Chapter IV: Part I: Forensic Medicine (1)

I.--CRIMES

Forensic medicine is also called Medical Jurisprudence or Legal Medicine, and includes all questions which bring medical matters into relation with the law. It deals, therefore, with (1) crimes and (2) civil injuries.

1. A _crime_ is the voluntary act of a person of sound mind harmful to others and also unjust. No act is a crime unless it is plainly forbidden by law. To constitute a crime, two circumstances are necessary to be proved--(a) that the act has been committed, (b) that a guilty mind or malice was present. The act may be one of omission or of commission. Every person who commits a crime may be punished, unless he is under the age of seven years, is insane, or has been made to commit it under compulsion.

Crimes are divided into _misdemeanours_ and _felonies_. The distinction is not very definite, but, as a rule, the former are less serious forms of crime, and are punishable with a term of imprisonment, generally under two years; while felonies comprise the more serious charges, as murder, manslaughter, rape, which involve the capital sentence or long terms of imprisonment.

An _offence_ is a trivial breach of the criminal law, and is punishable on summary conviction before a magistrate or justices only, while the more serious crimes (_indictable offences_) must be tried before a jury.

2. _Civil injuries_ differ from crimes in that the former are compensated by damages awarded, while the latter are punished; any person, whether injured or not, may prosecute for a crime, while only the sufferer can sue for a civil injury. The Crown may remit punishment for a crime, but not for a civil injury.

II.--MEDICAL EVIDENCE

On being called, the medical witness enters the witness-box and takes the oath. This is very generally done by uplifting the right hand and repeating the oath (Scottish form), or by kissing the Bible, or by making a solemn affirmation.

1. He may be called to give _ordinary evidence_ as a _common witness_. Thus he may be asked to detail the facts of an accident which he has observed, and of the inferences he has deduced. This evidence is what any lay observer might be asked.

2. _Expert Witness._--On the other hand, he may be examined on matters of a technical or professional character. The medical man then gives evidence of a skilled or expert nature. He may be asked his opinion on certain facts narrated--_e.g._, if a certain wound would be immediately fatal. Again, he may be asked whether he concurs with opinions held by other medical authorities.

In important cases specialists are often called to give evidence of a skilled nature. Thus the hospital surgeon, the nerve specialist, or the mental consultant may be served with a subpoena to appear at court on a certain date to give evidence. The evidence of such skilled observers will, it is supposed, carry greater weight with the jury than would the evidence of an ordinary practitioner.

Skilled witnesses may hear the evidence of ordinary witnesses in regard to the case in which they are to give evidence, and it is, indeed, better that they should understand the case thoroughly, but they are not usually allowed to hear the evidence of other expert witnesses.

In civil cases the medical witness should, previous to the trial, make an agreement with the solicitor who has called him with reference to the fee he is to receive. Before consenting to appear as a witness the practitioner should insist on having all the facts of the case put before him in writing. In this way only can he decide as to whether in his opinion the plaintiff or defendant is right as regards the medical evidence. If summoned by the side on which he thinks the medical testimony is correct, then it is his duty to consent to appear. If, however, he is of opinion that the medical evidence is clearly and correctly on the opposite side, then he ought to refuse to appear and give evidence; and, indeed, the lawyer would not desire his presence in the witness-box unless he could uphold the case.

Whether an expert witness who has no personal knowledge of the facts is bound to attend on a subpoena is a moot point. It would be safer for him to do so, and to explain to the judge before taking the oath that his memory has not been sufficiently 'refreshed.' The solicitor, if he desires his evidence, will probably see that the fee is forthcoming.

A witness may be subjected to _three_ examinations: first, by the party on whose side he is engaged, which is called the 'examination in chief,' and in which he affords the basis for the next examination or 'cross-examination' by the opposite side. The third is the 're-examination' by his own side. In the first he merely gives a clear statement of facts or of his opinions. In the next his testimony is subjected to rigid examination in order to weaken his previous statements. In the third he is allowed to clear up any discrepancies in the cross-examination, but he must not introduce any new matter which would render him liable to another cross-examination.

The medical witness should answer questions put to him as clearly and as concisely as possible. He should make his statements in plain and simple language, avoiding as much as possible technical terms and figurative expressions, and should not quote authorities in support of his opinions.

An expert witness when giving evidence may refer to notes for the purpose of refreshing his memory, but only if the notes were taken by him at the time when the observations were made, or as soon after as practicable.

There are various _courts_ in which a medical witness may be called on to give evidence:

1. =The Coroner's Court.=--When a coroner is informed that the dead body of a person is lying within his jurisdiction, and that there is reasonable cause to suspect that such person died either a violent or unnatural death, or died a sudden death of which the cause is unknown, he must summon a jury of not less than twelve men to investigate the matter--in other words, hold an inquest--and if the deceased had received medical treatment, the coroner may summon the medical attendant to give evidence. By the Coroners (Emergency Provisions) Act of 1917, the number of the jury has been cut down to a minimum of seven and a maximum of eleven men. By the Juries Act of 1918, the coroner has the power of holding a court without a jury if, in his discretion, it appears to be unnecessary. In charges of murder, manslaughter, deaths of prisoners in prison, inmates of asylums or inebriates' homes, or of infants in nursing homes, he must summon a jury. The coroner may be satisfied with the evidence as to the cause of a person's death, and may dispense with an inquest and grant a burial certificate.

Cases are notified to the coroner by the police, parish officer, any medical practitioner, registrar of deaths, or by any private individual.

Witnesses, having been cited to appear, are examined on oath by the coroner, who must, in criminal cases at least, take down the evidence in writing. This is then read over to each witness, who signs it, and this forms his _deposition_. At the end of each case the coroner sums up, and the jury return their verdict or _inquisition_, either unanimously or by a majority.

If this charges any person with murder or manslaughter, he is committed by the coroner to prison to await trial, or, if not present, the coroner may issue a warrant for his arrest.

A chemical analysis of the contents of the stomach, etc., in suspected cases of poisoning is usually done by a special analyst named by the coroner. If any witness disobeys the summons to attend the inquest, he renders himself liable to a fine not exceeding £2 2s., but in addition the coroner may commit him to prison for contempt of court. In criminal cases the witnesses are bound over to appear at the assizes to give evidence there. The coroner may give an order for the exhumation of a body if he thinks the evidence warrants a post-mortem examination.

Coroners' inquests are held in all cases of sudden or violent death, where the cause of death is not clear; in cases of assault, where death has taken place immediately or some time afterwards; in cases of homicide or suicide; where the medical attendant refuses to give a certificate of death; where the attendants on the deceased have been culpably negligent; or in certain cases of uncertified deaths.

The medical witness should be very careful in giving evidence before a coroner. Even though the inquest be held in a coach-house or barn, yet it has to be remembered it is a court of law. If the case goes on for trial before a superior court, your deposition made to the coroner forms the basis of your examination. Any misstatements or discrepancies in your evidence will be carefully inquired into, and you will make a bad impression on judge and jury if you modify, retract, or explain away your evidence as given to the coroner. You had your opportunity of making any amendments on your evidence when the coroner read over to you your deposition before you signed it as true.

By the Licensing Act of 1902, an inquest may not be held in any premises licensed for the sale of intoxicating liquor if other suitable premises have been provided.

The duties of the coroner are based partly on Common Law, and are also defined by statute, principally by the Coroners Act of 1887 (50 and 51 Vict. c. 71). They have been modified, however, by subsequent Acts--_e.g._, the Act of 1892, the Coroners (Emergency Provisions) Act, 1917, and the Juries Act of 1918.

The fee payable to a medical witness for giving evidence at an inquest is one guinea, with an extra guinea for making a post-mortem examination and report (in the metropolitan area these fees are doubled). The coroner must sign the order authorizing the payment, and should an inquest be adjourned to a later day, no further fee is payable. If the deceased died in a hospital, infirmary, or lunatic asylum, the medical witness is not paid any fee. Should a medical witness neglect to make the post-mortem examination after receiving the order to do so, he is liable to a fine of £5.

In Scotland the Procurator Fiscal fulfils many of the duties of the coroner, but he cannot hold a public inquiry. He interrogates the witnesses privately, and these questions with the answers form the _precognition_. More serious cases are dealt with by the Sheriff of each county, and capital charges must be dealt with by the High Court of Justiciary. In Scotland the verdicts of the jury may be 'guilty,' 'not guilty,' or 'not proven.'

2. =The Magistrate's Court or Petty Sessions= is also a court of preliminary inquiry. The prisoner may be dealt with summarily, as, for example, in minor assault cases, or, if the case is of sufficient gravity, and the evidence justifies such a course, may be committed for trial. The fee for a medical witness who resides within three miles of the court is ten shillings and sixpence; if at a greater distance, one guinea.

In the Metropolis the prisoner in the first instance is brought before a magistrate, technically known as the 'beak,' who, in addition to being a person of great acumen, is a stipendiary, and thus occupies a superior position to the ordinary 'J.P.,' who is one of the great unpaid. In the City of London is the Mansion House Justice-Room, presided over by the Lord Mayor or one of the Aldermen. The prisoner may ultimately be sent for trial to the Central Criminal Court, known as the Old Bailey, or elsewhere.

3. =Quarter Sessions.=--These are held every quarter by Justices of the Peace. All cases can be tried before the sessions except felonies or cases which involve difficult legal questions. In London this court is known as the Central Criminal Court, and it also acts as the Assize Court. In Borough Sessions a barrister known as the _Recorder_ is appointed as sole judge.

4. =The Assizes= deal with both criminal and civil cases. There is the _Crown Court_, where criminal cases are tried, and there is the _Civil Court_, where civil cases are heard. Before a case sent up by a lower court can be tried by the judge and petty jury, it is investigated by the _grand jury_, which is composed of superior individuals. If they find a 'true bill,' the case goes on; but if they 'throw it out,' the accused is at liberty to take his departure. At the Court of Assize the prisoner is tried by a jury of twelve. In bringing in the verdict the jury must be unanimous. If they cannot agree, the case must be retried before a new jury. At the Assize Court the medical witness gets a guinea a day, with two shillings extra to pay for his bed and board for every night he is away from home, with his second-class railway fare, if there is a second class on the railway by which he travels. If there is no railway, and he has to walk, he is entitled to threepence a mile for refreshments both ways.

5. =Court of Criminal Appeal.=--This was established in 1908, and consists of three judges. A right of appeal may be based (1) solely on a question of law; (2) on certificate from the judge who tried the prisoner; (3) on mitigation of sentence.

Speaking generally, in the Superior Courts the fees which may be claimed by medical men called on to give evidence are a guinea a day if resident in the town in which the case is tried, and from two to three guineas a day if resident at a distance from the place of trial, this to include everything except travelling expenses. The medical witness also receives a reasonable allowance for hotel and travelling expenses.

If a witness is summoned to appear before two courts at the same time, he must obey the summons of the higher court. Criminal cases take precedence of civil.

A medical man has no right to claim privilege as an excuse for not divulging professional secrets in a court of law, and the less he talks about professional etiquette the better. Still, in a civil case, if he were to make an emphatic protest, the matter in all probability would not be pressed. In a criminal case he would promptly be reminded of the nature of his oath.

A medical man may be required to furnish a _formal written report_. It may be the history of a fatal illness or the result of a post-mortem examination. These reports must be drawn up very carefully, and no technical terms should be employed.

No witness on being sworn can be compelled to 'kiss the book.' The Oaths Act (51 and 52 Vict., c. 46, § 5) declares, without any qualification, that 'if any person to whom an oath is administered desires to swear with uplifted hand, in the form and manner in which an oath is usually administered in Scotland, he shall be permitted to do so, and the oath shall be administered to him in such form and manner without further question.' The witness takes the oath standing, with the bare right hand uplifted above the head, the formula being: 'I swear by Almighty God that I will speak the truth, the whole truth, and nothing but the truth.' The presiding judge should say the words, and the witness should repeat them after him. There is no kissing of the book, and the words 'So help me, God,' which occur in the English form, are not employed. It will be noted that the Scotch form constitutes an oath, and is not an affirmation. The judge has no right to ask if you object on religious grounds, or to put any question. He is bound by the provisions of the Act, and the enactment applies not only to all forms of the witness oath, whether in civil or criminal courts, or before coroners, but to every oath which may be lawfully administered either in Great Britain or Ireland.

A witness engaged to give expert evidence should demand his fee before going into court, or, at all events, before being sworn.

With regard to notes, these should be made at the time, on the spot, and may be used by the witness in court as a refresher to the memory, though not altogether to supply its place. All evidence is made up of testimony, but all testimony is not evidence. The witness must not introduce hearsay testimony. In one case only is hearsay evidence admissible, and that is in the case of a _dying declaration_. This is a statement made by a dying person as to how his injuries were inflicted. These declarations are accepted because the law presumes that a dying man is anxious to speak the truth. But the person must believe that he is _actually_ on the point of death, with _absolutely_ no hope of recovery. A statement was rejected because the dying person, in using the expression 'I have no hope of recovery,' requested that the words 'at present' should be added. If after making the statement the patient were to say, 'I hope now I shall get better,' it would invalidate the declaration. To make the declaration admissible as evidence, death must ensue. If possible, a magistrate should take the dying declaration; but if he is not available, the medical man, without any suggestions or comments of his own, should write down the statements made by the dying person, and see them signed and witnessed. It must be made clear to the court that at the time of making his statement the witness was under the full conviction of approaching or impending death.

III.--PERSONAL IDENTITY

It is but seldom that medical evidence is required with regard to the identification of the living, though it may sometimes be so, as in the celebrated Tichborne case. The medical man may in such cases be consulted as to family resemblance, marks on the body, nævi materni, scars and tattoo marks, or with regard to the organs of generation in cases of doubtful sex. Tattoo marks may disappear during life; the brighter colours, as vermilion, as a rule, more readily than those made with carbon, as Indian ink; after death the colouring-matter may be found in the proximal glands. If the tattooing is superficial (merely underneath the cuticle) the marks may possibly be removed by acetic acid or cantharides, or even by picking out the colouring-matter with a fine needle. With regard to scars and their permanence, it will be remembered that scars occasioned by actual loss of substance, or by wounds healed by granulation, never disappear. The scars of leech-bites, lancet-wounds, or cupping instruments, may disappear after a lapse of time. It is difficult, if not impossible, to give any certain or positive opinion as to the age of a scar; recent scars are pink in colour; old scars are white and glistening. The cicatrix resulting from a wound depends upon its situation. Of incised wounds an elliptical cicatrix is typical, linear being chiefly found between the fingers and toes. By way of disguise the hair may be dyed black with lead acetate or nitrate of silver; detected by allowing the hair to grow, or by steeping some of it in dilute nitric acid, and testing with iodide of potassium for lead, and hydrochloric acid for silver. The hair may be bleached with chlorine or peroxide of hydrogen, detected by letting the hair grow and by its unnatural feeling and the irregularity of the bleaching.

Finger-print impressions are the most trustworthy of all means of identification. Such a print is obtained by rubbing the pulp of the finger in lampblack, and then impressing it on a glazed card. The impression reveals the fine lines which exist at the tips of the fingers. The arrangement of these lines is special to each person, and cannot be changed. Hence this method is employed by the police in the identification of prisoners.

In the determination of cases of doubtful sex in the living, the following points should be noticed: the size of the penis or clitoris, and whether perforate or not, the form of the prepuce, the presence or absence of nymphæ and of testicles or ovaries. Openings must be carefully sounded as to their communication with bladder or uterus. After puberty, inquiry should be made as to menstrual or vicarious discharges, the general development of the body, the growth of hair, the tone of voice, and the behaviour of the individual towards either sex.

With regard to the identification of the dead in cases of death by accident or violence, the medical man's assistance may be called. The sex of the skeleton, if that only be found, may be judged from the bones of the female generally being smaller and more slender than those of the male, by the female thorax being deeper, the costal cartilages longer, the ilia more expanded, the sacrum flatter and broader, the coccyx movable and turned back, the tuberosities of the ischia wider apart, the pubes shallow, and the whole pelvis shallower and with larger outlets. But of all these signs the only one of any real value is the roundness of the pubic arch in the female, as compared with the pointed arch in the male. Before puberty the sex cannot be determined from an examination of the bones.

Age may be calculated from the presence, nature and number of the erupted teeth; from the cartilages of the ribs, which gradually ossify as age advances; from the angle formed by the ramus of the lower jaw with its body (obtuse in infancy, a right angle in the adult, and again obtuse in the aged from loss of the teeth); and in the young from the condition of the epiphyses with regard to their attachment to their respective shafts.

To determine stature, the whole skeleton should be laid out and measured, 1-1/2 to 2 inches being allowed for the soft parts.

IV.--EXAMINATION OF PERSONS FOUND DEAD

When a medical man is called to a case of sudden death, he should carefully note anything likely to throw any light on the cause of death. He should notice the place where the body was found, the position and attitude of the body, the soil or surface on which the body lies, the position of surrounding objects, and the condition of the clothes. He should also notice if there are any signs of a struggle having taken place, if the hands are clenched, if the face is distorted, if there has been foaming at the mouth, and if urine or fæces have been passed involuntarily. Urine may be drawn off with a catheter and tested for albumin and sugar.

If required to make a post-mortem examination, every cavity and important organ of the body must be carefully and minutely examined, the seat of injury being inspected first.

V.--MODES OF SUDDEN DEATH

There are three modes in which death may occur: (1) Syncope; (2) asphyxia; (3) coma.

1. =Syncope= is death beginning at the heart--in other words, failure of circulation. It may arise from--(1) _Anæmia_, or deficiency of blood due to hæmorrhage, such as occurs in injuries, or from bleeding from the lungs, stomach, uterus, or other internal organs. (2) _Asthenia_, or failure of the heart's action, met with in starvation, in exhausting diseases, such as phthisis, cancer, pernicious anæmia, and Bright's disease, and in some cases of poisoning--for example, aconite.

The symptoms of syncope are faintness, giddiness, pallor, slow, weak, and irregular pulse, sighing respiration, insensibility, dilated pupils, and convulsions.

Post mortem the heart is found empty and contracted. When, however, there is sudden stoppage of the heart, the right and left cavities contain blood in the normal quantities, and blood is found in the venæ cavæ and in the arterial trunks. There is no engorgement of either lungs or brain.

2. =Asphyxia=, or death beginning at the lungs, may be due to obstruction of the air-passages from foreign bodies in the larynx, drowning, suffocation, strangling, and hanging; from injury to the cervical cord; effusion into the pleuræ, with consequent pressure on the lungs; embolism of the pulmonary artery; and from spasmodic contraction of the thoracic and abdominal muscles in strychnine-poisoning.

The symptoms of this condition are fighting for breath, giddiness, relaxation of the sphincters, and convulsions.

Post mortem, cadaveric lividity is well marked, especially in nose, lips, ears, etc.; the right cavities of the heart and the venæ cavæ are found gorged with dark fluid blood. The pulmonary veins, the left cavities of the heart, and the aorta, are either empty or contain but little blood. The lungs are dark and engorged with blood, and the lining of the air-tubes is bright red in colour. Much bloody froth escapes on cutting into the lungs. Numerous small hæmorrhages (Tardieu's spots) are found on the surface and in the substance of the internal organs, as well as in the skin of the neck and face.

3. =Coma=, or death beginning at the brain, may arise from concussion; compression; cerebral pressure from hæmorrhage and other forms of apoplexy; blocking of a cerebral artery from embolism; dietetic and uræmic conditions; and from opium and other narcotic poisons.

The symptoms of this condition are stupor, loss of consciousness, and stertorous breathing.

The post-mortem signs are congestion of the substance of the brain and its membranes, with accumulation of the blood in the cavities of the heart, more on the right side than on the left.

It must be remembered that, owing to the interdependence of all the vital functions, there is no line of demarcation between the various modes of death. In all cases of sudden death think of angina pectoris and the rupture of an aneurism.

The following is a list of some of the commoner causes of sudden death:

(a) =Instantaneously Sudden Death=--

1. Syncope (by far the commonest cause).

2. Aortic incompetence.

3. Rupture of heart.

4. Rupture of a valve.

5. Rupture of aortic aneurism.

6. Embolism of coronary artery.

7. Angina pectoris.

(b) =Less Sudden but Unexpected Death=--

1. Cerebral hæmorrhage or embolism.

2. Mitral and tricuspid valvular lesions if the patient exerts himself.

3. Rupture of a gastric or duodenal ulcer; rupture of liver, spleen, or extra-uterine gestation, or abdominal aneurism.

4. Suffocation during an epileptic fit; vomited matter or other material drawn into the trachea or air-passages; croup.

5. Arterio-sclerosis may lead to thrombosis, embolism, or aneurism.

6. Poisoning, as by hydrocyanic acid, cyanide of potassium, inhalation of carbonic acid or coal gas, oedema of glottis following inhalation of ammonia.

7. Rapid onset of some acute specific disease, such as pneumonia or diphtheria; collapse from cholera.

8. Heat-stroke, lightning, shocks of electricity of high tension.

9. Mental or physical shock.

10. Exertion while the stomach is overloaded.

11. Diabetic coma; uræmia.

12. _Status lymphaticus._ This is a general hyperplastic condition of the lymphatic structures in the body, and is seen in enlargement of tonsils, thymus, spleen, as well as of Peyer's patches and mesenteric glands. It is a frequent cause of death during chloroform anæsthesia for slight operations in young people.

In addition, it may be as well to remember that death sometimes occurs suddenly in exophthalmic goitre, hypertrophy of the thymus, and in Addison's disease.

In some cases of sudden death nothing has been found post mortem, even when the autopsy has been made by skilled observers, and the brain and cord have been submitted to microscopical examination.

VI.--SIGNS OF DEATH

(1) Cadaveric appearance; ashy white colour. (2) Cessation of the circulation and respiration, no sound being heard by the stethoscope. Cessation of the circulation may be determined by (a) placing a ligature round the base of a finger (Magnus' test); (b) injecting a solution of fluorescin (Icard's test); (c) looking through the web of the fingers at a bright light (diaphanous test); (d) the dulling of a steel needle when thrust into the living body; (e) the clear outline of the dead heart when viewed in the fluorescent screen. (3) The state of the eye; the tension is at once lost; iris insensible to light, fundus yellow in colour; cornea dull and sunken. (4) The state of the skin; pale, livid, with loss of elasticity. (5) Extinction of muscular irritability. The above signs afford no means of determining how long life has been extinct. The following, however, do:

=Cooling of the Body.=--The average internal temperature of the body is from 98° to 100° F. The time taken in cooling is from fifteen to twenty hours, but it may be modified by the kind of death, the age of the person, the presence or absence of clothing on the body, the surrounding temperature, and the stillness or otherwise of the air about the body. Still, the body, other things being equal, may be said to be _quite cold_ in about _twelve hours_.

=Hypostasis= or =post-mortem staining= is due to the settling down of the blood in the most dependent parts of the body while the body is cooling. It is a sure sign of death, and occurs in all forms of death, even in that due to hæmorrhage, although not so marked in degree. Post-mortem staining (_cadaveric lividity_) begins to appear in from eight to twelve hours after death, and its position on the body will help to determine the length of time the body has lain in the position in which it was found. The staining is of a dull red or slaty blue colour. It must be distinguished from ecchymosis the result of a bruise, by making an incision into the part; in the case of hypostasis a few small bloody points of divided arteries will be seen, in the case of ecchymosis the subcutaneous tissues are infiltrated with blood-clot. Internally, hypostasis must not be mistaken for congestion of the brain or lungs, or the results of inflammation of the intestines. If the intestine is pulled straight, inflammatory redness is continuous, hypostasis is disconnected. About the neck hypostasis must not be mistaken for the mark of a cord or other ligature. When the blood is of a bright red colour after death (as happens in poisoning by CO or HCN, or in death from cold), the hypostasis is bright red also.

=Cadaveric Rigidity--Rigor Mortis.=--For some time after death the muscles continue to contract under stimuli. When this irritability ceases--and it seldom exceeds two hours--rigidity and hardening sets in, and in _all_ cases precedes putrefaction. It is caused by the coagulation of the muscle plasma. It commences in the muscles of the back of the neck and lower jaw, and then passes into the muscles of the face, front of the neck, chest, upper extremities, and lastly to the lower extremities.

It has been noticed in the new-born infant, as well as in the foetus. It lasts from sixteen to twenty hours or more. In lingering diseases, after violent exertion, and in warm climates, it sets in quickly, and disappears in two or three hours; in those who are in perfect health and die from accident or asphyxia, it may not come on until from ten to twenty-four hours, and may last three or four days. After death from convulsions or strychnine-poisoning, the body may pass at once into rigor mortis. Rigor mortis must be distinguished from _cadaveric spasm_ or the _death clutch_; in the former, articles in the hands are readily removable, in the latter this is not the case. In tetanic spasm the limbs when bent return to their former position; not so in rigor mortis.

=Putrefaction= appears in from one to three days after death, as a greenish-blue discoloration of the abdomen; in the drowned, over the head and face. This increases, becomes darker and more general, a strong putrefactive odour is developed, the thorax and abdomen become distended with gas, and the epidermis peels off. The muscles then become pulpy, and assume a dark greenish colour, the whole body at length becoming changed into a soft, semi-fluid mass. The organ first showing the putrefactive change is the trachea; that which resists putrefaction longest is the uterus. These putrefactive changes are modified by the fat or lean condition of the body, the temperature (putrefaction taking place more rapidly in summer than in winter), access of air, the period, place, mode of interment, age, etc. Bodies which remain in water putrefy more slowly than those in air.

=Saponification.=--In bodies which are very fat and have lain in water or moist soil for from one to three years this process takes place, the fat uniting with the ammonia given off by the decomposition to form _adipocere_. This consists of a margarate or stearate of ammonium with lime, oxide of iron, potash, certain fatty acids, and a yellowish odorous matter. It has a fatty, unctuous feel, is either pure white or pale yellow, with an odour of decayed cheese. Small portions of the body may show signs of this change in six weeks.

=Post-Mortem Examination.=--Never make an autopsy in criminal cases without a written order from the coroner or Procurator Fiscal. If authorized, however, first have the body identified, then photographed if it has not been identified. A medical man representing the accused may be present, but only by consent of the Crown authorities or of the Sheriff. Clothing should be examined for blood-stains, cuts, etc.

Examine external surface of body and take accurate measurements of wounds, marks, deformities, tattooings; note degree and distribution of post-mortem staining, rigidity, etc.

Examine brain by making incision from ear to ear across vertex, reflect scalp forwards and backwards, and saw off calvarium. Examine brain carefully externally and on section.

Examine organs of chest and abdomen through an incision made from symphysis menti to pubis, reflecting tissues from chest wall and cutting through costal cartilages.

In cases of suspected poisoning have several clean jars into which you place the stomach with contents, intestines with contents, piece of liver, kidney, spleen, etc., and seal each up carefully, attaching label with name of deceased, date, and contained organs, and transmit these personally to the analyst.

=Exhumation.=--A body which has been buried cannot be exhumed without an order from a coroner, fiscal, or from the Home Secretary. There is no legal limit in England as to when a body may be exhumed; in Scotland, however, if an interval of twenty years has elapsed, an accused person cannot be prosecuted (_prescription of crime_).

VII.--DEATH FROM ANÆSTHETICS, ETC.

The coroner in England and Wales and Ireland must inquire into every case of death during the administration of an anæsthetic. The anæsthetist has to appear at the inquest, and must answer a long series of questions relative to the administration of the drug.

Before, therefore, giving an anæsthetic, and so as to furnish yourself with a proper defence in the event of death occurring, you ought to examine the heart, lungs, and kidneys of the patient to see if they are healthy. Should a fatal result follow, the anæsthetist will require to prove that it was necessary to give the anæsthetic, that the one employed was the most suitable, that the patient was in a fit state of health to have it administered, that it was given skilfully and in moderate amount, that he had the usual remedies at hand in case of failure of the heart or lungs, and that he employed every means in his power to resuscitate the patient.

The condition of the lungs is of more importance than the state of the heart.

The chloroformist ought always to use the best chloroform.

An anæsthetic should never be administered except in the presence of a _third person_. This applies especially to dentists who give gas to females.

=Malpractice.=--In every case where a medical man attends a patient, he must give him that amount of care, skill, knowledge, or judgment, that the law expects of him. If he does not, then the charge of malpractice may be brought against him. It is most frequently alleged in connection with surgical affections--_e.g._, overlooking a fracture or dislocation. Before a major operation is performed, it is well to get a written agreement.

VIII.--PRESUMPTION OF DEATH; SURVIVORSHIP

=Presumption of Death.=--If a person be unheard of for seven years, the court may, on application by the nearest relative, presume death to have taken place. If, however, it can be shown that in all probability death had occurred in a certain accident or shipwreck, the decree may be made much earlier.

=Presumption of Survivorship.=--When two or more related persons perish in a common accident, it may be necessary, in order to decide questions of succession, to determine which of them died first. It is generally accepted that the stronger and more vigorous will survive longest.

IX.--ASSAULT, MURDER, MANSLAUGHTER, ETC.

=Assault.=--This is an attempt or offer to do violence to another person; it is not necessary that actual injury has been done, but evil intention must be proved. When a corporal hurt has been sustained, then _assault and battery_ has been committed. The assault may be aggravated by the use of weapons, etc.

=Homicide= may be _justifiable_, as in the case of judicial execution, or _excusable_, as in defence of one's family or property.

_Felonious homicide_ is murder. This means that a human being has been killed by another maliciously and deliberately or with reckless disregard of consequences.

=Manslaughter= or =Culpable Homicide= (Scotland) is the unlawful killing of a human being without malice--as homicide after great provocation; signalman who allows a train to pass, and so collide with another in front.

X.--WOUNDS AND MECHANICAL INJURIES

A wound may be defined as a 'breach of continuity in the structures of the body, whether external or internal, suddenly occasioned by mechanical violence.' The law does not define 'a wound,' but the _true skin must be broken_. Wounds are dangerous from shock, hæmorrhage, from the supervention of crysipelas or pyæmia, and from _malum regimen_ on the part of the patient or surgeon. _Is the wound dangerous to life?_ This question can only be answered by a full consideration of all the circumstances of the case; a guarded prognosis is wise in all cases.

=Burns= are caused by flames, highly heated solids, or very cold solids, as solid carbonic acid; scalds, by steam or hot fluids. Burns may cause death from shock, suffocation, oedema glottidis, inflammation of serous surfaces, bronchitis, pneumonia, duodenal ulcer, coma, or exhaustion. A burn of the skin inflicted during life is followed by a bleb containing serum; the edges of this blister are bright red, and the base, seen after removing the cuticle, is red and inflamed; if sustained after death, a bleb, if present, contains but little fluid, and there are no signs of vital reaction. There are six degrees of burns: (1) Superficial inflammation; (2) formation of vesicles; (3) destruction of superficial layer of skin; (4) destruction of cellular tissue; (5) deep parts charred; (6) carbonization of bones.

The larger the area of skin burnt, the more grave is the prognosis. Burns of the abdomen and genital organs are especially dangerous. Young children are specially liable to die after burns.

XI.--CONTUSED WOUNDS AND INJURIES UNACCOMPANIED BY SOLUTION OF CONTINUITY

If a blow be inflicted with a blunt instrument, there is produced a bruise, or _ecchymosis_, of which it is unnecessary here to describe the appearance and progress. A bruise may be distinguished from a post-mortem stain by the cuticle in the former often being abraded and raised. When an incision is made into the bruise, the whole of the subcutaneous tissues are found to be infiltrated with blood-clot, and there is no clear margin. In the case of a post-mortem stain the edges are sharply defined, not raised, and, on section, mere bloody points are seen which are the cut ends of the divided blood vessels.

XII.--INCISED WOUNDS AND THOSE ACCOMPANIED BY SOLUTION OF CONTINUITY

These comprise incised, punctured, and lacerated wounds. In a recent incised wound inflicted during life there is copious hæmorrhage, the cellular tissue is filled with blood, the edges of the wound gape and are everted, and the cavity of the wound is filled with coagula.

Lacerated wounds combine the characters of incised and contused wounds. They are caused by falls, being ridden over, machinery crushes, bites, blows from blunt weapons, etc. The wounds heal by suppuration.

_Punctured wounds_ come intermediate between incised and lacerated. They are greater in depth than in length, being caused by sword or rapier thrusts. They cause little hæmorrhage externally, but death may be due to internal hæmorrhage. They may be complicated by (1) the introduction of septic material adhering to the instrument; (2) the entrance of foreign bodies which lodge in the wound, not only carrying in septic matter, but acting as mechanical irritants; (3) injury to deeper parts, which may at the time be difficult to detect.

An apparently _incised wound_ may be produced by a hard, blunt weapon over a bone--_e.g._, shin or cranium. It is often difficult to distinguish between a wound of the scalp inflicted with a knife and one made by a blow with a stick. A puncture with a sharp-edged, pointed knife leaves a fusiform or spindle-shaped wound. A wound from a blow with a stick might be of this character, or it might present a jagged, swollen appearance at the margin, with much contusion of the surrounding tissues. If the wound is seen soon after it is inflicted, examination with a lens may disclose irregularities of the margins, or little bridges of connective tissue or vessels running across the wound, and so be inconsistent with its production by a cutting instrument. _Lacerated wounds_ as a rule bleed less freely than those which are incised. Symptoms of concussion would favour the theory of the injury having been inflicted by a heavy instrument. Again, it is often difficult to decide whether the injury which caused death was the result of a blow or a fall. A heavy blow with a stick may at once cause fatal effusion of blood, but this might equally result from fracture of the skull resulting from a fall. The wound should be carefully examined for foreign bodies, such as grit, dirt, or sand. The distinction between incised wounds inflicted during life and after death is found in the fact that a wound inflicted during life presents the appearances already described, whereas in a post-mortem incised wound only a small quantity of liquid venous blood is effused; the edges are close, yielding, inelastic; the blood is not effused into the cellular tissue, and there are no signs of vital reaction. The presence of inflammatory reaction or pus shows that the wound must have been inflicted some time before death, probably two or three days.

_Self-inflicted wounds_ are made by the person himself in order to divert suspicion, or in order to bring accusation against another. Such wounds are always in front, not over vital organs, and superficial in character. Note the condition of the clothes in such cases.

XIII.--GUNSHOT WOUNDS

These may be punctured, contused, or lacerated. Round balls make a larger opening than those which are conical. Small shot fired at a short distance make one large ragged opening; while at distances greater than 3 feet the shot scatter and there is no central opening. The Lee-Metford bullet is more destructive than the Mauser. The former is the larger, but the difference in size is not great. The Martini-Henry bullet weighs 480 grains, the Lee-Metford 215, and the Mauser 173. Speaking generally, a gunshot wound, unlike a punctured wound, becomes larger as it increases in depth; the aperture of entrance is round, clean, with inverted edges, and that of exit larger, less regular than that of entrance, and with everted edges.

In the case of high-velocity bullets from smooth-bore rifles, including the Mauser and Lee-Metford, the aperture of entry is small; the aperture of exit is slightly larger, and tends to be more slit-like. There is but little tendency to carry in portions of clothing or septic material, and the wound heals by first intention, if reasonable precautions be taken. The external cicatrices finally look very similar to those produced by bad acne pustules.

The contents of all gunshot wounds should be preserved, as they may be useful in evidence. A pocket revolver, as a rule, leaves the bullet in the body.

Wounds inflicted by firearms may be due to accident, homicide, or suicide. Blackening of the wound, singeing of the hair, scorching of the skin and clothing, show that the weapon was fired at close quarters, whilst blackening of the hand points to suicide. Even when the weapon is fired quite close there may be no blackening of the skin, and the hand is not always blackened in cases of suicide. Smokeless powder does not blacken the skin. Wounds on the back of the body are not usually self-inflicted, but a suicide may elect to blow off the back of his head. A wound in the back may be met with in a sportsman who indulges in the careless habit of dragging a loaded gun after him. If a revolver is found tightly grasped in the hand it is probably a case of suicide, whilst if it lies lightly in the hand it may be suicide or homicide. If no weapon is found near the body, it is not conclusive proof that it is not suicide, for it may have been thrown into a river or pond, or to some distance and picked up by a passer-by.

A bullet penetrating the skull even from a distance of 3,000 yards may act as an explosive, scattering the contents in all directions; but the bullet from a revolver will usually be found in the cranium.

The prognosis depends partly on the extent of the injury and the parts involved, but there is also risk from secondary hæmorrhage, and from such complications as pleurisy, pericarditis, and peritonitis. Death may result from shock, hæmorrhage, injury to brain or important nervous structures.

XIV.--WOUNDS OF VARIOUS PARTS OF THE BODY

1. =Of the Head.=--Wounds of the scalp are likely to be followed by (1) erysipelatous inflammation; (2) inflammation of the tendinous structures, with or without suppuration. A severe blow on the vertex may cause fracture of the base of the skull. Injuries of the brain include concussion, compression, wounds, contusion, and inflammation. Concussion is a common effect of blows or violent shocks, and the symptoms follow immediately on the accident, death sometimes taking place without reaction. Compression may be caused by depressed bone or effused blood (rupture of middle meningeal artery) and serum. The symptoms may come on suddenly or gradually. Wounds of the brain present very great difficulties, and vary greatly in their effect, very slight wounds producing severe symptoms, and _vice versâ_. A person may receive an injury to the head, recover from the first effects, and then die with all the symptoms of compression from internal hæmorrhage. This is due to the fact that the primary syncope arrests the hæmorrhage, which returns during the subsequent reaction, or on the occurrence of any excitement. Inflammation of the meninges or brain may follow injuries, not only to the brain itself, but to the scalp and adjacent parts, as the orbit and ear. Inflammation does not usually come on at once, but after variable periods.

2. =Injuries to the Spinal Cord= may be due to concussion, compression (fracture-dislocation), or wounds. That the wound has penetrated the meninges is shown by the escape of cerebro-spinal fluid. The cord and nerves may be injured (1) by the puncture; (2) by extravasation of blood and the formation of a clot; and (3) by subsequent septic inflammation. Division or complete compression of the cord at or above the level of the fourth cervical vertebra is immediately fatal (as happens in judicial hanging). When the injury is below the fourth, the diaphragm continues forcibly in action, but the lungs are imperfectly expanded, and life will not be maintained for more than a day or two. When the injury is in the dorsal region, there is paralysis of the legs and of the sphincters of the bladder and rectum, but power is retained in the arms and the upper intercostal muscles act, the extent of paralysis depending on the level of the lesion. In injuries to the lumbar region the legs may be partly paralysed, and the rectal and bladder sphincters may be involved.

_Railway spine_, or traumatic neurasthenia, may be set up by concussion of the cord as a result of blows or falls. Passengers after railway accidents, or miners, often suffer from this affection.

3. =Of the Face.=--These produce great disfigurement and inconvenience, and there is a risk of injury to the brain. The seventh nerve may be involved, giving rise to facial paralysis. Punctured wounds of the orbit are especially dangerous. Wounds apparently confined to the external parts often conceal deep-seated mischief.

4. =Of the Eye.=--The iris may be injured by sharp blows, as from the cork of a soda-water bottle. It is usually followed by hæmorrhage into the anterior chamber, and there may be separation of the iris from its ciliary border. Wounds at the edge of the cornea are often followed by prolapse of the iris. Acute traumatic iritis or irido-cyclitis may supervene four or five days after the injury. The lens is frequently wounded in addition to the cornea and iris. In dislocation of the lens into the anterior chamber as the result of a blow, the lens appears like a large drop of oil lying at the back of the cornea, the margin exhibiting a brilliant yellow reflex. Partial dislocations of the lens as the result of severe blows generally terminate in cataract.

5. =Of the Throat.=--Very frequently inflicted by suicides. Division of the carotid artery is fatal, and of the internal jugular vein very dangerous on account of entrance of air. Wounds of the larynx and trachea are not necessarily or immediately dangerous, but septic pneumonia is very apt to follow. Wounds of the throat inflicted by suicides are commonly situated at the upper part, involving the hyoid bone and the thyroid and cricoid cartilages. The larynx is opened, but the large vessels often escape. In most suicidal wounds of the throat the direction is from left to right, the incision being slightly inclined from above downwards. At the termination of a suicidal cut-throat the skin is the last structure divided, the wound being shallower as it reaches its termination; the wounds often show parallelism. The weapon is often firmly grasped in the hand. Inquiry should be made as to whether the patient is right or left handed, or ambidextrous.

Homicidal cut throat is usually very severe and situated low down in the neck or far to the side.

6. =Of the Chest.=--Incised wounds of the walls are not of necessity dangerous; but severe blows, by causing fracture of the bones and internal injuries, are often fatal. The symptoms of penetrating wounds of the chest are--(1) The passage of blood and air through the wound; (2) hæmoptysis; (3) pneumothorax; and (4) protrusion of the lung forming a tumour covered with pleura. Fracture of the ribs may be due to direct violence, as from a blow, when the ends are driven inwards, or to indirect violence, as from a squeeze in a crowd, when the ends are driven outwards.

7. =Of the Lungs.=--These usually cause hæmorrhage, and are frequently followed by pleurisy, either dry or with effusion, and by pneumonia.

8. =Of the Heart.=--Penetrating wounds are fatal from hæmorrhage, of the base more speedily than of the apex; but life may be prolonged for some time even after a severe wound to the heart. Injury to the right ventricle is the most fatal injury and the most frequent. Rupture from disease usually occurs in the left ventricle; rupture from a crush is usually towards the base and on the right side.

9. =Of the Aorta and Pulmonary Artery.=--Fatal.

10. =Of the Diaphragm.=--Generally fatal, owing to the severe injury of the other abdominal organs. If the diaphragm be ruptured, hernia of the organs may result.

11. =Of the Abdomen.=--Of the walls, may be dangerous from division of the epigastric artery; ventral hernia may follow, internal hæmorrhage, etc. Blows on the abdomen are prone to cause death from cardiac inhibition.

12. =Of the Liver.=--May divide the large vessels. Venous blood flows profusely from a punctured wound of the liver. Wounds of the gall-bladder cause effusion of bile and peritoneal inflammation. Laceration of the liver may result from external violence without leaving any outward sign of the injury; it is commonly fatal. There is rapid and acute anæmia from the pouring out of blood into the abdominal cavity. This may also occur with injuries of other organs in the abdomen.

13. =Of the Spleen.=--Fatal hæmorrhage may result from penetrating wounds or from rupture due to kicks, blows, crushes, especially if the spleen be enlarged.

14. =Of the Stomach.=--May be fatal from shock, from hæmorrhage, from extravasation of contents, or from inflammation. The danger is materially lessened by prompt surgical intervention.

15. =Of the Intestines.=--May be fatal in the same way as those of the stomach. More dangerous in the small than in the large intestines.

16. =Of the Kidneys.=--May prove fatal from hæmorrhage, extravasation of urine, or inflammation.