided, viz., that, a poison is a substance capable of acting injuriously on the body when taken or administered in a small dose.

Husband defined a poison as “any substance which, introduced into the system or applied to the body, is injurious to health and destroys life, irrespective of temperature or mechanical means.”

Taylor and Stevenson define a poison as “a substance which when absorbed into the blood is, by its direct action, capable of seriously affecting health or destroying life.”

There are substances, however, which do not require absorption into the blood in order to exert their deleterious action, e.g. the corrosive acids and alkalies; but, although the chief action is a local one in most cases, some absorption does take place and is evidenced in systemic effects, and are so classified as poisons differing from powdered glass, which acts mechanically only and is not a poison in the true sense of the word.

Winter Blyth considers that “a substance of definite chemical composition, whether mineral or organic, may be called a poison if it is capable of being taken into any living organism, and causes, by its own inherent chemical nature, impairment or destruction of function.”

According to Luff a poison is “a substance which, either by its direct action upon the skin or mucous membranes, or after its absorption into the blood, is capable of injuriously affecting health or destroying life.”

Letheby defines a poison as “anything which otherwise than by the agency of heat or electricity is capable of destroying life, either by chemical action on the tissues of the living body, or by physiological action from absorption into the system.”

The law does not recognise the manner in which the substance acts, nor the result; the legal standpoint is the intent of the administrator qua administrator. The law is as follows: “Whosoever shall administer or cause to be administered or taken by any person any poison or other destructive thing with intent to commit murder shall be guilty of a felony” (24 and 25 Vict. c. 100, sec. 11).

Section 22. “Whosoever shall unlawfully apply or administer to or cause to be taken by, or attempt to apply or administer to, or attempt to cause to be administered to or taken by, any person, any chloroform, laudanum, or other stupefying or overpowering drug, matter, or thing, with intent, in any of such cases, thereby to enable himself or any other person to commit, or with intent, &c., to assist any other person in committing any indictable offence, shall be guilty of felony.”

Section 23 enacts that, “Whosoever shall unlawfully administer to, or cause to be administered to, or taken by any other person, any poison or other destructive or noxious thing so as thereby to endanger the life of such person, or so as thereby to inflict upon such person any grievous bodily harm, shall be guilty of a felony.”

Section 24. “Whosoever shall unlawfully or maliciously administer to or cause to be administered to or taken by any other person any poison or other destructive or noxious thing with intent to injure or aggrieve or annoy such person shall be guilty of a misdemeanour.”

Section 25. “If upon the trial of any person charged with the felony above mentioned the jury shall not be satisfied that such person is guilty thereof, but shall be satisfied that he is guilty of the misdemeanour above mentioned, then, and in every such case, the jury may acquit the accused for such felony and find him guilty of a misdemeanour.”

Administration of Noxious Drugs.—The law throws on the medical witness the responsibility of the definition of a noxious thing, and whether it was given in excess, or liable to cause annoyance or injury to health. At a Bodmin Assize, Lord Chief-Justice Cockburn, after consultation with Mr. Justice Hawkins, delivered an important judgment on the subject. A man was charged with having administered cantharides with criminal intent. The judges ruled that there must not only be an administration of a noxious drug with a guilty intent, but the drug must have been administered in such quantities as to be noxious, whereas the dose here given was too small to be seriously deleterious. Distinction was drawn between a drug like cantharides, which is only noxious when given in excess, and strychnine, a well-established poison. Acquittal was therefore directed. In the case of R. v. Cramp, the prisoner was charged with having administered half an ounce of oil of juniper with intent to procure abortion. He was convicted, but appealed on the legal ground that the substance must be noxious in itself, and not only when given in excess. Lord Coleridge ruled that “if a person administers with intent to produce miscarriage something which as administered is ‘noxious,’ he administers a ‘noxious thing.’”

The Sale of Poisons.—The law, by the Pharmacy Act, 1868, and its amendments, restricts the sale of poisons to pharmaceutical chemists, chemists and druggists, and registered medical practitioners. The Acts define and indicate by schedule “Poisons within the meaning of the Act.” The Schedule of Poisons, as amended in the “Poisons and Pharmacy Act, 1908,” and “Additions to Schedule 1913,” is:

Memorandum.—Special importance attaches to the last paragraph of Part II. of the schedule, as the effect of that paragraph is to include in Part II. many preparations and admixtures of vegetable drugs which contain poisonous alkaloids, although the drugs containing them are not specified in the schedule.

With those in Part I. a registration of the sale is compulsory, the purchaser must be known to or introduced by some person known to the vendor, and the purpose for which the poison is required, the date, the name and amount of the poison sold, the name and address of the buyer, and the entry must be signed by the purchaser and introducer. All substances in Parts I. and II. must be labelled by the vendor with a label bearing the name of the poison, the name and address of the seller, and the word “Poison”; but with those in Part II. no registration as in Part I. is required. In the sale of arsenic both the seller and purchaser must sign the entry, and the introducer must witness it. No arsenic can be legally sold to a person under the age of twenty-one years; nor may it be sold in quantities of less than 10 lbs. unless mixed with soot or indigo—one ounce of the former, or half an ounce of the latter, to each pound of arsenic. If quantities of over 10 lbs. be sold, and the soot or indigo would render it unfit for use in the way desired, then they may be omitted (Arsenic Act, 1851).

Classification of Poisons.—A good and scientific classification of poisons is still wanted. The following simple general division, depending upon the chief effect, may be taken as guides by the student:

(a) Corrosives—Local corrosion.
(b) Irritants—Gastro-intestinal irritation.
(c) Neurotics—Altered action of the nervous system.
1. INORGANIC
Corrosive—Sulphuric acid, &c.
Irritant—Arsenic, &c.
2. ORGANIC
Irritant—Savin, Cantharides.
Affecting Brain—Opium.
Affecting Spinal Cord—Strychnia.
Affecting Heart—Digitalis.
Affecting Lungs—Carbonic acid.
(Guy.)
IRRITANTS
Mineral		Acid poisons—Sulphuric acid, &c.
		Alkaline poisons—Caustic soda, &c.
		Non-metallic—Phosphorus, Iodine, &c.
		Metallic—Arsenic, Antimony, &c.
Vegetable—Savin, Elaterium, &c.
Animal—Cantharides.
NEUROTICS
Cerebral—Opium, Hydrocyanic acid, Alcohol.
Spinal—Strychnia, Nux vomica.
Cerebro-spinal—Conium, Belladonna, Aconite.
Cerebro-cardiac—Calabar bean, Digitalis.
(Taylor.)

The subjoined classification is based upon that adopted by the late Professor Sir Douglas Maclagan. Where the poison acts in such a manner as to place it in two or more groups, I have fully described it in one, merely drawing attention to it under the others:

DIVISION I
CHEMICAL
Corrosive,		Acids.
		Alkalies.
		Caustic salts.
Vulnerant,		Needles.
DIVISION II
VITAL
Irritant,	Metalloid,		Phosphorus, Iodine.
“	Metallic,		Arsenic, Antimony, Mercury, &c.
“	Vegetable,		Gamboge, Elaterium, Colchicum, Squill.
“	Animal,		Cantharides, Ptomaines.
Narcotic,	Somniferous,		Opium.
“	Deliriant,		Hyoscyamus, Belladonna.
“	Inebriant,		Alcohol, Cocculus Indicus, Chloroform,
			Ether, Cannabis Indica.
Sedative,	Cardiac,		Digitalis, Aconite, &c.
“	Cerebral,		Ether, Chloroform, Hydrocyanic acid.
“	Neural,		Conium, Aconite.
Excitomotory,			Strychnia, Ergot.
Irrespirable Gases,			Carbonic acid, Carbon monoxide,
			Coal gas, Chlorine.
Toxicohæmic or Septic,			Snake venom, Ptomaines, “Toxins.”

Action of Poisons.—Amid the difficulties which surround this subject, three points appear to have been clearly made out: (1) That it is necessary for all poisons to enter the blood before their specific action can be produced. (2) That poisons possess an elective affinity for certain tissues and organs. Thus, arsenic, however introduced into the system, as a rule attacks the stomach; and this peculiarity of action closely allies it to the poisons of typhoid, scarlet fever, smallpox, &c., which appear to have, respectively, an elective affinity for the glands of the intestines, the throat, and the skin. (3) That the habitual use of a poison in medicinal doses does not ensure a perfect toleration on the part of the system with regard to the action of the poison, for sooner or later a complete cachexia is produced, showing that the poisonous effect of the drug is not arrested.

Besides the above, there are also certain conditions connected with the action of poisons: (1) The poison is absorbed and distributed by the blood. (2) A portion is eliminated by the fluid secretions and excretions. (3) Another portion is for a time deposited in the tissues and organs of the body. These processes are of necessity simultaneous.

The channels of entrance and exit are as follows: Of entrance we have—(1) The blood-vessels as a result of wounds—more important in a physiological than a medico-legal question. (2) The skin and cellular membrane.—Absorption by the skin is modified by the condition of the part, and also by the form in which the drug is applied. Thus the skin of the arm-pits and groins is more absorbent than the palms of the hands. Watery solutions are not so effective as oily preparations, and the application of the drug in fine powder is more effectual than a watery solution of it. This is explained by the presence of a natural oily, unctuous substance on the skin, which prevents the direct contact of the watery solution, but if the solution be allowed to evaporate on the part, the substance thus left in minute division is then readily absorbed. The danger of allowing strong solutions of corrosive sublimate to evaporate on the head in the treatment of certain skin eruptions is thus explained. (3) The lungs and air-passages.—Absorption by these organs is most active, hence the intense rapidity in the action of aerial poisons. (4) The stomach and intestines.—Poisons introduced into the stomach or intestines take longer to arrive at the special organs on which they act than by the other channels of entrance. They are absorbed by the capillaries into the mesenteric veins, and before passing to the heart, by which they enter the general circulation, they pass through the liver, where they are in part excreted in the bile or deposited in the gland. The absorbing power of the stomach is modified by its fulness or emptiness, and poisons not soluble in water may be rendered so by the gastric secretion.

The avenue of entrance may materially modify the action, and some poisons which act rapidly when entering by a wound, are inert when taken into the stomach. Snake poisons when given by the mouth are entirely harmless. Hydrogen sulphide is more toxic when inhaled than when taken in solution. This, though true in some cases, does not always occur; and the inertness of these poisons, it has been suggested, may be due to the elimination of them being as rapid as their absorption, so that a poisonous dose never enters the circulation. The intestines absorb more rapidly than the stomach, and this must be borne in mind when administering powerful drugs per anum.

Of the channels of exit we have: (1) The kidneys. (2) The lungs. (3) The bile. (4) The milk. (5) The saliva. (6) Mucous membrane. (7) The skin.

We know not the cause, but certain poisons appear to select a particular route for their exit—thus iodide of potassium leaves by the urine; mercury and its salts by the saliva; arsenic and eserine, the active principle of the Calabar bean, in small quantities, by the stomach, &c. We are, however, prepared to show that all poisons must enter the blood before they produce their effects, and that almost simultaneously with the entrance of the poison into the blood a process of elimination begins, and that fatal effects depend upon absorption taking place more rapidly than elimination. On the amount also of the poison absorbed do its fatal effects depend, and not on the quantity actually taken. Whilst absorption and elimination are both going on, some of the poison is being deposited in the organs and tissues of the body. As proofs of these statements it has been shown that poisons have been detected in the blood, and that urine, saliva, and milk, fluids secreted from it, may contain portions of the poison taken, and produce dangerous symptoms when given to other animals. Poisons applied to the brain tissue, or to nerve trunks, do not produce symptoms, and the action of a poison may be arrested for a time by compressing by a ligature the main vessels of the limb under the skin of which the poison has been injected. After death no trace of the poison may be detected, the quantity taken being just sufficient to produce a fatal result, or elimination may be so rapid that, although death was directly due to the poison, any remains of its existence cannot be made out. This occurred in the case of Dr. Alexander, who died from an accidental dose of arsenic, all the arsenic being eliminated in seventeen days—in another fatal case, in seven days. (Taylor)

As evidence of the diffusion of poisons the following table may be of use:

Physiological.		Dilatation of the pupil in poisoning by
		belladonna, hyoscyamus, &c.
		Contraction of the pupil in poisoning by
		opium, Calabar bean.
Physical.		Taste.—	Bitter taste of the secretions. Strychnia,
			picrotoxin. The milk of animals fed on wormwood
			may become bitter; on colchicum, poisonous.
		Smell.—	Prussic acid, tobacco, conium, &c.
		Colour.—	Skin blackened by nitrate of silver, given
			internally.

N.B.—By the aid of the spectroscope the salts of lithium and thalium have been detected in the liver and other tissues.

Recapitulation of the Mode of Action of Poisons,
and the Causes which Modify their Action.

MODE OF ACTION
I. LOCAL
1. Corrosion of the part		Strong acid, alkali, &c.
to which the poison
is applied.
2. Inflammation as the		Arsenic, cantharides, &c.
result of irritants
applied to a part.
3. Effects on the nerves		Dilatation of the pupil by belladonna,
of motion and sensation.		tingling of the tongue and skin by
		aconite, paralysis by conium.

II. REMOTE
1. Common—not to be distinguished from the effects of
injury or disease.
2. Specific—peculiar to the poison itself.
(1) General—affecting the whole system.—Antimony.
(2) Partial—acting on a particular organ.—Antimony
MODIFYING CAUSES
1. Quantity.		1. Quantity of the poison increases its rapidly
		fatal action.
		2. Action changed by the size of the dose. Thus,
		oxalic acid in large doses acts as a corrosive; in
		small doses on the heart, brain, or spinal cord.
2. Form.		Solubility increases the activity of poisons.
		Chemical Combinations.—Baryta is poisonous,
		sulphate of baryta is inert.
		Mixture.—Dilution may retard or accelerate
		the action of a poison.[19]
3. Point of application—Skin, lungs, mucous and serous membranes.
4. Condition of  the body.		Habit—generally lessens the action of
		poisons, e.g. arsenic-eater, morphine
		taker, morphine taker.
		Idiosyncrasy—increases or may lessen the
		action of poisons.
		Disease—generally lessens, but in some
		cases increases the action of poisons.

It will now be necessary to consider briefly the general evidences of poisoning, in order to determine whether a death alleged to be due to poison is not really the result of disease. For convenience of description, this subject will be divided into five sections:

• 1. Evidence from the Symptoms.
• 2. Evidence from the Post-mortem Appearances.
• 3. Evidence from Chemical Analysis.
• 4. Evidence from Experiments on Animals.
• 5. Moral Evidence.

1. Evidence from the Symptoms.—As a general rule the symptoms come on suddenly while the person is in apparent health, except in cases of slow poisoning, when the poison may be so administered by frequently repeated and small doses as to simulate disease, and the physician is more easily misled than when a single large dose is given. In cases of suspected homicide this suddenness in the accession of the symptoms is particularly to be noticed, and we may have to decide as to the probabilities of accident, suicide, or homicide. Here collateral evidence must be our guide. The slowness, obscurity, and irregularity of the symptoms are more in favour of homicide than either accident or suicide. But it must also be borne in mind that the invasion of many diseases is sudden, as is the case with cholera, gastritis, and some others.

Certain conditions of the system more or less modify the effects of some poisons. Thus, sleep delays the action of arsenic; and this may also be the case with other poisons. Intoxication has also been said to exert a retarding power over the action of certain poisons. This is probably more apparent than real, the fact being that the symptoms in the cases observed are masked.

Much more important, however, is the influence of disease. Large doses of opium are well borne in mania, delirium tremens, dysentery, and tetanus; whereas it is well known that even small doses of mercury in cases of Bright‘s disease of the kidney, or in children recovering from any of the eruptive fevers, have produced dangerous salivation.

The symptoms of poisoning go on from bad to worse in a steady course; but there may be remissions, followed, under treatment, by their entire disappearance, no ill effect remaining. Remissions are most likely to occur in slow poisoning with the metallic irritants, from fear of detection or cunning on the part of the poisoner to imitate the progress of disease. In nervous affections, all the symptoms must be taken into consideration, and these will be found to differ from those of any known poison. The history of the case should also have due attention paid to it.

In poisoning, the symptoms appear soon after food or drink has been taken. This is open to the objection that apoplexy has occurred immediately after a meal. The probative value of the above statement is, however, increased if several persons have been similarly affected after partaking of the same dish, especially if the symptoms followed within a short time—under four hours—of the meal. But it must also be remembered that all persons are not affected alike by the same poison. Again, the diagnostic value is weakened if it can be proved that the person or persons affected have taken nothing in the way of food for two or three hours previously.

The flesh of animals poisoned by accident, or intentionally, may seriously affect those who eat it.—As a case in point may be mentioned the injurious effects produced in some persons who had partaken of the Canadian partridges imported to this country some years ago, and which had probably eaten some poisonous berries during the severe winter of that year.

Poisons may be introduced into the system otherwise than by the mouth; that is, they may be placed in the vagina or rectum, or inhaled when volatile poisons are used. Sometimes a poison has been introduced into the medicine, or a poisonous draught substituted for the one prescribed. In any case, where suspicious symptoms suddenly occur, the poison has most probably been taken in from half an hour to an hour previously, and it is of special importance to note the period of time that may have elapsed between the accession of the symptoms and the last meal, or administration of medicine.

When called in to a case of suspected poisoning, and in many cases where no suspicion at the time arises, the medical attendant should pay attention to the following points:

2. Evidence from Post-mortem Appearances.—The morbid appearances found in cases of poisoning will be treated more in detail when each poison, or group of poisons, comes to be separately considered. A caution may be given here against allowing the post-mortem signs of disease or external injury to exclude the idea of poisoning; for death may to all appearance be the result of disease or injury, and yet be caused by poison. An attention to the post-mortem appearances is important in all cases; for in many instances, where the symptoms were unknown to the experts at the time the inspection was made, they were subsequently found to correspond with the morbid changes which the autopsy revealed. The normal appearance of the stomach is white or nearly so, except during digestion, when it is reddened; yet we may sometimes come across cases in which the mucous membrane of this organ may be found so reddened as to lead to a suspicion of poisoning. The knowledge of this fact, and the absence of symptoms, will prevent an error in diagnosis. Ulceration from disease and from irritant poisoning must be distinguished. In that due to disease, the ulcers formed are, as a rule, small and circumscribed; in those from poison, there is diffused inflammatory redness over other parts of the stomach, and even in the intestines; and the poison, as in the case of arsenic, may be found adhering to the sides of the ulcer. Ulceration is more frequently the result of disease than of the action of poisons. Perforation of the stomach or intestines may be due to ulceration or to corrosion. The condition of the mouth and gullet will help the diagnosis. The appearance of the ulcer and the parts around it, together with the hints just given, must guide the diagnosis. Of post-mortem softening little need be said, beyond stating that it very rarely occurs, and is of course not preceded by symptoms. (For the diagnosis between inflammatory redness of the intestines and post-mortem staining, see page 45.)

3. Evidence from Chemical Analysis.—The objects of a chemical analysis are to determine: (1) The presence and nature of the poison. (2) The proportion or quantity of the poison taken. (3) The solution of certain questions connected with the administration of the poison.

The detection of poison in the body is of course the most important proof of poisoning; but it may be suggested that the poison was introduced after death, which, to say the least, is a most ingenious line of defence, but which, at the same time, must be held to be highly improbable, and impossible if found deposited in one or more of the solid organs. Again, granting that poison has been taken, is it the cause of death? This question may arise when injuries are found on the body, and it then becomes a matter of importance to know something of the symptoms which preceded death, and the morbid appearances found after death. The case of the girl who took arsenic to escape a beating by her father is a case in point. The father was tried for causing the death of the girl by undue severity, but it was subsequently shown that arsenic self-administered was the true cause of death. The poison may disappear from the body. This disappearance may be effected by vomiting, purging, or by the urine, or the poison may become absorbed and decomposed. The person poisoned may live sufficiently long to allow of the entire elimination of the poison, and yet die of the induced exhaustion. (See case of Dr. Alexander, ante.)

Some poisons, especially those which are sparingly soluble, are with difficulty removed from the stomach, even by the most incessant and violent vomiting. This is notably the case with arsenic, which adheres to the mucous coat of the stomach with considerable tenacity. But even after all traces of the poison have left the stomach, it may be detected in the solid viscera.

Temporary deposit of poison in the organs or tissues (Taylor): (1) The Liver. (2) The Kidneys. (3) The Spleen. (4) The Heart. (5) The Lungs. (6) The Muscles. (7) The Brain. (8) The Fat. (9) The Bones.

With regard to arsenic, the following table, taken from Taylor, is of importance, as showing the amount of the poison which may be found in the liver at certain intervals:

Is it necessary that the poison should be found in the body or in the evacuations to lead to a conviction for poisoning? On this point, Christison was of opinion that if the symptoms, post-mortem, appearances, and moral evidence are very strong, it is not necessary that the poison be found in order to establish a charge of poisoning. This opinion was also supported by the late Dr. Geoghehan, Professor of Medical Jurisprudence in the Royal College of Surgeons, Ireland, and was also virtually acted upon in the case of Palmer, where the non-detection of strychnia was strongly dwelt upon by the counsel for the defence, but without success. Many of the vegetable poisons almost defy detection, except by the symptoms, post-mortem appearances, and some experiments on animals of doubtful value. The detection of poison in the food taken, or in the vomited matters, is of great importance; but it is of still greater importance if it can be found in the urine, drawn from the bladder, this being a proof that it has passed through the system. Here again a caution is necessary—for it must be remembered that poisoning may be feigned or imputed—the poison being mixed with the food and evacuations, and an innocent person accused.

The following suggestions should be carefully considered by every analyst when substances are sent to him for examination:

He should carefully note when and from whom the substances were received; in what state they were received—secured, or exposed—the number of articles, and whether properly labelled. He must make the analysis himself, and state where it was made. The character and nature of the substances examined should be noted, and he must be prepared to give an outline of the methods or processes used for their determination. He must also be able to guarantee the purity of his reagents, and be prepared to answer the following questions:

• 1. Is the poison free or combined?
• 2. What is the strength and quantity found?
• 3. Could the poisonous substance exist naturally?
• 4. How much of the poison found is a fatal dose?
• 5. If no poison is found, is there anything noxious
• or injurious to health?