PART I. Forensic Medicine

FORENSIC MEDICINE

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 L2 2s., but in addition the coroner may commit him to prison for contempt of court. In criminal cases the witnesses are bound over to appear at the assizes to give evidence there. The coroner may give an order for the exhumation of a body if he thinks the evidence warrants a post-mortem examination.

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

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

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

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

The fee payable to a medical witness for giving evidence at an inquest is one guinea, with an extra guinea for making a post-mortem examination and report (in the metropolitan area these fees are doubled). The coroner must sign the order authorizing the payment, and should an inquest be adjourned to a later day, no further fee is payable. If the deceased died in a hospital, infirmary, or lunatic asylum, the medical witness is not paid any fee. Should a medical witness neglect to make the post-mortem examination after receiving the order to do so, he is liable to a fine of L5.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

IV.--EXAMINATION OF PERSONS FOUND DEAD

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

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

V.--MODES OF SUDDEN DEATH

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

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

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

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

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

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

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

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

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

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

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

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

(a) =Instantaneously Sudden Death=--

1. Syncope (by far the commonest cause).

2. Aortic incompetence.

3. Rupture of heart.

4. Rupture of a valve.

5. Rupture of aortic aneurism.

6. Embolism of coronary artery.

7. Angina pectoris.

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

1. Cerebral haemorrhage or embolism.

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

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

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

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

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

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

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

9. Mental or physical shock.

10. Exertion while the stomach is overloaded.

11. Diabetic coma; uraemia.

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

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

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

VI.--SIGNS OF DEATH

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

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

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

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

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

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

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

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

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

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

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

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

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

VII.--DEATH FROM ANAESTHETICS, ETC.

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

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

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

The chloroformist ought always to use the best chloroform.

An anaesthetic should never be administered except in the presence of a third person. This applies especially to dentists who give gas to females.

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

VIII.--PRESUMPTION OF DEATH; SURVIVORSHIP

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

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

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

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

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

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

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

X.--WOUNDS AND MECHANICAL INJURIES

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

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

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

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

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

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

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

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

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

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

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

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 haemorrhage, and from such complications as pleurisy, pericarditis, and peritonitis. Death may result from shock, haemorrhage, injury to brain or important nervous structures.

XIV.--WOUNDS OF VARIOUS PARTS OF THE BODY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17. =Of the Bladder.=--Dangerous from extravasation of urine. In fracture of the pelvis the bladder is often injured, and extraperitoneal infiltration of urine occurs, with frequently a fatal issue.

18. =Of Genital Organs.=--Incised wounds of penis may produce fatal haemorrhage. Removal of testicles may prove fatal from shock to nervous system. Wounds of the spermatic cord may be dangerous from haemorrhage. Wounds to the vulva are dangerous, owing to haemorrhage from the large plexus of veins without valves.

XV.--DETECTION OF BLOOD-STAINS, ETC.

Stains may require detection on clothing, on cutting instruments, on floors and furniture, etc. The following are the distinctive characters of blood-stains:

(a) =Ocular Inspection.=--Blood-stains on dark-coloured materials, which in daylight might be easily overlooked, may be readily detected by the use of artificial light, as that of a candle, brought near the cloth. Blood-spots when recent are of a bright red colour if arterial, of a purple hue if venous, the latter becoming brighter on exposure to the air. After a few hours blood-stains assume a reddish-brown or chocolate tint, which they maintain for years. This change is due to the conversion of haemoglobin into methaemoglobin, and finally into haematin. The change of colour in warm weather usually occurs in less than twenty-four hours. The colour is determined, not entirely by the age of the stain, but is influenced by the presence or absence of impurities in the air, such as the vapours of sulphurous, sulphuric, and hydrochloric acids. If recent, a jelly-like material may be seen by the aid of a magnifying-glass lying between the fibres. If old, a cinnabar-red streak is seen on drawing a needle across the stain.

(b) =Microscopic Demonstration.=--With the aid of the microscope, blood may be detected by the presence of the characteristic blood-corpuscles. The human blood-corpuscle is a non-nucleated, biconcave disc, having a diameter of about 1/3500 of an inch. All mammalian red corpuscles have the same shape, except those of the camel, which are oval. The corpuscles of birds, fishes, reptiles, and amphibians, are oval and nucleated. The corpuscles of most mammals are smaller than those of man, but the size of a corpuscle is affected by various circumstances, such as drying or moisture, so that the medical witness is rarely justified in going farther than stating whether the stain is that of the blood of a mammal or not. Unfortunately, the corpuscles are usually so dried that little information regarding their size can be given.

(c) =Action of Water.=--Water has a solvent action on blood, fresh stains rapidly dissolving when the material on which they occur is placed in cold distilled water, forming a bright red solution. The haematin of old stains dissolves very slowly, so employ a weak solution of ammonia, and this will give a solution of alkaline haematin. Rust is not soluble in water.

(d) =Action of Heat.=--Blood-stains on knives may be removed by heating the metal, when the blood will peel off, at once distinguishing it from rust. Should the blood-stain on the metal be long exposed to the air, rust may be mixed with the blood, when the test will fail. The solution obtained in water is coagulated by heat, the colour entirely destroyed, and a flocculent muddy-brown precipitate formed.

(e) =Action of Caustic Potash.=--The solution of blood obtained in water is boiled, when a coagulum is formed soluble in hot caustic potash, the solution formed being greenish by transmitted and red by reflected light.

(f) =Action of Nitric Acid.=--Nitric acid added to a watery solution produces a whitish-grey precipitate.

(g) =Action of Guaiacum.=--Tincture of guaiacum produces in the watery solution a reddish-white precipitate of the resin, but on addition of an aqueous solution of peroxide of hydrogen, or of an ethereal solution of the same substance (known as ozonic ether), a blue or bluish-green colour is developed. This test is delicate, and succeeds best in dilute solutions. It is not absolutely indicative of the presence of blood, for tincture of guaiacum is coloured blue by milk, saliva, and pus.

(h) =Haemin Crystals (Teichman's Crystals).=--These are produced by heating a drop of blood, or a watery solution of it, with a minute crystal of sodium chloride on a glass slide and evaporating to dryness. A cover-glass is placed over this, and a drop of glacial acetic acid allowed to run in. It is again heated until bubbles appear. Crystals of haemin may now be detected by the microscope. They are dark brown or yellow rhombic prisms.

An improvement on this test is the use of formic acid alone; on slowly evaporating it, numerous very small dark crystals are visible if haemoglobin has been present (Whitney's test).

(i) =Spectroscopic Appearances.=--If a solution of a recent stain be examined by the spectroscope, we get two absorption bands situated between the lines D and E, the one nearer E being doubly as broad as the other. These bands indicate oxyhaemoglobin.

If we now add a little ammonium sulphide to this solution, we get the spectrum of reduced haemoglobin, which is a single broad absorption band situated in the interval between the preceding oxyhaemoglobin bands. By shaking the solution, oxyhaemoglobin is again reproduced, and gives its special absorption bands.

If ammonia be added to the original solution, alkaline haematin is produced, or if acetic acid be chosen, acid haematin is produced, and each gives its appropriate absorption bands.

Methaemoglobin is formed in stains which have been exposed to the air for a few days, and haematin is found in old stains. Haemochromogen gives a very characteristic spectrum, and is obtained by reducing alkaline haematin by ammonium sulphide. Carbon monoxide haemoglobin gives a spectrum which resembles that of oxyhaemoglobin, but it is not reduced by ammonium sulphide.

(j) =Precipitin Test.=--This allows us to tell whether the blood is from a human being or not. A specific serum must be obtained from a rabbit which is sensitized as follows: 10 c.c. of human blood is injected into its peritoneal cavity at intervals, until from three to five injections have been given. The serum of this animal's blood will then give a white precipitate only when brought into contact with dilute solutions of human blood, but with the blood of no other animal. This is known also as the 'biologic,' or Uhlenhuth's test.

=Rust Stains.=--These are yellowish-red in colour, and do not stiffen the cloth. The iron may be dissolved by placing the stain in a dilute solution of hydrochloric acid, when, on adding ferrocyanide of potassium, Prussian blue is produced.

=Fruit Stains= are seldom so dark as blood-stains. Solutions of these do not change colour or coagulate on boiling; ammonia changes the colour to blue or green; acid brightens the original colour, while chlorine bleaches it.

=Hairs.=--Human hairs must be identified and distinguished from those of the lower mammals. If the hair has been pulled out from the root, the microscope will show that the bulbous root has a concave surface which fitted over the hair papilla, or that the root is encased in a fatty sheath.

=Fibres of Clothing.=--Microscopically, wool fibres are coarse, curly, and striated transversely; cotton fibres appear as flattened bands twisted into spirals; linen fibres are round, jointed at frequent intervals, with small root-like filaments; silk fibres are solid, continuous, and highly glistening.

XVI.--DEATH BY SUFFOCATION

Signs and Symptoms.--There are usually three stages:

1. Exaggerated respiratory activity; air hunger; anxiety; congested appearance of face; ringing in ears.

2. Loss of consciousness; convulsions; relaxation of sphincters.

3. Respirations feeble and gasping, and soon cease; convulsions of stretching character; heart continues to beat for three to four minutes after breathing ceases.

Post-Mortem Appearances--External.--Cadaveric lividity well marked; nose, lips, ears, finger-tips almost black in colour; appearance may be placid or, if asphyxia has been sudden, the tongue may be protruded and eyeballs prominent, with much bloody mucus escaping from mouth and nose.

Internal.--The blood is dark and remains fluid; great engorgement of venous system, right side of heart, great veins of thorax and abdomen, liver, spleen, etc. Lungs dark purple in colour; much bloody froth escapes on squeezing them; mucous lining of trachea and bronchi congested and bright red in colour; air-cells distended or ruptured; many small haemorrhages on surface of lungs and other organs, as well as in their substance (Tardieu's spots), due to rupture of venous capillaries from increased vascular pressure.

XVII.--DEATH BY HANGING

In hanging, death occurs by asphyxia, as in drowning. Sensibility is soon lost, and death takes place in four or five minutes. The eyes in some cases are brilliant and staring, tongue swollen and livid, blood or bloody froth is found about the mouth and nostrils, and the hands are clenched. In other cases the countenance is placid, with an almost entire absence of the signs just given. The mark on the neck, which may be more or less interrupted by the beard, shows the course of the cord, which in hanging is obliquely round the neck following the line of the jaw, but straight round in strangulation. In judicial hanging, death is not due to asphyxiation, but, owing to the long drop, the cervical vertebrae are dislocated, and the spinal cord injured so high up that almost instant death takes place. On dissection the muscles and ligaments of the windpipe may be found stretched, bruised, or torn, and the inner coats of the carotid arteries are sometimes found divided. In ordinary suicidal hanging there may be entire absence of injury to the soft parts about the neck, the length of the drop modifying these appearances. The mark of the cord is not a sign of hanging, is a purely cadaveric phenomenon, and may be produced some hours after death.

XVIII.--DEATH BY STRANGULATION

This differs from hanging in that the body is not suspended. It may be effected by a ligature round the neck, or by direct pressure on the windpipe with the hand, in which case death is said to be caused by throttling. Strangulation is frequently suicidal, but may be accidental. When homicidal, much injury is done to the neck, owing to the force with which the ligature is drawn. In throttling, the marks of the finger-nails are found on the neck.

XIX.--DEATH BY DROWNING

Death by drowning occurs when breathing is arrested by watery or semi-fluid substances--blood, urine, etc. The fluid acts mechanically by entering the air-cells of the lung and preventing the due oxidation of the blood. The post-mortem appearances include those usually present in death by asphyxia, together with the following, peculiar to death by drowning: Excoriations of the fingers, with sand or mud under the nails; fragments of plants grasped in the hand; water in the stomach (this is a vital act, and shows that the person fell into the water alive); fine froth at the mouth and nostrils; cutis anserina; retraction of penis and scrotum. On post-mortem examination, the lungs are found to be increased in size ('ballooned'); on section, froth, water mud, sand, in air-tubes. The presence of this fine (often blood-stained) froth is the most characteristic sign of drowning. Froth like that of soap-suds in the trachea is an indication of a vital act, and must not be mistaken for the tenacious mucus of bronchitis. The presence of vomited matters in the trachea and bronchi is a valuable sign of drowning. The blood collects in the venous system, and is dark and fluid. Tardieu's spots are not so frequently met with in cases of drowning as in other forms of asphyxia. The other signs of death by asphyxia are present. Wounds may be present on the body, due to falling on stakes, injuries from passing vessels, etc.

The methods of performing artificial respiration in the case of the apparently drowned are the following (the best and most easily performed is Schaefer's prone pressure method):

1. Schaefer's.--Place the patient on his face, with a folded coat under the lower part of the chest. Unfasten the collar and neckband. Go to work at once. Kneel over him athwart or on one side facing his head. Place your hands flat over the lower part of his back, and make pressure on his ribs on both sides, and throw the weight of your body on to them so as to squeeze out the air from his chest. Get back into position at once, but leave your hands as they were. Do this every five seconds, and get someone to time you with a watch. Keep this going for half an hour, and when you are tired get someone to relieve you.

Other people may apply hot flannels to the limbs and hot water to the feet. Hypodermic injections of 1/50 grain of atropine, suprarenal or pituitary extracts, may be found useful.

2. Silvester's.--In this method the capacity of the chest is increased by raising the arms above the head, holding them by the elbows, and thus dragging upon and elevating the ribs, the chest being emptied by lowering the arms against the sides of the chest and exerting lateral pressure on the thorax. The patient is in the supine position--but first the water must have been drained from the mouth and nose by keeping the body in the prone position. The tongue must be kept forward by transfixing with a pin.

3. Marshall Hall's.--This consists in placing the patient in the prone position, with a folded coat under the chest, and rolling the body alternately into the lateral and prone positions.

4. Howard's.--This consists in emptying the thorax by forcibly compressing the lower part of the chest; on relaxing the pressure the chest again fills with air. Here the patient is placed in the supine position.

The objections to the supine position are that the tongue falls back, and not only blocks the entrance of air, but prevents the escape of water, mucus, and froth from the air-passages.

5. Laborde's Method.--This consists in holding the tongue by means of a handkerchief, and rhythmically drawing it out fully at the rate of fifteen times per minute. This excites the respiratory centre, and this method may be employed along with any of the other methods.

XX.--DEATH FROM STARVATION

The post-mortem appearances in death from starvation are as follows: There is marked general emaciation; the skin is dry, shrivelled, and covered with a brown, bad-smelling excretion; the muscles soft, atrophied, and free from fat; the liver is small, but the gall-bladder is distended with bile. The heart, lungs, and internal organs are shrivelled and bloodless. The stomach is sometimes quite healthy; in other cases it may be collapsed, empty, and ulcerated. The intestines are also contracted, empty, and translucent.

In the absence of any disease productive of extreme emaciation (e.g., tuberculosis, stricture of oesophagus, diabetes, Addison's disease), such a state of body will furnish a strong presumption of death by starvation.

In the case of children there is not always absolute deprivation of food, but what is supplied is insufficient in quantity or of improper quality. The defence commonly set up is that the child died either of marasmus or of tuberculosis.

In cases where it is alleged that a child has been starved and ill-used, one must examine the body for signs of neglect--e.g., dirtiness of skin and hair, presence of vermin, bruises or skin eruptions. Compare its weight with a normal child of the same age and sex. If the disproportion be great and signs of neglect present, then the probability is great (provided there be no actual disease present) that the child has been starved.

XXI.--DEATH FROM LIGHTNING AND ELECTRICITY

The signs of death from lightning vary greatly. In some cases there are no signs; in others the body may be most curiously marked. Wounds of various characters--contused, lacerated, and punctured--may be produced. There may be burns, vesications, and ecchymoses; arborescent markings are not uncommon. The hair may be singed or burnt and the clothing damaged. Rigor mortis is very rapid in its onset and transient. Post mortem there are no characteristic signs, but the blood may be dark in colour and fluid. The presence or absence of a storm may assist the diagnosis.

Injuries by electrical currents of high pressure are not uncommon; speaking generally, 1,000 to 2,000 volts will kill. In America, where electricity is adopted as the official means of destroying criminals, 1,500 volts is regarded as the lethal dose, but there are many instances of persons having been exposed to higher voltages without bad effects. The alternating current is supposed to be more fatal than the continuous. Much depends on whether the contact is good (perspiring hands or damp clothes). Death has been attributed in these cases to respiratory arrest or sudden cessation of the heart's action. The best treatment is artificial respiration, but the inhalation of nitrite of amyl may prove useful. Rescuers must be careful that they, also, do not receive a shock. The patient should be handled with india-rubber gloves or through a blanket thrown over him.

XXII.--DEATH FROM COLD OR HEAT

=Cold.=--The weak, aged, or infants, readily succumb to low temperatures. The symptoms are increasing lassitude, drowsiness, coma, with sometimes illusions of sight. Post mortem, bright red patches are found on the skin surface, and the blood remains fluid for long.

=Heat.=--Death may result from syncope, the result of exposure to great heat.

=Sunstroke.=--The person loses consciousness and falls down insensible; the body temperature may be 112 deg. F., the pulse is full, and a peculiar pungent odour is given off from the skin. Coma, convulsions with (rarely) delirium, may precede death. Treatment consists in lowering the body temperature by application of cold cloths, stimulants, strychnine or digitalin hypodermically.

XXIII.--PREGNANCY

The signs of the existence of pregnancy are of two kinds, uncertain and certain, or maternal and foetal. Amongst the former class are included--Cessation of menstruation (which may occur without pregnancy); morning vomiting; salivation; enlargement of the breasts and of the abdomen; quickening. It must be borne in mind that every woman with a big abdomen is not necessarily pregnant. The tests which afford conclusive evidence of the existence of a foetus in the uterus are--Ballottement, the uterine souffle, intermittent uterine contractions, foetal movements, and, above all, the pulsation of the foetal heart. The uterine souffle is synchronous with the maternal pulse; the foetal heart is not, being about 120 beats per minute.

Evidence of pregnancy may also be afforded by the discharge from the uterus of an early ovum, of moles, hydatids, etc. Disease of the uterus and ovarian dropsy may be mistaken for pregnancy. Careful examination is necessary to determine the nature of the condition present. Pregnancy may be pleaded in bar of immediate capital punishment, in which case the woman must be shown to be 'quick with child.' A woman may also plead pregnancy to delay her trial in Scotland, and both in England and Scotland, in civil cases, to produce a successor to estates, to increase damages for seduction, in compensation cases where a husband has been killed, to obtain increased damages, etc. A woman may become pregnant within a month of her last delivery.

In cases of rape and suspected pregnancy, it must be borne in mind that a medical man who examines a woman under any circumstances against her will renders himself liable to heavy damages, and that the law will not support him in so doing. If, on being requested to permit an examination, the woman refuse, such refusal may go against her, but of this she is the best judge. The duty of the medical man ends on making the suggestion.

XXIV.--DELIVERY

The signs of recent delivery are as follows: The face is pale, with dark circles round the eyes; the pulse quickened; the skin soft, warm, and covered with a peculiar sweat; the breasts full, tense, and knotty; the abdomen distended, its integuments relaxed, with irregular light pink streaks on the lower part. The labia and vagina show signs of distension and injury. For the first three or four days there is a discharge from the uterus more or less sanguineous in character, consisting of blood, mucus, epithelium, and shreds of membrane. During the next four or five days it becomes of a dirty green colour, and in a few days more of a yellowish, milky, mucous character, continuing for two to three weeks. The change in character of the lochial discharge is due to the quantity of blood decreasing and its place being taken by fatty granules and leucocytes. The os uteri is soft, patulous, and its edges are torn. The uterus may be felt for two or three hours above the pubis as a hard round ball, regaining its normal size in about eight weeks after delivery. Most of these signs disappear about the tenth day, after which it becomes impossible to fix the date of delivery.

In the dead the external parts have the same appearance as given above. The uterus will vary in appearance according to the time elapsed since delivery. If death occurred immediately after delivery, the uterus will be wide open, about 9 or 10 inches long, with clots of blood inside, and the inner surface lined by decidua.

The signs of a previous delivery consist in silvery streaks in the skin of the abdomen, which, however, may be due to distension from other causes; similar marks on the breast; circular and jagged condition of the os uteri (the virgin os being oval and smooth); marks of rupture of the perineum or fourchette; absence of the vaginal rugae; dark-coloured areola round the nipples, etc. The difference between the virgin corpus luteum and that of recent pregnancy is not so marked as to justify a confident use of it for medico-legal purposes.

XXV.--FOETICIDE, OR CRIMINAL ABORTION

This consists in giving to any woman, or causing to be taken by her, with intent to procure her miscarriage, any poison or other noxious thing, or using for the same purpose any instruments or other means whatsoever. It is a felony to procure or attempt to procure the miscarriage of a woman, whether she be pregnant or not, and it is a felony for the woman, if pregnant, to attempt to procure her own miscarriage. It is a misdemeanour for any person or persons to procure drugs or instruments for a like purpose. It is not necessary that the woman be quick with child. The offence is the intent to procure the miscarriage of any woman, whether she be or be not with child. When from any causes it is necessary to procure abortion, a medical man should do so only after consultation with a brother practitioner. Even in these cases there is no exemption legally. Any medical man who gives even the most harmless medicine where he suspects the possibility of pregnancy may render himself liable to grave suspicion should the woman abort.

In medicine, an abortion is said to occur when the foetus is expelled before the sixth month; after that it is premature birth. In law, however, any expulsion of the contents of the uterus before the full time is an abortion or miscarriage.

In deciding whether any substance expelled from the uterus is really a foetus or a mole, and therefore the result of conception, or the coat of the uterus, and unconnected with pregnancy, the examination of the substances expelled must be carefully made. Moles are blighted foetuses. An examination of the woman will be necessary, though it is not easy during the early months of pregnancy, and especially in those who have borne children, to say whether abortion has taken place or not. The history must be inquired into; the regular or exceptional use of drugs to promote menstruation is important, for in the former case no criminal intent may exist, although pregnancy be present. The state of the breasts, the hymen, and the os uteri, should all be carefully examined. Putting a few apparently unimportant questions as to the frequent use of purgatives, the presence or absence of constipation, will often assist the diagnosis as showing that the woman has acted in an unusual manner. Abortion may be procured by the introduction of instruments, by falls, violent exercise, blows on the abdomen, etc. In the hands of ignorant persons the use of instruments (sounds, bougies, skewers, etc.) is attended with great danger. Perforation of the vaginal walls, bladder, cervix, or uterus, may follow their use. Septic pelvic peritonitis may ensue, and the woman may lose her life. The person who has employed such means for inducing abortion is liable to be charged with the crime of murder. There is no evidence to show that ergot, savin, bitter-apple, pennyroyal, or any other drug administered internally, will cause a woman to abort, except when taken in such large doses that actual poisoning results, with inflammation of the contents of the true pelvis. In such cases reflex uterine contractions may be set up, and abortion may follow. Diachylon pills are largely employed to induce abortion, and very often the woman taking them suffers severely from lead-poisoning.

XXVI.--INFANTICIDE

Infanticide, or the murder of a new-born child, is not treated as a specific crime, but is tried by the same rules as in cases of felonious homicide. The term is applied technically to those cases in which the mother kills her child at, or soon after, its birth. She is often in such a condition of mental anxiety as not to be responsible for her actions. It is usually committed with the object of concealing delivery, and to hide the fact that the girl has, in popular language, 'strayed from the paths of virtue.' The child must have had a separate existence. To constitute 'live birth,' the child must have been alive after its body was entirely born--that is, entirely outside the maternal passages--and it must have had an independent circulation, though this does not imply the severance of the umbilical cord. Every child is held in law to be born dead until it has been shown to have been born alive. Killing a child in the act of birth and before it is fully born is not infanticide, but if before birth injuries are inflicted which result in death after birth, it is murder. Medical evidence will be called to show that the child was born alive.

The methods of death usually employed are--(1) Suffocation by the hand or a cloth. (2) Strangulation with the hands, by a tape or ribbon, or by the umbilical cord itself. (3) Blows on the head, or dashing the child against the wall. (4) Drowning by putting it in the privy or in a bucket of water. (5) Omission: by neglecting to do what is absolutely necessary for the newly-born child--e.g., not separating the cord; allowing it to lie under the bed-clothes and be suffocated.

With regard to the question of the maturity of a child, the differences between a child of six or seven months and one at full term may be stated as follows:

Between the sixth and seventh month, length of child 10 to 14 inches--that is, the length of the child after the fifth month is about double the lunar months--weight 1 to 3 pounds; skin, dusky red, covered with downy hair (lanugo) and sebaceous matter; membrana pupillaris disappearing; nails not reaching to ends of fingers; meconium at upper part of large intestine; testes near kidneys; no appearance of convolutions in brain; points of ossification in four divisions of sternum.

At nine months, length of child 18 to 22 inches; weight, 7 to 8 pounds; skin rosy; lanugo only about shoulders; sebaceous matter on the body; hair on head about an inch long; testes past inguinal ring; clitoris covered by the labia; membrana pupillaris disappeared; nails reach to ends of fingers; meconium at termination of large intestine; points of ossification in centre of cartilage at lower end of femur, about 1-1/2 to 2-1/2 lines in diameter; umbilicus midway between the ensiform cartilage and pubis.

Owing to the difficulty of proving that the crime of infanticide has been committed, the woman may in England be tried for concealment of birth, and in Scotland for concealment of pregnancy, if she conceal her pregnancy during the whole time and fail to call for assistance in the birth. Either of these charges would only be brought against a woman who had obviously been pregnant, and now the child is missing or its dead body has been found. It is expected that every pregnant woman should make provision for the child about to be born, and so should have talked about it or have made clothes, etc., for it. The punishment for concealment is imprisonment for any term not exceeding two years. The charge of concealment is very often alternative to infanticide. To substantiate the charge, however, it must be proved that there had been a secret disposition of the dead body of the infant, as well as an endeavour to conceal its birth.

A woman may be delivered of a child unconsciously, for the contractile power of the womb is independent of volition. Under an anaesthetic the uterus acts as energetically as if the patient were in the full possession of her senses.

Nowadays a woman is rarely hanged for infanticide, and it is a mere travesty of justice to pass on her the death sentence, well knowing that it will never be executed.

XXVII.--EVIDENCES OF LIVE BIRTH

The signs of live birth prior to respiration are negative and positive. A negative opinion may be formed when evidence is found of the child having undergone intra-uterine maceration. In this case the body will be flaccid and flattened; the ilia prominent; the head soft and yielding; the cuticle more or less detached, and raised into large bullae; the skin of a red or brownish-red colour; the cavities filled with abundant bloody serum; the umbilical cord straight and flaccid.

A positive opinion is justified when such injuries are found on the body as could not have been inflicted during birth, and are attended with such haemorrhage as could only have occurred while the blood was circulating. Fractures of the cranium from accidental falls (precipitate labour) are as a rule stellate, and are situated on the vertex or in the parietal protuberance. The fractures from violence are more extensive, usually depressed, and accompanied by laceration of the scalp.

The evidences of live birth after respiration has taken place are usually deduced from the condition of the lungs, though indications are also found in other organs. The diaphragm is more arched before than after respiration, and rises higher in the thorax in the former case than in the latter. The lungs before respiration are situated in the back of the thorax, and do not fill that cavity; they are of a dark, red-brown colour and of the consistence of liver, without mottling. After respiration they expand and occupy the whole thorax, and closely surround the heart and thymus gland. The portions containing air are of a light brick-red colour, and crepitate under the finger. The lungs are mottled from the presence of islands of aerated tissue, surrounded by arteries and veins. The weight of the lungs before respiration is about 550 grains, after an hour's respiration 900 grains; but this test is of little value. The ratio of the weight of the lungs to that of the body (Ploucquet's test), which is also unreliable, is, before respiration, about 1 to 70; after, 1 to 35. Lungs in which respiration has taken place float in water; those in which it has not, sink. There are exceptions to this rule, on which, however, is founded the hydrostatic test. As originally performed, this test consisted merely in placing the lungs, with or without the heart, in water, and noticing whether they sank or floated. The test is now modified by squeezing, and by cutting the lungs up into pieces.

The objections to the test as originally performed are--(1) That the lungs may sink as the result of disease--e.g., double pneumonia. (2) That respiration may have been so limited in extent that the lungs may sink, owing to large portions of lung tissue remaining unexpanded (atelectasis). (3) Putrefaction may cause the lungs to float when respiration has not taken place. (4) The lungs may have been inflated artificially. Few of these objections apply, however, when the hydrostatic test, modified by pressure, is employed. To take these objections in detail, it may be stated: (1) If the lungs sink from disease, the question of live birth is answered. (2) This objection is too refined for practical use. The lungs sink, there is an absence of any of the signs of suffocation, and the matter ends. The examiner has only to describe the conditions which he finds, and is not required to indulge in conjectures as to the amount of respiration which may or may not have taken place. (3) Gas due to putrefaction collects under the pleural membrane, and can be expelled by pressure, and is not found in the air cells. The lungs decompose late, hence in a fresh body putrefaction of the lungs is absent; in a putrefied child, if the lungs sink, it must have been stillborn. The so-called emphysema pulmonum neonatorum is simply incipient putrefaction.

The lung test simply shows that the child has breathed, but affords no proof that the child has been born alive. The child may have breathed as soon as its head protruded, the rest of the body being in the maternal passages. The child is not born alive until it has been completely expelled, although it is not necessary that the umbilical cord should have been cut.

In addition to these tests, live birth may be suspected from the following conditions: The stomach may contain milk or food, recognized by the microscope and by Trommer's test for sugar; the large intestines in stillborn children are filled with meconium, in those born alive they are usually empty; the bladder is generally emptied soon after birth; the skin is in a condition of exfoliation soon after birth. The organs of circulation undergo the following changes after birth, and the extent to which these changes have advanced will give an idea of how long the child has lived: The ductus arteriosus begins to contract within a few seconds of birth; at the end of a week it is about the size of a crow quill, and about the tenth day is obliterated. The umbilical arteries and vein: the arteries are remarkably diminished in calibre at the end of twenty-four hours, and obliterated almost up to the iliacs in three days; the umbilical vein and the ductus venosus are generally completely contracted by the fifth day. The foramen ovale becomes obliterated at extremely variable periods, and may continue open even in the adult.

Importance of late has been attached to the stomach-bowel test. If the stomach and duodenum contain air, and consequently float in water, the chances are that the child did not die immediately after birth; this is known as Breslau's second life test, and the lower the air in the intestinal canal, the greater is the probability that the child survived birth.

The umbilical cord in a new-born child is fresh, firm, round, and bluish in colour; blood is contained in its vessels. The cord may be ruptured by the child falling from the maternal parts in a precipitate labour, and the ruptured parts present ragged ends. It is seldom that a child bleeds to death from an untied or cut umbilical cord, and the chances in a torn cord are still more remote. The changes in the cord are as follows: First it shrinks from the ligature towards the navel; this change may begin early, and is rarely delayed beyond thirty hours; the cord becomes flabby, and there is a distinct inflammatory circle round its insertion. The next change is that of desiccation or mummification; the cord becomes reddish-brown, then flattened and shrivelled, then translucent and of the colour of parchment, and falls off about the fifth day. The third stage, that of cicatrization, then ensues about the tenth to the twelfth day. The bright red rim round the insertion of the cord, with inflammatory thickening and slight purulent secretion, may be considered as evidence of live birth, and the stage at which the separation of the cord by ulcerative process has arrived will point to the probable duration of time the child has existed after birth.

There are many fallacies in the application of any of these tests, and the whole subject bristles with difficulties. The medical witness would do well to exhibit a cautious reserve, for if the child dies immediately after birth it is almost impossible to prove that it was born alive.

XXVIII.--CAUSE OF DEATH IN THE FOETUS

The death of the foetus may be due to--(1) Immaturity or intra-uterine malnutrition, or simply from deficient vitality; (2) complications occurring during or immediately after birth, which may either be unavoidable or inherent in the process of parturition, or may be induced with criminal intent.

In the latter category come such accidents as the pressure of tumours in the pelvic passages, or disease of the bones in the mother, or pressure on the cord from malposition of the child during labour, asphyxiation from the funis being twisted tightly round the neck or limbs, or from injuries due to falls on the floor in sudden labours. Where the death of the foetus has been induced with criminal intent, it may be due to punctured wounds of the fontanelles, orbits, heart, or spinal marrow; dislocation of the neck; separation of the head from the body; fracture of the bones of the head and face; strangulation; suffocation; drowning in the closet pan or privy, or from being thrown into water.

Under the head of infanticide by commission, we have injuries of all kinds; under infanticide by omission, neglecting to tie the cord, allowing it to be suffocated by discharges in the bed, neglect to provide food, clothes, and warmth, for the new-born child.

XXIX.--DURATION OF PREGNANCY

The natural period of gestation is considered as forty weeks, ten lunar months, or 280 days. A medical witness would have to admit the possibility of gestation being prolonged to 300 days, and if this time were not very materially exceeded it would be well to give the woman the benefit of the doubt. It may be mentioned that 300 days is the extreme limit fixed by the French and Scottish law. No fixed period is assigned in English or American law to the duration of pregnancy, though it is allowed that utero-gestation may be greatly prolonged. In a recent case decided, the Lord Chancellor accepted a case where it was alleged pregnancy had extended to 331 days. A child only five months old may live, for a short time at all events. There is considerable difficulty in many cases in fixing the date of conception. The data from which it is calculated are the following: (1) Peculiar sensations attending conception, which are not sufficiently defined to be recognized by those conceiving for the first time. (2) Cessation of the catamenia. Other causes may, however, cause this; and, on the other hand, a woman may menstruate during the whole period of her pregnancy. This datum also gives a variable period, and may involve an error of several days or a month, for the menses may be arrested by cold, etc., at one monthly period, and the woman become pregnant before the next. (3) The period of quickening. This, when perceived (which is not always the case), also occurs at variable periods from the tenth to the twenty-sixth week. (4) A single coitus. This does not, however, correspond to the time of fertilization. Several days may elapse before the spermatozoa meet with an ovum and fertilize it.

In Scotland a child born six months after marriage is legitimate, which is allowing an ample margin.

XXX.--VIABILITY OF CHILDREN

A child may be born alive, but may not be viable, by which is meant that it is not endowed with a capacity of maintaining its life. Speaking generally, 180 days represents the lowest limit at which a child is viable, but prolonged survival under these circumstances is the exception. Many cases, however, have been recorded in which children born at six months have been reared. The signs of immaturity and maturity may be thus tabulated:

IMMATURITY. MATURITY.

Centre of body high; head Strong movements and cries as soon disproportionate in size; membrana as born; body clear, red colour, pupillaris present; testicles coated with sebaceous matter; mouth, undescended; deep red colour of nostrils, eyelids, and ears, open; parts of generation; intense red skull somewhat firm, and fontanelles colour, mottled appearance, and not far apart; hair, eyebrows, and downy covering, of skin; nails not nails, perfectly developed; formed; feeble movements; testicles descended; free discharge inability to suck; necessity for of urine and meconium; power of artificial heat; almost unbroken suction, indicated by seizure on the sleep; rare and imperfect nipple or a finger placed in the discharges of urine and meconium; mouth. closed state of mouth, eyelids, and nostrils.

XXXI.--LEGITIMACY

A child born in wedlock is presumed to have the mother's husband for its father. This may, however, be open to question upon the following grounds: Absence or death of the reputed father; impotence or disease in the husband preventing matrimonial intercourse; premature delivery in a newly-married woman; want of access; and the marriage of the woman again immediately on the death of her husband. In the last case, where either husband might have been the father, the child at the age of twenty-one is at liberty to select its father from the possible pair.

A child born of parents before marriage is in Scotland rendered legitimate by their subsequent marriage, but in England the offspring remains illegitimate whether the parents marry or not after its birth. The offspring of voidable or invalid marriages may be made legitimate by application to the courts.

There is a difference between being legitimate and lawfully begotten. A child born in wedlock is legitimate, but if the parents were married only a week previously it could not have been lawfully begotten.

The Acts and rulings relating to Marriage and Legitimacy are extremely complicated. It is not putting it too strongly to say that a very large number of people in this country who believe themselves to be legally married are not married at all, and that thousands of children who have not the slightest doubt as to their legitimacy are in the eyes of the law bastards.

XXXII.--SUPERFOETATION

By superfoetation is meant the conception, by a woman already pregnant, of a second embryo, resulting in the birth of two children at the same time, differing much in their degree of maturity, or in two separate births, with a considerable interval between. The possibility of the occurrence of superfoetation has been doubted, but there are well-authenticated cases which countenance the theory of a double conception. It has been shown that the os uteri is not closed, as was once supposed, immediately on conception. Should an ovum escape into the uterus, it may become impregnated a month or so after a previous conception. The most probable explanation is that the case has been one of twins, one being born prematurely; or, on the other hand, the uterus may have been double, and conception may have taken place in one cornu at a later period than in the other cornu.

XXXIII.--INHERITANCE

In order to inherit, the child must be born alive, must be born during the lifetime of the mother, and must be born capable of inheriting--that is to say, monsters are incapable of inheriting. There is a mode of inheritance called 'tenancy by courtesy.' When a man marries a woman possessed of an estate or inheritance, and has, by her, issue born alive in her lifetime capable of inheriting her estate, in this case he shall, on the death of his wife, hold the lands for his life as tenant by the courtesy of England. The meaning of the words 'born alive' in this instance is not the same as in cases of infanticide. In Civil law any motion of the child's body, however slight, or the fact of it having been heard to cry by witnesses, is held to be sufficient proof of the child having been born alive. It may die immediately afterwards, and it is not necessary that the child be viable.

XXXIV.--IMPOTENCE AND STERILITY

In the male, impotence may arise from physical or mental causes. The physical causes may be--too great or too tender an age; malformation of the genital organs; crypsorchides, defect or disease in the testicles; constitutional disease (diabetes, neurasthenia, etc.); or debility from acute disease, as mumps. Masturbation, and early and excessive sexual indulgence, are also causes. The mental causes include--passion, timidity, apprehension, aversion, and disgust. The case will be remembered of the man who was impotent unless the lady were attired in a black silk dress and high-heeled French kid boots.

If a man is impotent when he marries, the marriage may be set aside on the ground that it had never been consummated. The law requires that the impotency should have existed ab initio--that is, before marriage--and should be of a permanent or incurable nature; marriage, as far as the law goes, being regarded as a contract in which it is presupposed that both the contracting parties are capable of fulfilling all the objects of marriage. In the case of the Earl of Essex the defendant admitted the charge as regards the Countess, but pleaded that he was not impotent with others, as many of her waiting-maids could testify. When a man becomes impotent after marriage, his wife must accept the situation, and has no redress. A man may be sterile without being impotent, but the law will not take cognizance of that. The wife may be practically impotent, but the law will not assist the husband. He must continue to do his best under difficult circumstances. In former times in case of doubt a husband was permitted to demonstrate his competency in open court, but this custom is no longer regarded with favour by the judges.

The removal of the testicles does not of necessity render a man impotent, although it deprives him of his procreative power. Eunuchs are capable of affording illicit pleasure, whilst the male sopranos, or castrati, are often utilized for that purpose.

In the female, impotence may be caused by the narrowness of the vagina, adhesion of the vulva, absence of vagina, imperforate hymen, and tumours of the vagina.

Sterility in women may occur from the above-named causes of impotence, together with absence of the uterus and ovaries, or from great debility, syphilis, constant amenorrhoea, dysmenorrhoea, or menorrhagia.

XXXV.--RAPE

Rape is the carnal knowledge of a woman by force and against her will. The resistance of the woman must be to the utmost of her power, but if she yield through fear or duress it is still rape. The woman is a competent witness, but her statements may be impugned on the ground of her previous bad character, and evidence may be called to substantiate the charge. The perpetrator must be above the age of fourteen years.

The definition of rape which we have given is not altogether satisfactory. Take, for example, the case of a woman who goes to bed expecting her husband to return at a certain hour. The lodger, let us say, takes advantage of this fact, and, getting into bed, has connection with her, she not resisting, assuming all the while that it is her husband. This is rape, but it is not 'by force,' and it is not 'against her will,' but it is 'without her consent,' as she has not been fully informed as to all the circumstances of the case.

In all cases of rape in which there is no actual resistance or objection, consent may be assumed. It is not essential that the woman should state in so many words that she does not object. The force used may be moral and not physical--e.g., threats, fear, horror, syncope.

By 48 and 49 Vict., c. 49, the carnal knowledge of a girl under thirteen is technically rape. The consent of the girl makes no difference, since she is not of an age to become a consenting party.

An attempt at carnal knowledge of a girl under thirteen is a misdemeanour. Her consent makes no difference, and even the solicitation of the act on the part of the child will not exonerate the accused.

Intercourse with a girl between thirteen and sixteen, even with her consent, is a misdemeanour.

This Act is a favourite with the blackmailer. The child is sent out to solicit, dressed like a woman, but appears in the witness-box in a much more juvenile costume.

To constitute rape there must be penetration, but this may be of the slightest. There may be a sufficient degree of penetration to constitute rape without rupturing the hymen. Proof of actual emission is now unnecessary.

The subject of carnal knowledge (C.K.) or its attempt may be summed up as follows:

Under thirteen C.K. Felony. Under thirteen Attempt Misdemeanour.

Consent no defence.

From thirteen to sixteen C.K. Misdemeanour. From thirteen to sixteen Attempt Misdemeanour.

Consent and even solicitation no defence. Reasonable cause to believe the girl over sixteen is a good defence. Charge must be brought within three months.

Over sixteen C.K. with consent Nil.

Subject to civil action for loss of girl's services by father.

Idiot or imbecile C.K. with violence Rape. Idiot or imbecile C.K. without violence Misdemeanour. Personation of husband Rape.

Tacit consent no defence, for obtained by fraud.

Married woman C.K. with consent Adultery. Mother, sister, daughter, C.K. consent immaterial; Incest. grand-daughter born in wedlock or not Females Indecent assaults Misdemeanour.

It is a misdemeanour to give to a woman any drug so as to stupefy her, and so enable any person to have unlawful connection with her.

False charges of rape are very often made. The motive may be to extort blackmail, revenge, or mere delusion. On examining such cases bruises are seldom found, but scratches which the woman has made on the front of her body may be discovered, and the local injuries to the generative organs are slight, if present at all.

Physical Signs.--In the adult the hymen may be ruptured, the fourchette lacerated, and blood found on the parts, together with scratches and other marks and signs of a struggle. In the child there may be no haemorrhage, but there will be indications of bruising on the external organs, with probably considerable laceration of the hymen, the laceration in some cases extending into the rectum. Severe haemorrhage, and even death, may follow the rape of a young child. The patient will have difficulty in walking, and in passing water and faeces. After some hours the parts are very tender and swollen, and a sticky greenish-yellow discharge is present. These signs last longer in children than in adults; but as a rule--in the adult, at least--all signs of rape disappear in three or four days. Young and delicate children may suffer from a vaginal discharge, with swelling of the external genitals, simulating an attempt at rape. Infantile leucorrhoea is common, and many innocent people have been exposed to danger from false charges of rape on children, instituted as a means of levying blackmail. A knowledge of these facts suggests the necessity of giving a guarded opinion when children are brought for examination in suspected cases. Pregnancy may follow rape.

Seminal stains render the clothing stiff and greyish-yellow in colour, with translucent edges. On being moistened they give the characteristic seminal odour.

Semen may be found on the linen of the woman and man, and will be recognized under the microscope by the presence in it of spermatozoa, minute filamentary bodies with a pear-shaped head; but it must not be forgotten that the non-detection of spermatozoa is no proof of absence of sexual intercourse, for these bodies are not always present in the semen of even healthy adult young men. Spermatozoa must not be mistaken for the Trichomonas vaginae found in the vaginae of some women. The latter have cilia surrounding the head, which is globular.

Florence's Micro-Chemical Test for Spermatic Fluid.--If a drop of the fluid obtained by wetting a supposed spermatic stain be mixed with a drop of the following solution (KI, parts 1.65; pure iodine, 2.54; distilled water, 30) in a watch-glass, brownish-red pointed crystals resembling haemin crystals are obtained.

Barberio's Test.--Mix a drop of the spermatic stain with a drop of a saturated solution of picric acid, when needle-shaped yellow rhombic crystals are formed.

Gonorrhoeal Stains.--A cover-glass preparation stained with methylene blue reveals the gonococci lying in pairs within the leucocytes.

XXXVI.--UNNATURAL OFFENCES

Trials for =sodomy= and =bestiality= are common at the assizes, but, as they are rarely reported, they fail to attract attention. Sodomy is a crime both in the active and passive agent, unless the latter is a non-consenting party. The evidence of either associated may be received as against his colleague. If the crime is committed on a boy under fourteen, it is a felony in the active agent only. As in cases of rape, emission is not essential, and penetration, however slight, answers all practical purposes.

There can be no doubt that in the majority of these cases there exists a congenitally abnormal condition of the sexual instinct, these individuals from their childhood manifesting a perverted sexual instinct. The man is physically a man, but psychically a woman, and vice versa. The tendency nowadays is not to charge these people with the more serious offence, but to deal with them under Section 11 of the Criminal Law Amendment Act, 1885 (48 and 49 Vict., c. 69). This section, which is sufficiently comprehensive, runs as follows: 'Any male person who in public or private commits or is a party to the commission, or attempts to procure the commission by any male person, of any act of gross indecency with another male person, shall be guilty of a misdemeanour.' The penalty is imprisonment for two years, with or without hard labour. It is provided by Section 4 of the same Act that a boy under sixteen may be whipped.

=Incest.=--This crime is dealt with under the Punishment of Incest Act, 1908 (8 Edward VII., c. 45). Carnal knowledge with mother, sister, daughter, or grand-daughter, is a misdemeanour, provided the relationship is known. It also applies to the half-brother and half-sister. It is equally an offence whether the relationship can or cannot be traced through lawful wedlock. Consent is no defence. A woman may be charged under the Act if she, being above the age of sixteen, with consent permits her grandfather, father, brother, or son, to have carnal knowledge of her.

XXXVII.--BLACKMAILING

There are in London and every large city scores of men and women who live by blackmailing or chantage. There are many different forms of this industry. There is the man who knows something about your past life, which he threatens to reveal to your friends or colleagues unless you buy him off. There is the breach-of-promise blackmailer, and there is the female patient, who threatens to charge you with improper conduct or indecent assault. Medical men from their position are often selected as victims. The introduction of corridor carriages on many of our railways has done much to stamp out one particular form of blackmailing, but public urinals are still a source of danger.

It is the worst possible policy to temporize with a blackmailer. If you give him a single penny, you are his for life. It is as well to remember that it is just as criminal to attempt to extract money from a guilty as from an innocent person. It is of no use attempting to deal with these cases single-handed. You must not only deny the allegation, but 'spurn the allegator.' Put the matter into the hands of a good sharp criminal solicitor, and instruct him to rid you of the nuisance by taking criminal proceedings.

XXXVIII.--MARRIAGE AND DIVORCE

Marriage may be accomplished in many ways: (1) By the publication of banns; (2) by an ordinary licence; (3) by a special licence; (4) by the Superintendent-Registrar's licence; (5) by a special licence granted by the Archbishop of Canterbury in consideration of the payment of the sum of L25. Then, for persons having a domicile in Scotland, there is the marriage by repute. The consent of the parties, which is the essence of the contract, may be expressed before witnesses, and it is not requisite that a clergyman should assist, but it is essential that the expressions of consent must be for a matrimonial intent. 'Habit and repute' constitute good evidence, but the repute must be the general, constant, and unvarying belief of friends and neighbours. The cohabitation must be in Scotland.

Any irregularity in the marriage ceremony or the non-observance of any formality will not invalidate the marriage, unless it were known to both the contracting parties. If a man were married in a wrong name the contract would still be valid if the wife were unacquainted with the deception at the time. If the person who officiated were a bogus clergyman, the marriage would hold good if the contracting parties supposed him to be a properly ordained priest. In a case in which a marriage was solemnized in a building near the church at a time when the church was undergoing repairs, and where during such alterations Divine service had been performed, it was held that the ceremony was good. To all intents and purposes marriage comes under the 'Law of Contract' (see Anson, W.R., Bart.), and the law looks to the intention rather than to the actual details. All marriages between persons within the prohibited degrees of consanguinity or affinity are null and void. This prohibition extends both to the illegitimate as well as the legitimate children of the late wife's or husband's parents. A marriage with a deceased wife's sister is now legal in Great Britain and the Colonies, and is recognized in most foreign countries. A common device with people within the prohibited degrees is to get married abroad, but such marriage is strictly speaking inoperative, and the children of such union are illegitimate. Practically, however, it is a matter of no importance, for when people live together and say they are married, they are accepted at their own estimate.

A man can obtain a divorce from his wife if he can prove that she has been guilty of adultery since her marriage. This may be established by inference. Obviously, it is difficult in the majority of cases to establish by ocular demonstration that adultery has been committed. But given evidence of familiarity and affection with opportunity and suspicious conduct, a jury will commonly infer it.

A woman cannot obtain a divorce from her husband for adultery alone. She must prove adultery plus cruelty, or adultery plus desertion without reasonable cause. Failing this, she may be able to prove either bigamy or incestuous adultery. Legal cruelty is a very comprehensive term, and does not of necessity mean physical violence. If the husband as the result of his infidelity were to give his wife a contagious disease, that would constitute cruelty. Taking a more extreme case, if a husband were to have connection in her house with his wife's maid, that would probably be held to constitute cruelty, as it would tend to lower her in the eyes of her servants.

A wife can obtain a judicial separation if she can prove (1) adultery, (2) cruelty, or (3) desertion without reasonable cause for two years. If a husband is away on his business, as, for example, the case of an officer ordered abroad, that is not desertion. For a woman to get a judicial separation, it is sufficient if she can prove one variety of matrimonial offence, but for a divorce she requires more than one.

The jury may find that Mrs. A. has committed adultery with Mr. B., but that Mr. B. has not committed adultery with Mrs. A. The explanation is, that a wife's confession is evidence against herself, but not against another person. You can confess your own sins, but not another's.

The Divorce Law of Scotland differs materially from that of England. In Scotland there is no decree nisi, no decree absolute, and no intervention by the King's Proctor. Instead there is a single and final judgment, and when a decree of divorce is pronounced the successful litigant at once succeeds to all rights, legal and conventional, that would have come to him or her on the death of the losing party. If the husband is the offender, the wife in such circumstances may claim her right to one-third of his real estate; and if there are children, to one-third of his personal property, and to one-half if there are none.

=Voidable Marriages.=--If a man and woman go through the marriage ceremony, such a contract is null and void under the following circumstances: (1) Where bigamy has been committed; (2) if one of the parties were insane at the time of marriage; (3) where the plaintiff is under sixteen years of age; (4) when the marriage has not been consummated or followed by cohabitation; (5) when one of the parties was incapable of performing the marital act (impotent, and such not known by the other at the time); (6) when drunkenness had been induced so as to obtain consent; (7) concealment of pregnancy at the time of marriage.

XXXIX.--FEIGNED DISEASES

Malingering in its various forms is by no means uncommon, and by many is regarded as a disease in itself. It is necessary, however, to distinguish between those cases in which it is feigned for some definite purpose--for example, to escape punishment or avoid public service--and those in which there is adequate motive, and the patient shams simply with the view of exciting sympathy, or from the mere delight of giving trouble. It is not uncommon for individuals summoned on a jury, or to give evidence in the law courts, to apply to their doctor for a certificate, assigning as a cause of exemption neuralgia, or some similar complaint unattended with objective symptoms. In such cases it is well to remind the patient that in most courts such certificates are received with suspicion, and are often rejected, and that the personal attendance of the medical man is required to endorse his certificate on oath.

Malingering has become much more common since the National Health Insurance Act has been passed. The possibility of obtaining a fair sum each week without the necessity of working for it induces many persons either to feign disease or to make recovery from actual disease or accident much more tedious than it ought really to be.

The feasibility of successfully malingering is greatly enhanced by the possession of some chronic organic disease. An old mitral regurgitant murmur is useful for this purpose.

It is not flattering to one's vanity to overlook a case of malingering, but should this occur little harm is done. It is a much more serious matter to accuse a person of malingering when in reality he may be suffering from an organic disease.

Here are some of the diseases which are most frequently feigned:

=Nervous Diseases=, as headache, vertigo, paralysis of limbs, vomiting, sciatica, or incontinence or suppression of urine, spitting of blood; others, again, simulate hysteria, epilepsy, or insanity.

On the other hand, the malingerer may actually produce injuries on his person either to excite commiseration or to escape from work. Thus, the beggar produces ulcers on his legs by binding a penny-piece tightly on for some days; the hospital patient, in order to escape discharge, produces factitious skin diseases by the application of irritants or caustics.

It is much more difficult to decide whether certain symptoms are due to a real disease which is present, or whether they are merely exaggerations of slight symptoms or simulations of past ones. The miner, after an injury to his back, recovers very slowly, if at all. He is suffering from 'traumatic neurasthenia'--a condition only too often simulated, and a disease very difficult to diagnose accurately. The miner takes advantage of our ignorance, and continues to draw his compensation. A workman during his work receives a fracture; instead of being able to resume work in six weeks, he asserts that the pain and stiffness prevent him, and this disability may persist for months. Such cases as these frequently come before the courts when the employer has discontinued to pay the weekly compensation for the injury. Medical men are called to give evidence for or against the injured workman.

=Epilepsy= is often simulated. The foaming at the mouth is produced by a piece of soap between the gums and the cheek. The true epileptic, especially if he suspects that a fit is imminent, takes his walks abroad in some secluded spot, whilst the impostor selects a crowded locality for his exertions. The epileptic often injures himself in falling, his imitator never; one bites his tongue, but the other carefully refrains from doing so. The skin of an epileptic during an attack is cold and pallid, but that of the exhibitor is covered with sweat as the result of his exertions. In epilepsy the urine and faeces are passed involuntarily, but his colleague rarely considers it necessary to carry his deception to this extent. In true epilepsy the eyes are partly open, with the eyeballs rolling and distorted, whilst the pupils are dilated and do not contract to light; the impostor keeps his eyes closed, and he cannot prevent the iris from contracting when a bicycle-lamp is flashed across his face. A useful test is to give the impostor a pinch of snuff, which promptly brings the entertainment to an end.

=Lumbago= is often feigned, and the imposture should be suspected when there is a motive, and when physical signs, such as nodes and tender spots, are absent. A simple test is to inadvertently drop a shilling in front of him, when he will promptly stoop and pick it up. The same principles apply to spurious sciatica.

=Haemorrhages= purporting to come from the lungs, stomach, or bowels, rarely present much difficulty. The microscope is of use in all cases of bleeding. Possibly the gums or the inside of the cheeks may have been scratched or abraded with a pin.

=Skin Diseases= are excited artificially, especially those which may be produced by mechanical and chemical irritants. The most commonly employed are vinegar, acetic acid, carbolic acid, nitric acid, and carbonate of sodium; but tramps frequently use sorrel and various species of ranunculus. The lesions simulated are usually inflammatory in character, such as erythema, vesicular and bullous eruptions, and ulceration of the skin. They may be complicated by the presence of pediculi and other animal and vegetable parasites. Chromidrosis of the lower eyelids in young women often owes its origin to a box of paints. Factitious skin diseases are seen most commonly on the face and extremities, especially on the left side--in other words, on the most accessible parts of the body.

Feigned menstruation, pregnancy, abortion, and recent delivery are common, and should give rise to no difficulty. The same may be said of feigned insanity, aphonia, deaf-mutism, and loss of memory.

The following hints may be useful to a medical man when called to a supposed case of malingering: Do not be satisfied with one visit, but go again and unexpectedly; see that the patient is watched between the visits; make an objective examination, compare the indications with the statements of the patient, noting especially any discrepancies between his account of his symptoms and the real symptoms of disease; ask questions the reverse of the patient's statements, or take them for granted, and he will often be found to contradict himself; have all dressings and bandages removed; suggest, in the hearing of the patient, some heroic methods of treatment--the actual cautery, or severe surgical operation, for example; finally, chloroform will be found of great use in the detection of many sham diseases.

XL.--MENTAL UNSOUNDNESS

The presumption in law is in favour of a person's sanity, even though he may be deaf, dumb, or blind.

The terms 'insanity,' 'lunacy,' 'unsoundness of mind,' 'mental derangement,' 'madness,' and 'mental alienation or aberration,' are indifferently applied to those states of disordered mind in which the person loses the power of regulating his actions and conduct according to the ordinary rules of society. The reasoning power is lost or perverted, and he is no longer fitted to discharge those duties which his social position demands. In some cases of insanity, as in confirmed idiocy, there is no evidence of the exercise of the intellectual faculties. It is probable that no standard of sanity as fixed by nature can be said to exist. The medical witness should decline to commit himself to any definition of insanity. There is no practical advantage in attempting to classify the different forms of insanity.

According to English law, madness absolves from all guilt, but in order to excuse from punishment on this ground it must be proved that the individual was not capable of distinguishing right from wrong in relation to the particular act of which he is accused, and that he did not know at the time of committing the crime that the offence was against the laws of God and nature.

Lunatics are competent witnesses in relation to testimony, as in relation to crime, if they understand the nature of an oath and the character of the proceedings in which they are engaged. The judge, as in the case of children, examines the lunatic tendered as a witness as to his knowledge of the nature and obligation of an oath, and, if satisfied, he allows him to be sworn.

A person, if suffering from such a state of mental unsoundness as to be unable to take care of his property, may be placed under the care of the Court of Chancery. The Court then administers his property, and otherwise allows him entire freedom of action.

With regard to the care of lunatics, no person is allowed to receive more than one lunatic into his house unless such house is licensed and the proper certificates have been signed. One patient may be taken without the house being licensed, but the usual certificates must in all cases be signed, and the Lunacy Commissioners communicated with. If a person receives another not of unsound mind into his house, and such person becomes subsequently insane, the person so keeping him renders himself liable to heavy penalties, unless the legal certificates are at once procured and the Commissioners of Lunacy communicated with.

At common law it appears that a lunatic cannot be placed in an asylum unless dangerous to himself or to others, but under the Lunacy Acts the placing of a madman in an asylum is considered as a part of the treatment with a view to the cure of the patient.

XLI.--IDIOCY, IMBECILITY, CRETINISM

=Idiocy= is not a disease, but a congenital condition in which the intellectual faculties are either never manifested or have not been sufficiently developed to enable the idiot to acquire an amount of knowledge equal to that acquired by other persons of his own age and in similar circumstances with himself. Idiots, as a rule, are deformed in body as well as deficient in mind. Their heads are generally small and badly-shaped, and their features ill-formed and distorted. The teeth are few in number and very irregular. The hard palate has a very deep arch, or may even be cleft. The complexion is sallow and unhealthy, the limbs imperfectly developed, and the gait is awkward, shambling, and unsteady. In his legal relations an absolute idiot is civilly disabled and irresponsible, but in regard to crime, or as a witness, see remarks made above.

=Imbecility= is a form of mental defect not usually congenital, but commencing in infancy or in early life. The line of demarcation between the imbecile and the idiot may be found in the possession by the former of the faculty of speech, in distinction from the mere parrot-like utterance of a few words which can be taught the idiot. Imbecility may be intellectual, moral, or general. Questions frequently arise as to their responsibility for actions done by them, or as to their ability to manage their own affairs.

=Cretinism= is a form of amentia, which is endemic in certain districts, especially in some of the valleys of Switzerland, Savoy, and France. The malady is not congenital, but its symptoms usually appear within a few months of birth. The characteristics of this form of idiocy are an enlarged thyroid gland constituting a goitre or bronchocele, a high-arched palate, dwarfed stature, squinting eyes, sallow complexion, small legs, conical head, large mouth, and indistinct speech.

=Feeble-Minded.=--These are persons who are capable of earning a living under favourable circumstances, but are incapable, from mental defect which has existed from birth or from an early age, of (a) competing on equal terms with their normal fellows, or (b) of managing themselves and their affairs with ordinary prudence. Feeble-mindedness may affect the moral nature only, rendering the person selfish, untruthful, obscene, or unemployable. The Act of 1899 controls feeble-minded children; many such become paupers, criminals, prostitutes, etc.

=Mental Deficiency and Lunacy Act, 1913.=--Those included under this Act are idiots, imbeciles, feeble-minded persons, and moral imbeciles. The parents or guardians of such children between the ages of five and sixteen years must provide for them education and proper care. If they are unable to do so, the School Boards or Parish Councils must do so.

XLII.--DEMENTIA: ACUTE, CHRONIC, SENILE, AND PARALYTIC

In dementia the mental aberration does not occur until the mind has become fully developed, thus differing from amentia, which is congenital or comes on very early in life.

=Acute Dementia.=--This is a condition of profound melancholy or stupor, which arises from sudden mental shock, the mind being, as it were, arrested and fixed in abstraction on the event.

=Chronic Dementia= is generally caused by the gradual action on the mind of grief or anxiety, by severe pain, mania, apoplexy, paralysis, or repeated attacks of epilepsy.

=Senile Dementia= is a form which is incidental to aged persons, and commences gradually with such symptoms as loss of memory for recent events, dulness of perception, and inability to fix the attention. Later on the reasoning powers begin to fail, and finally, memory, reason, and power of attention, are quite lost, the muscular power and force remaining intact. In the last stage there is simply bare physical existence.

=General Paralysis of the Insane, Paralytic Dementia.=--This is a most interesting form of dementia. It is closely allied to, if not identical with, locomotor ataxy. Its most prominent and characteristic symptom consists in delusions of great power, exalted position, and unlimited wealth--megalomania. The exaltation is universal, and the patient may maintain at one and the same time that he is running a theatrical company, that he is the Prince of Wales, and that he is the Almighty. Moral perversion is a common symptom, and the patient is often guilty of criminal assaults, indecent exposures, bigamous marriages, and the like. It is accompanied with progressive bodily and mental decay. Women are comparatively rarely affected by it, and it generally commences in men about middle age, and its duration is from a few months to three years. It is commonly parasyphilitic in origin. Paralytic symptoms first appear in the tongue, lips, and face; the speech becomes thick and hesitating. The paralytic symptoms gradually go on increasing, the sphincters refuse to act, and death may occur from suffocation and choking. Sometimes, during the earlier stages especially, there may be maniacal paroxysms or epileptic fits. The delusions remain the same throughout, the patient always expresses himself as being happy, and his last words will probably have reference to money and other absurd delusions.

When a person of hitherto blameless life is charged with an act of indecency, he should be examined for G.P.I. The condition of his prostate should also be investigated. He may be suffering from either mental or physical disease, or both (see p. 59).

XLIII.--MANIA

Under the term 'mania' are included all those forms of mental unsoundness in which there is undue excitement. It is divided into general, intellectual, and moral, and each of the two latter classes again into general and partial.

=General Mania= affects the intellect as well as the passions and emotions. Mania is usually preceded by an incubative period in which the patient's general health is affected. The duration of this period may vary from a few days to fifteen or twenty years. When the disease is established, the patient has paroxysms of violence directed against himself as well as others. He tears his clothes to pieces, either abstains from food and drink or eats voraciously, and sustains immense muscular exertion without apparent fatigue. The face becomes flushed, the eye wild and sparkling; there is pain, weight, and giddiness in the head, with restlessness.

=General Intellectual Mania=, attacking the intellect alone, is rare; but some one emotion or passion, as pride, vanity, or love of gain, may obtain ascendancy, and fill the mind with intellectual delusions.

A delusion may be defined as a perversion of the judgment, a chimerical thought; an illusion, an incorrect impression of the senses, counterfeit appearances; hence we speak of a delusion of the mind, an illusion of the senses. Lawyers lay great stress on the presence of delusions as indicative of insanity. An hallucination is a sensation which is supposed by the patient to be produced by external impressions, although no material object acts upon his senses at the time.

=Partial Intellectual Mania=, or =Monomania=, also called =Melancholia=, is a form of the disease in which the patient becomes possessed of some single notion, contradictory alike to common-sense and his own experience.

=General Moral Mania.=--This is a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the intellect, or knowing and reasoning faculties, and particularly without any insane illusion or hallucination. It is often difficult to distinguish this form of mania from the moral depravity which we associate with the criminal classes.

=Partial Moral Mania--Paranoia--Delusional Insanity.=--In this form one or two only of the moral powers are perverted. Delusions are always present, and very frequently are those of persecution. The patient's conduct is dominated by his delusion; thus murder and suicide may be committed. There are several forms:

Kleptomania, a propensity to theft; common in women in easy circumstances. Dipsomania, or Oinomania, an insatiable desire for drink. Morphinomania, a craving for morphine or its preparations. Erotomania, or amorous madness. When occurring in women this is also called Nymphomania, and in men Satyriasis. It consists in an uncontrollable desire for sexual intercourse. Pyromania, an insane impulse to set fire to everything. Homicidal mania, a propensity to murder. Suicidal mania, a propensity to self-destruction. Some consider suicide as always a manifestation of insanity.

=Insanity of Pregnancy.=--This may show itself after the third month of pregnancy in the form of melancholia. It is not recovered from until after delivery.

=Puerperal Mania.=--This form of mania attacks women soon after childbirth. There is in many cases a strong homicidal tendency against the child.

=Insanity of Lactation= comes on four to eight months after parturition, either as mania or melancholia. The mother may repeatedly attempt suicide.

=Mania with Lucid Intervals.=--In many cases mania is intermittent or recurrent in its nature, the patient in the interval being in his right mind. The question of the presence or absence of a lucid interval frequently occurs where attempts are made to set aside wills made by persons having property. In these cases the law, from the reasonableness of the provisions of the will, may assume the existence of the lucid interval. A will made during a lucid interval is valid. When an attempt is made to set aside the provisions of a will on the ground of insanity in a person not previously judged insane, the plaintiff must show that the testator was mad; when the provisions of the will of a lunatic are attempted to be upheld, the plaintiff must show that the will was made during a lucid interval.

A testator is capable of making a valid will when he has (1) a knowledge of his property and of his kindred; (2) memory sufficient to recognize his proper relations to those about him; (3) freedom from delusions affecting his property and his friends; and (4) sufficient physical and mental power to resist undue influence. The fact of a man being subject to delusions may not affect his testamentary capacity. He may believe himself to be a tea-kettle, and yet be sufficiently sound mentally to make a valid will.

=Undue Influence.=--Persons of weak mind or those suffering from senile dementia are often said to have been unduly influenced in making their wills, and subsequently their dispositions are disputed in court. Before witnessing the will made by such a person, the medical man should satisfy himself that the testator is of a 'sound disposing mind.' This he will do by questioning, and his knowledge of the home-life of the patient will either confirm or set aside the idea of influence.

A person who is aphasic may be competent to make a will. He may not be able to speak, but may understand what is said to him, and may be able to indicate his wishes by nods and shakes of the head. Ask him if he wishes to make a will, then inquire if he has L10,000 to leave, then if he has L100, and in this way arrive approximately at the sum. Then ask him if he wishes to leave it all to one person. If he nods assent, ask if it be to his wife or some other likely person. If he wishes to divide it, ascertain his intention by definite questions, and, having ascertained his views, commit them to writing, read the document over to him, and ask if it expresses his intentions. That being settled, a mark which he acknowledges in the presence of two witnesses, preferably men of standing, will constitute a valid document.

In certain forms of neurasthenia, the 'phobias' are common, but must not be regarded as evidence of insanity. 'Agoraphobia' is the fear of crossing an open space, 'batophobia' is the fear that high things will fall, 'siderophobia' is the fear of thunder and lightning, 'pathophobia' is the fear of disease, whilst 'pantophobia' is the fear of everything and everybody.

=Epilepsy in Relation to Insanity.=--The subjects of this disease are often subject to sudden fits of uncontrollable passion; their conduct is sometimes brutal, ferocious, and often very immoral. As the fits increase in number, the intellect deteriorates and chronic dementia or delusional insanity may supervene. (1) Before a fit the patient may develop paroxysms of rage with brutal impulses (preparoxysmal insanity), and may commit crimes such as rape or murder. (2) Instead of the usual epileptic fit, the patient may have a violent maniacal attack (masked epilepsy, epileptic equivalent, psychic form of epilepsy). (3) After the fit the patient may perform various automatic actions (post-epileptic automatism) of which he has no subsequent recollection. Thus the patient may urinate or undress in a public place, and may be arrested for indecent exposure. Epileptics who suffer from both petit and grand mal attacks are specially liable to maniacal attacks. Such insanity differs from ordinary insanity in its sudden onset, intensity of symptoms, short duration and abrupt ending. To establish a plea of epilepsy in cases of crime, one must show that the individual really did suffer from true epilepsy, and that the crime was committed at a period having a definite relation to the epileptic seizure.

=Alcoholic Insanity.=--This may occur in three forms:

1. Acute Alcoholic Delirium (mania a potu), due to excessive amount of alcohol consumed.

2. Delirium Tremens, due to long-continued over-drinking. The patient suffers from horrible dreams, illusions, and suspicions, which may lead him to attack people or commit suicide.

3. Chronic Alcoholic Insanity. Loss of memory is the chief symptom, with paralysis of motion, hallucinations and delusions of persecution.

=Responsibility for Criminal Acts.=--To establish a defence on the ground of insanity, it must be proved that the prisoner at the time when the crime was committed did not know the nature and quality of the act he was committing, and did not know that it was wrong. At the present time, however, the power of controlling his actions is usually made the test.

The plea of insanity is brought forward, as a rule, only in capital charges, so that the prisoner, if found guilty, will escape hanging. If proved 'guilty, but insane,' the person is sentenced to be kept in a criminal lunatic asylum 'during His Majesty's pleasure.'

XLIV.--EXAMINATION OF PERSONS OF UNSOUND MIND

The following hints with regard to the examination of patients supposed to be insane will be useful: The general appearance and shape of head, complexion, and expression of countenance, gait, movements, and speech, should be noted; the state of the general health, appetite, bowels, tongue, skin, and pulse, should be inquired into; and in women the state of the menstrual function should be ascertained. The family history must be traced out, and the personal history taken with care, especially as to whether the unsoundness came on late in life or followed any physical cause. Ascertain whether it is a first attack, whether the patient has suffered from epilepsy, has squandered his money, grown restless, has absurd delusions, etc. In order to ascertain the capacity of the mind, questions should be asked with regard to age, birthplace, profession, number of family, and common events, such as the day of week, month, and year. The power of performing simple arithmetical operations may be tested. It may be necessary to pay more than one visit. The examiner should be careful to ask questions adapted to the station of life of the supposed lunatic; a man is not necessarily mad because he cannot perform simple arithmetical operations, or does not know about things with which his questioner is well acquainted. The opinion of a supposed lunatic that his examiner's feet were large was not considered by the Commissioners among the facts indicating insanity, yet statements quite as absurd are made by medical men as 'facts of insanity' observed by themselves. 'Reads his Bible and is anxious about the salvation of his soul' is another example of a bad certificate. Some well-marked delusion should be recorded.

For a lunacy certificate (Reception Order on Petition or Judicial Reception Order), except in the case of a pauper patient, there are required the signatures of two independent medical men and of a relation or friend. The medical men must not be in partnership or in any way interested in the patient; they must make separate visits at different times, and write on the proper forms the facts observed by themselves and those observed by others, giving the name of the informer. A certificate is valid only for seven days. In very urgent non-pauper cases the signature of one medical man is sufficient, but such certificate (Emergency Certificate or Urgency Order) is only valid for two days, and, as the patient can only be detained in the asylum under this order for seven days in England or three in Scotland, it must be supplemented by another signed as above directed. The medical certificate must contain a statement that it is expedient for the alleged lunatic to be placed forthwith under care, with reasons for making such statement. The certifying medical practitioner must have personally examined the patient not more than two clear days before his reception. In London and other large towns, where an expert opinion is readily obtainable, it is not expedient to resort to such urgency orders. Medical men should be careful how they sign certificates of insanity. No medical man is bound to certify, but if he does so he must be prepared to take the responsibility of his acts. There must be no reasonable ground for alleging want of 'good faith' or 'reasonable care.' The practitioner must exercise that amount of care and skill which he may reasonably be expected to possess.

XLV.--THE INEBRIATES ACTS

It is somewhat difficult to define an inebriate, but for the moment the following will suffice, and will ultimately, in all probability, be officially adopted:

An inebriate is a person who habitually takes or uses any intoxicating thing or things, and while under the influence of such thing or things, or in consequence of the effects thereof, is--(a) dangerous to himself or others; or (b) a cause of harm or serious annoyance to his family or others; or (c) incapable of managing himself or his affairs, or of ordinary proper conduct.

Under the provisions of the Habitual Drunkards Acts (42 and 43 Vict., c. 19, and 51 and 52 Vict., c. 19), any habitual drunkard may voluntarily place himself under restraint. He must make an application to the owner of a licensed retreat, stating the time during which he undertakes to remain. His application must be accompanied by a statutory declaration of two persons stating that they knew the applicant to be a confirmed drunkard. Without this testimony as to moral character his application cannot be entertained. His signature must also be attested by two justices, who must state that he understands the effect of his application, and that it has been explained to him. The limit to the term of restraint is twelve months, after which he must resume his former habits if he wishes to qualify for another period. The Act works automatically, and, when it has been set for a certain time, the patient cannot release himself until the period has expired. The Inebriates' Retreat must be duly licensed, and the licensee incurs distinct obligation in return for the powers entrusted to him. It is an offence against the Act to assist any habitual drunkard to escape from his retreat, and should he succeed in effecting his escape he may be arrested on a warrant. A drunkard who does not obey orders and conform to the rules of the establishment may be sent to prison for seven days. It may be as well to mention that it is an offence to supply any drunkard under the Act with any intoxicating drink or sedative or stimulant drug without authority, and that the penalty is a fine of L20 or three months' imprisonment. The Act is a good one, but might be carried farther with advantage. It has been ruled that a crime committed during drunkenness is as much a crime as if committed during sobriety. A person is supposed to know the effect of drink, and if he takes away his senses by drink it is no excuse. He is held answerable both for being under the influence of alcohol or of any other drug, and for the acts such influence induces.

=Inebriates Act= (1898-1900).--If an habitual drunkard be sentenced to imprisonment or penal servitude for an offence committed during drunkenness, or if he has been convicted four times in one year, the court may order him to be detained for a term not exceeding three years in an inebriate reformatory.