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.
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.
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.
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, œdema 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.
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.
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.
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.
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.
17. Of the Bladder.—Dangerous from extravasation of urine. In fracture of the pelvis the bladder is often injured, and extraperitoneal infiltration of urine occurs, with frequently a fatal issue.
18. Of Genital Organs.—Incised wounds of penis may produce fatal hæmorrhage. Removal of testicles may prove fatal from shock to nervous system. Wounds of the spermatic cord may be dangerous from hæmorrhage. Wounds to the vulva are dangerous, owing to hæmorrhage from the large plexus of veins without valves.
Stains may require detection on clothing, on cutting instruments, on floors and furniture, etc. The following are the distinctive characters of blood-stains:
(a) Ocular Inspection.—Blood-stains on dark-coloured materials, which in daylight might be easily overlooked, may be readily detected by the use of artificial light, as that of a candle, brought near the cloth. Blood-spots when recent are of a bright red colour if arterial, of a purple hue if venous, the latter becoming brighter on exposure to the air. After a few hours blood-stains assume a reddish-brown or chocolate tint, which they maintain for years. This change is due to the conversion of hæmoglobin into methæmoglobin, and finally into hæmatin. The change of colour in warm weather usually occurs in less than twenty-four hours. The colour is determined, not entirely by the age of the stain, but is influenced by the presence or absence of impurities in the air, such as the vapours of sulphurous, sulphuric, and hydrochloric acids. If recent, a jelly-like material may be seen by the aid of a magnifying-glass lying between the fibres. If old, a cinnabar-red streak is seen on drawing a needle across the stain.
(b) Microscopic Demonstration.—With the aid of the microscope, blood may be detected by the presence of the characteristic blood-corpuscles. The human blood-corpuscle is a non-nucleated, biconcave disc, having a diameter of about 1/3500 of an inch. All mammalian red corpuscles have the same shape, except those of the camel, which are oval. The corpuscles of birds, fishes, reptiles, and amphibians, are oval and nucleated. The corpuscles of most mammals are smaller than those of man, but the size of a corpuscle is affected by various circumstances, such as drying or moisture, so that the medical witness is rarely justified in going farther than stating whether the stain is that of the blood of a mammal or not. Unfortunately, the corpuscles are usually so dried that little information regarding their size can be given.
(c) Action of Water.—Water has a solvent action on blood, fresh stains rapidly dissolving when the material on which they occur is placed in cold distilled water, forming a bright red solution. The hæmatin of old stains dissolves very slowly, so employ a weak solution of ammonia, and this will give a solution of alkaline hæmatin. Rust is not soluble in water.
(d) Action of Heat.—Blood-stains on knives may be removed by heating the metal, when the blood will peel off, at once distinguishing it from rust. Should the blood-stain on the metal be long exposed to the air, rust may be mixed with the blood, when the test will fail. The solution obtained in water is coagulated by heat, the colour entirely destroyed, and a flocculent muddy-brown precipitate formed.
(e) Action of Caustic Potash.—The solution of blood obtained in water is boiled, when a coagulum is formed soluble in hot caustic potash, the solution formed being greenish by transmitted and red by reflected light.
(f) Action of Nitric Acid.—Nitric acid added to a watery solution produces a whitish-grey precipitate.
(g) Action of Guaiacum.—Tincture of guaiacum produces in the watery solution a reddish-white precipitate of the resin, but on addition of an aqueous solution of peroxide of hydrogen, or of an ethereal solution of the same substance (known as ozonic ether), a blue or bluish-green colour is developed. This test is delicate, and succeeds best in dilute solutions. It is not absolutely indicative of the presence of blood, for tincture of guaiacum is coloured blue by milk, saliva, and pus.
(h) Hæmin Crystals (Teichman's Crystals).—These are produced by heating a drop of blood, or a watery solution of it, with a minute crystal of sodium chloride on a glass slide and evaporating to dryness. A cover-glass is placed over this, and a drop of glacial acetic acid allowed to run in. It is again heated until bubbles appear. Crystals of hæmin may now be detected by the microscope. They are dark brown or yellow rhombic prisms.
An improvement on this test is the use of formic acid alone; on slowly evaporating it, numerous very small dark crystals are visible if hæmoglobin has been present (Whitney's test).
(i) Spectroscopic Appearances.—If a solution of a recent stain be examined by the spectroscope, we get two absorption bands situated between the lines D and E, the one nearer E being doubly as broad as the other. These bands indicate oxyhæmoglobin.
If we now add a little ammonium sulphide to this solution, we get the spectrum of reduced hæmoglobin, which is a single broad absorption band situated in the interval between the preceding oxyhæmoglobin bands. By shaking the solution, oxyhæmoglobin is again reproduced, and gives its special absorption bands.
If ammonia be added to the original solution, alkaline hæmatin is produced, or if acetic acid be chosen, acid hæmatin is produced, and each gives its appropriate absorption bands.
Methæmoglobin is formed in stains which have been exposed to the air for a few days, and hæmatin is found in old stains. Hæmochromogen gives a very characteristic spectrum, and is obtained by reducing alkaline hæmatin by ammonium sulphide. Carbon monoxide hæmoglobin gives a spectrum which resembles that of oxyhæmoglobin, but it is not reduced by ammonium sulphide.
(j) Precipitin Test.—This allows us to tell whether the blood is from a human being or not. A specific serum must be obtained from a rabbit which is sensitized as follows: 10 c.c. of human blood is injected into its peritoneal cavity at intervals, until from three to five injections have been given. The serum of this animal's blood will then give a white precipitate only when brought into contact with dilute solutions of human blood, but with the blood of no other animal. This is known also as the 'biologic,' or Uhlenhuth's test.
Rust Stains.—These are yellowish-red in colour, and do not stiffen the cloth. The iron may be dissolved by placing the stain in a dilute solution of hydrochloric acid, when, on adding ferrocyanide of potassium, Prussian blue is produced.
Fruit Stains are seldom so dark as blood-stains. Solutions of these do not change colour or coagulate on boiling; ammonia changes the colour to blue or green; acid brightens the original colour, while chlorine bleaches it.
Hairs.—Human hairs must be identified and distinguished from those of the lower mammals. If the hair has been pulled out from the root, the microscope will show that the bulbous root has a concave surface which fitted over the hair papilla, or that the root is encased in a fatty sheath.
Fibres of Clothing.—Microscopically, wool fibres are coarse, curly, and striated transversely; cotton fibres appear as flattened bands twisted into spirals; linen fibres are round, jointed at frequent intervals, with small root-like filaments; silk fibres are solid, continuous, and highly glistening.
Signs and Symptoms.—There are usually three stages:
Post-Mortem Appearances—External.—Cadaveric lividity well marked; nose, lips, ears, finger-tips almost black in colour; appearance may be placid or, if asphyxia has been sudden, the tongue may be protruded and eyeballs prominent, with much bloody mucus escaping from mouth and nose.
Internal.—The blood is dark and remains fluid; great engorgement of venous system, right side of heart, great veins of thorax and abdomen, liver, spleen, etc. Lungs dark purple in colour; much bloody froth escapes on squeezing them; mucous lining of trachea and bronchi congested and bright red in colour; air-cells distended or ruptured; many small hæmorrhages on surface of lungs and other organs, as well as in their substance (Tardieu's spots), due to rupture of venous capillaries from increased vascular pressure.
In hanging, death occurs by asphyxia, as in drowning. Sensibility is soon lost, and death takes place in four or five minutes. The eyes in some cases are brilliant and staring, tongue swollen and livid, blood or bloody froth is found about the mouth and nostrils, and the hands are clenched. In other cases the countenance is placid, with an almost entire absence of the signs just given. The mark on the neck, which may be more or less interrupted by the beard, shows the course of the cord, which in hanging is obliquely round the neck following the line of the jaw, but straight round in strangulation. In judicial hanging, death is not due to asphyxiation, but, owing to the long drop, the cervical vertebræ are dislocated, and the spinal cord injured so high up that almost instant death takes place. On dissection the muscles and ligaments of the windpipe may be found stretched, bruised, or torn, and the inner coats of the carotid arteries are sometimes found divided. In ordinary suicidal hanging there may be entire absence of injury to the soft parts about the neck, the length of the drop modifying these appearances. The mark of the cord is not a sign of hanging, is a purely cadaveric phenomenon, and may be produced some hours after death.
This differs from hanging in that the body is not suspended. It may be effected by a ligature round the neck, or by direct pressure on the windpipe with the hand, in which case death is said to be caused by throttling. Strangulation is frequently suicidal, but may be accidental. When homicidal, much injury is done to the neck, owing to the force with which the ligature is drawn. In throttling, the marks of the finger-nails are found on the neck.
Death by drowning occurs when breathing is arrested by watery or semi-fluid substances—blood, urine, etc. The fluid acts mechanically by entering the air-cells of the lung and preventing the due oxidation of the blood. The post-mortem appearances include those usually present in death by asphyxia, together with the following, peculiar to death by drowning: Excoriations of the fingers, with sand or mud under the nails; fragments of plants grasped in the hand; water in the stomach (this is a vital act, and shows that the person fell into the water alive); fine froth at the mouth and nostrils; cutis anserina; retraction of penis and scrotum. On post-mortem examination, the lungs are found to be increased in size ('ballooned'); on section, froth, water mud, sand, in air-tubes. The presence of this fine (often blood-stained) froth is the most characteristic sign of drowning. Froth like that of soap-suds in the trachea is an indication of a vital act, and must not be mistaken for the tenacious mucus of bronchitis. The presence of vomited matters in the trachea and bronchi is a valuable sign of drowning. The blood collects in the venous system, and is dark and fluid. Tardieu's spots are not so frequently met with in cases of drowning as in other forms of asphyxia. The other signs of death by asphyxia are present. Wounds may be present on the body, due to falling on stakes, injuries from passing vessels, etc.
The methods of performing artificial respiration in the case of the apparently drowned are the following (the best and most easily performed is Schäfer's prone pressure method):
1. Schäfer's.—Place the patient on his face, with a folded coat under the lower part of the chest. Unfasten the collar and neckband. Go to work at once. Kneel over him athwart or on one side facing his head. Place your hands flat over the lower part of his back, and make pressure on his ribs on both sides, and throw the weight of your body on to them so as to squeeze out the air from his chest. Get back into position at once, but leave your hands as they were. Do this every five seconds, and get someone to time you with a watch. Keep this going for half an hour, and when you are tired get someone to relieve you.
Other people may apply hot flannels to the limbs and hot water to the feet. Hypodermic injections of 1/50 grain of atropine, suprarenal or pituitary extracts, may be found useful.
2. Silvester's..—In this method the capacity of the chest is increased by raising the arms above the head, holding them by the elbows, and thus dragging upon and elevating the ribs, the chest being emptied by lowering the arms against the sides of the chest and exerting lateral pressure on the thorax. The patient is in the supine position—but first the water must have been drained from the mouth and nose by keeping the body in the prone position. The tongue must be kept forward by transfixing with a pin.
3. Marshall Hall's.—This consists in placing the patient in the prone position, with a folded coat under the chest, and rolling the body alternately into the lateral and prone positions.
4. Howard's.—This consists in emptying the thorax by forcibly compressing the lower part of the chest; on relaxing the pressure the chest again fills with air. Here the patient is placed in the supine position.
The objections to the supine position are that the tongue falls back, and not only blocks the entrance of air, but prevents the escape of water, mucus, and froth from the air-passages.
5. Laborde's Method.—This consists in holding the tongue by means of a handkerchief, and rhythmically drawing it out fully at the rate of fifteen times per minute. This excites the respiratory centre, and this method may be employed along with any of the other methods.
The post-mortem appearances in death from starvation are as follows: There is marked general emaciation; the skin is dry, shrivelled, and covered with a brown, bad-smelling excretion; the muscles soft, atrophied, and free from fat; the liver is small, but the gall-bladder is distended with bile. The heart, lungs, and internal organs are shrivelled and bloodless. The stomach is sometimes quite healthy; in other cases it may be collapsed, empty, and ulcerated. The intestines are also contracted, empty, and translucent.
In the absence of any disease productive of extreme emaciation (e.g., tuberculosis, stricture of œsophagus, diabetes, Addison's disease), such a state of body will furnish a strong presumption of death by starvation.
In the case of children there is not always absolute deprivation of food, but what is supplied is insufficient in quantity or of improper quality. The defence commonly set up is that the child died either of marasmus or of tuberculosis.
In cases where it is alleged that a child has been starved and ill-used, one must examine the body for signs of neglect—e.g., dirtiness of skin and hair, presence of vermin, bruises or skin eruptions. Compare its weight with a normal child of the same age and sex. If the disproportion be great and signs of neglect present, then the probability is great (provided there be no actual disease present) that the child has been starved.
The signs of death from lightning vary greatly. In some cases there are no signs; in others the body may be most curiously marked. Wounds of various characters—contused, lacerated, and punctured—may be produced. There may be burns, vesications, and ecchymoses; arborescent markings are not uncommon. The hair may be singed or burnt and the clothing damaged. Rigor mortis is very rapid in its onset and transient. Post mortem there are no characteristic signs, but the blood may be dark in colour and fluid. The presence or absence of a storm may assist the diagnosis.
Injuries by electrical currents of high pressure are not uncommon; speaking generally, 1,000 to 2,000 volts will kill. In America, where electricity is adopted as the official means of destroying criminals, 1,500 volts is regarded as the lethal dose, but there are many instances of persons having been exposed to higher voltages without bad effects. The alternating current is supposed to be more fatal than the continuous. Much depends on whether the contact is good (perspiring hands or damp clothes). Death has been attributed in these cases to respiratory arrest or sudden cessation of the heart's action. The best treatment is artificial respiration, but the inhalation of nitrite of amyl may prove useful. Rescuers must be careful that they, also, do not receive a shock. The patient should be handled with india-rubber gloves or through a blanket thrown over him.
Cold.—The weak, aged, or infants, readily succumb to low temperatures. The symptoms are increasing lassitude, drowsiness, coma, with sometimes illusions of sight. Post mortem, bright red patches are found on the skin surface, and the blood remains fluid for long.
Heat.—Death may result from syncope, the result of exposure to great heat.
Sunstroke.—The person loses consciousness and falls down insensible; the body temperature may be 112° F., the pulse is full, and a peculiar pungent odour is given off from the skin. Coma, convulsions with (rarely) delirium, may precede death. Treatment consists in lowering the body temperature by application of cold cloths, stimulants, strychnine or digitalin hypodermically.
The signs of the existence of pregnancy are of two kinds, uncertain and certain, or maternal and fœtal. Amongst the former class are included—Cessation of menstruation (which may occur without pregnancy); morning vomiting; salivation; enlargement of the breasts and of the abdomen; quickening. It must be borne in mind that every woman with a big abdomen is not necessarily pregnant. The tests which afford conclusive evidence of the existence of a fœtus in the uterus are—Ballottement, the uterine souffle, intermittent uterine contractions, fœtal movements, and, above all, the pulsation of the fœtal heart. The uterine souffle is synchronous with the maternal pulse; the fœtal heart is not, being about 120 beats per minute.
Evidence of pregnancy may also be afforded by the discharge from the uterus of an early ovum, of moles, hydatids, etc. Disease of the uterus and ovarian dropsy may be mistaken for pregnancy. Careful examination is necessary to determine the nature of the condition present. Pregnancy may be pleaded in bar of immediate capital punishment, in which case the woman must be shown to be 'quick with child.' A woman may also plead pregnancy to delay her trial in Scotland, and both in England and Scotland, in civil cases, to produce a successor to estates, to increase damages for seduction, in compensation cases where a husband has been killed, to obtain increased damages, etc. A woman may become pregnant within a month of her last delivery.
In cases of rape and suspected pregnancy, it must be borne in mind that a medical man who examines a woman under any circumstances against her will renders himself liable to heavy damages, and that the law will not support him in so doing. If, on being requested to permit an examination, the woman refuse, such refusal may go against her, but of this she is the best judge. The duty of the medical man ends on making the suggestion.
The signs of recent delivery are as follows: The face is pale, with dark circles round the eyes; the pulse quickened; the skin soft, warm, and covered with a peculiar sweat; the breasts full, tense, and knotty; the abdomen distended, its integuments relaxed, with irregular light pink streaks on the lower part. The labia and vagina show signs of distension and injury. For the first three or four days there is a discharge from the uterus more or less sanguineous in character, consisting of blood, mucus, epithelium, and shreds of membrane. During the next four or five days it becomes of a dirty green colour, and in a few days more of a yellowish, milky, mucous character, continuing for two to three weeks. The change in character of the lochial discharge is due to the quantity of blood decreasing and its place being taken by fatty granules and leucocytes. The os uteri is soft, patulous, and its edges are torn. The uterus may be felt for two or three hours above the pubis as a hard round ball, regaining its normal size in about eight weeks after delivery. Most of these signs disappear about the tenth day, after which it becomes impossible to fix the date of delivery.
In the dead the external parts have the same appearance as given above. The uterus will vary in appearance according to the time elapsed since delivery. If death occurred immediately after delivery, the uterus will be wide open, about 9 or 10 inches long, with clots of blood inside, and the inner surface lined by decidua.
The signs of a previous delivery consist in silvery streaks in the skin of the abdomen, which, however, may be due to distension from other causes; similar marks on the breast; circular and jagged condition of the os uteri (the virgin os being oval and smooth); marks of rupture of the perineum or fourchette; absence of the vaginal rugæ; dark-coloured areola round the nipples, etc. The difference between the virgin corpus luteum and that of recent pregnancy is not so marked as to justify a confident use of it for medico-legal purposes.
This consists in giving to any woman, or causing to be taken by her, with intent to procure her miscarriage, any poison or other noxious thing, or using for the same purpose any instruments or other means whatsoever. It is a felony to procure or attempt to procure the miscarriage of a woman, whether she be pregnant or not, and it is a felony for the woman, if pregnant, to attempt to procure her own miscarriage. It is a misdemeanour for any person or persons to procure drugs or instruments for a like purpose. It is not necessary that the woman be quick with child. The offence is the intent to procure the miscarriage of any woman, whether she be or be not with child. When from any causes it is necessary to procure abortion, a medical man should do so only after consultation with a brother practitioner. Even in these cases there is no exemption legally. Any medical man who gives even the most harmless medicine where he suspects the possibility of pregnancy may render himself liable to grave suspicion should the woman abort.
In medicine, an abortion is said to occur when the fœtus is expelled before the sixth month; after that it is premature birth. In law, however, any expulsion of the contents of the uterus before the full time is an abortion or miscarriage.
In deciding whether any substance expelled from the uterus is really a fœtus or a mole, and therefore the result of conception, or the coat of the uterus, and unconnected with pregnancy, the examination of the substances expelled must be carefully made. Moles are blighted fœtuses. An examination of the woman will be necessary, though it is not easy during the early months of pregnancy, and especially in those who have borne children, to say whether abortion has taken place or not. The history must be inquired into; the regular or exceptional use of drugs to promote menstruation is important, for in the former case no criminal intent may exist, although pregnancy be present. The state of the breasts, the hymen, and the os uteri, should all be carefully examined. Putting a few apparently unimportant questions as to the frequent use of purgatives, the presence or absence of constipation, will often assist the diagnosis as showing that the woman has acted in an unusual manner. Abortion may be procured by the introduction of instruments, by falls, violent exercise, blows on the abdomen, etc. In the hands of ignorant persons the use of instruments (sounds, bougies, skewers, etc.) is attended with great danger. Perforation of the vaginal walls, bladder, cervix, or uterus, may follow their use. Septic pelvic peritonitis may ensue, and the woman may lose her life. The person who has employed such means for inducing abortion is liable to be charged with the crime of murder. There is no evidence to show that ergot, savin, bitter-apple, pennyroyal, or any other drug administered internally, will cause a woman to abort, except when taken in such large doses that actual poisoning results, with inflammation of the contents of the true pelvis. In such cases reflex uterine contractions may be set up, and abortion may follow. Diachylon pills are largely employed to induce abortion, and very often the woman taking them suffers severely from lead-poisoning.
Infanticide, or the murder of a new-born child, is not treated as a specific crime, but is tried by the same rules as in cases of felonious homicide. The term is applied technically to those cases in which the mother kills her child at, or soon after, its birth. She is often in such a condition of mental anxiety as not to be responsible for her actions. It is usually committed with the object of concealing delivery, and to hide the fact that the girl has, in popular language, 'strayed from the paths of virtue.' The child must have had a separate existence. To constitute 'live birth,' the child must have been alive after its body was entirely born—that is, entirely outside the maternal passages—and it must have had an independent circulation, though this does not imply the severance of the umbilical cord. Every child is held in law to be born dead until it has been shown to have been born alive. Killing a child in the act of birth and before it is fully born is not infanticide, but if before birth injuries are inflicted which result in death after birth, it is murder. Medical evidence will be called to show that the child was born alive.
The methods of death usually employed are—(1) Suffocation by the hand or a cloth. (2) Strangulation with the hands, by a tape or ribbon, or by the umbilical cord itself. (3) Blows on the head, or dashing the child against the wall. (4) Drowning by putting it in the privy or in a bucket of water. (5) Omission: by neglecting to do what is absolutely necessary for the newly-born child—e.g., not separating the cord; allowing it to lie under the bed-clothes and be suffocated.
With regard to the question of the maturity of a child, the differences between a child of six or seven months and one at full term may be stated as follows:
Between the sixth and seventh month, length of child 10 to 14 inches—that is, the length of the child after the fifth month is about double the lunar months—weight 1 to 3 pounds; skin, dusky red, covered with downy hair (lanugo) and sebaceous matter; membrana pupillaris disappearing; nails not reaching to ends of fingers; meconium at upper part of large intestine; testes near kidneys; no appearance of convolutions in brain; points of ossification in four divisions of sternum.
At nine months, length of child 18 to 22 inches; weight, 7 to 8 pounds; skin rosy; lanugo only about shoulders; sebaceous matter on the body; hair on head about an inch long; testes past inguinal ring; clitoris covered by the labia; membrana pupillaris disappeared; nails reach to ends of fingers; meconium at termination of large intestine; points of ossification in centre of cartilage at lower end of femur, about 1-1/2 to 2-1/2 lines in diameter; umbilicus midway between the ensiform cartilage and pubis.
Owing to the difficulty of proving that the crime of infanticide has been committed, the woman may in England be tried for concealment of birth, and in Scotland for concealment of pregnancy, if she conceal her pregnancy during the whole time and fail to call for assistance in the birth. Either of these charges would only be brought against a woman who had obviously been pregnant, and now the child is missing or its dead body has been found. It is expected that every pregnant woman should make provision for the child about to be born, and so should have talked about it or have made clothes, etc., for it. The punishment for concealment is imprisonment for any term not exceeding two years. The charge of concealment is very often alternative to infanticide. To substantiate the charge, however, it must be proved that there had been a secret disposition of the dead body of the infant, as well as an endeavour to conceal its birth.
A woman may be delivered of a child unconsciously, for the contractile power of the womb is independent of volition. Under an anæsthetic the uterus acts as energetically as if the patient were in the full possession of her senses.
Nowadays a woman is rarely hanged for infanticide, and it is a mere travesty of justice to pass on her the death sentence, well knowing that it will never be executed.
The signs of live birth prior to respiration are negative and positive. A negative opinion may be formed when evidence is found of the child having undergone intra-uterine maceration. In this case the body will be flaccid and flattened; the ilia prominent; the head soft and yielding; the cuticle more or less detached, and raised into large bullæ; the skin of a red or brownish-red colour; the cavities filled with abundant bloody serum; the umbilical cord straight and flaccid.
A positive opinion is justified when such injuries are found on the body as could not have been inflicted during birth, and are attended with such hæmorrhage as could only have occurred while the blood was circulating. Fractures of the cranium from accidental falls (precipitate labour) are as a rule stellate, and are situated on the vertex or in the parietal protuberance. The fractures from violence are more extensive, usually depressed, and accompanied by laceration of the scalp.
The evidences of live birth after respiration has taken place are usually deduced from the condition of the lungs, though indications are also found in other organs. The diaphragm is more arched before than after respiration, and rises higher in the thorax in the former case than in the latter. The lungs before respiration are situated in the back of the thorax, and do not fill that cavity; they are of a dark, red-brown colour and of the consistence of liver, without mottling. After respiration they expand and occupy the whole thorax, and closely surround the heart and thymus gland. The portions containing air are of a light brick-red colour, and crepitate under the finger. The lungs are mottled from the presence of islands of aerated tissue, surrounded by arteries and veins. The weight of the lungs before respiration is about 550 grains, after an hour's respiration 900 grains; but this test is of little value. The ratio of the weight of the lungs to that of the body (Ploucquet's test), which is also unreliable, is, before respiration, about 1 to 70; after, 1 to 35. Lungs in which respiration has taken place float in water; those in which it has not, sink. There are exceptions to this rule, on which, however, is founded the hydrostatic test. As originally performed, this test consisted merely in placing the lungs, with or without the heart, in water, and noticing whether they sank or floated. The test is now modified by squeezing, and by cutting the lungs up into pieces.
The objections to the test as originally performed are—(1) That the lungs may sink as the result of disease—e.g., double pneumonia. (2) That respiration may have been so limited in extent that the lungs may sink, owing to large portions of lung tissue remaining unexpanded (atelectasis). (3) Putrefaction may cause the lungs to float when respiration has not taken place. (4) The lungs may have been inflated artificially. Few of these objections apply, however, when the hydrostatic test, modified by pressure, is employed. To take these objections in detail, it may be stated: (1) If the lungs sink from disease, the question of live birth is answered. (2) This objection is too refined for practical use. The lungs sink, there is an absence of any of the signs of suffocation, and the matter ends. The examiner has only to describe the conditions which he finds, and is not required to indulge in conjectures as to the amount of respiration which may or may not have taken place. (3) Gas due to putrefaction collects under the pleural membrane, and can be expelled by pressure, and is not found in the air cells. The lungs decompose late, hence in a fresh body putrefaction of the lungs is absent; in a putrefied child, if the lungs sink, it must have been stillborn. The so-called emphysema pulmonum neonatorum is simply incipient putrefaction.
The lung test simply shows that the child has breathed, but affords no proof that the child has been born alive. The child may have breathed as soon as its head protruded, the rest of the body being in the maternal passages. The child is not born alive until it has been completely expelled, although it is not necessary that the umbilical cord should have been cut.
In addition to these tests, live birth may be suspected from the following conditions: The stomach may contain milk or food, recognized by the microscope and by Trommer's test for sugar; the large intestines in stillborn children are filled with meconium, in those born alive they are usually empty; the bladder is generally emptied soon after birth; the skin is in a condition of exfoliation soon after birth. The organs of circulation undergo the following changes after birth, and the extent to which these changes have advanced will give an idea of how long the child has lived: The ductus arteriosus begins to contract within a few seconds of birth; at the end of a week it is about the size of a crow quill, and about the tenth day is obliterated. The umbilical arteries and vein: the arteries are remarkably diminished in calibre at the end of twenty-four hours, and obliterated almost up to the iliacs in three days; the umbilical vein and the ductus venosus are generally completely contracted by the fifth day. The foramen ovale becomes obliterated at extremely variable periods, and may continue open even in the adult.
Importance of late has been attached to the stomach-bowel test. If the stomach and duodenum contain air, and consequently float in water, the chances are that the child did not die immediately after birth; this is known as Breslau's second life test, and the lower the air in the intestinal canal, the greater is the probability that the child survived birth.
The umbilical cord in a new-born child is fresh, firm, round, and bluish in colour; blood is contained in its vessels. The cord may be ruptured by the child falling from the maternal parts in a precipitate labour, and the ruptured parts present ragged ends. It is seldom that a child bleeds to death from an untied or cut umbilical cord, and the chances in a torn cord are still more remote. The changes in the cord are as follows: First it shrinks from the ligature towards the navel; this change may begin early, and is rarely delayed beyond thirty hours; the cord becomes flabby, and there is a distinct inflammatory circle round its insertion. The next change is that of desiccation or mummification; the cord becomes reddish-brown, then flattened and shrivelled, then translucent and of the colour of parchment, and falls off about the fifth day. The third stage, that of cicatrization, then ensues about the tenth to the twelfth day. The bright red rim round the insertion of the cord, with inflammatory thickening and slight purulent secretion, may be considered as evidence of live birth, and the stage at which the separation of the cord by ulcerative process has arrived will point to the probable duration of time the child has existed after birth.
There are many fallacies in the application of any of these tests, and the whole subject bristles with difficulties. The medical witness would do well to exhibit a cautious reserve, for if the child dies immediately after birth it is almost impossible to prove that it was born alive.
The death of the fœtus may be due to—(1) Immaturity or intra-uterine malnutrition, or simply from deficient vitality; (2) complications occurring during or immediately after birth, which may either be unavoidable or inherent in the process of parturition, or may be induced with criminal intent.
In the latter category come such accidents as the pressure of tumours in the pelvic passages, or disease of the bones in the mother, or pressure on the cord from malposition of the child during labour, asphyxiation from the funis being twisted tightly round the neck or limbs, or from injuries due to falls on the floor in sudden labours. Where the death of the fœtus has been induced with criminal intent, it may be due to punctured wounds of the fontanelles, orbits, heart, or spinal marrow; dislocation of the neck; separation of the head from the body; fracture of the bones of the head and face; strangulation; suffocation; drowning in the closet pan or privy, or from being thrown into water.
Under the head of infanticide by commission, we have injuries of all kinds; under infanticide by omission, neglecting to tie the cord, allowing it to be suffocated by discharges in the bed, neglect to provide food, clothes, and warmth, for the new-born child.
The natural period of gestation is considered as forty weeks, ten lunar months, or 280 days. A medical witness would have to admit the possibility of gestation being prolonged to 300 days, and if this time were not very materially exceeded it would be well to give the woman the benefit of the doubt. It may be mentioned that 300 days is the extreme limit fixed by the French and Scottish law. No fixed period is assigned in English or American law to the duration of pregnancy, though it is allowed that utero-gestation may be greatly prolonged. In a recent case decided, the Lord Chancellor accepted a case where it was alleged pregnancy had extended to 331 days. A child only five months old may live, for a short time at all events. There is considerable difficulty in many cases in fixing the date of conception. The data from which it is calculated are the following: (1) Peculiar sensations attending conception, which are not sufficiently defined to be recognized by those conceiving for the first time. (2) Cessation of the catamenia. Other causes may, however, cause this; and, on the other hand, a woman may menstruate during the whole period of her pregnancy. This datum also gives a variable period, and may involve an error of several days or a month, for the menses may be arrested by cold, etc., at one monthly period, and the woman become pregnant before the next. (3) The period of quickening. This, when perceived (which is not always the case), also occurs at variable periods from the tenth to the twenty-sixth week. (4) A single coitus. This does not, however, correspond to the time of fertilization. Several days may elapse before the spermatozoa meet with an ovum and fertilize it.
In Scotland a child born six months after marriage is legitimate, which is allowing an ample margin.