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By William Thorburn, B.S., B.Sc, M.D., Assistant-Surgeon to the Manchester Koyal Infirmary. 1.2s. 6d. The Surgery Of the Kidneys, being the Harveian Lectures for 1889. By .1. Knowsi.f.y rHORNTOK, M.K.. M.< '.. Surgeon to the Samaritan Free Hospital. &c. 5s. %* Volumes on other Subjects in active preparation. An Illustrated List of the Series post free on application. London: CHAS. GRIFFIN k CO., Ltd., Exeter Street, Strand. E b Oxyha moglobin. obin Reduced Hcemogldbin need Hcematin CO Haemoglobin CO Hemoglobin & Reduced Haemoglobin Blood Spectra .-lsson&C (Xr FORENSIC MEDICINE AND TOXICOLOGY. J. DIXON MANN, M.D., F.R.C.P., PROFESSOR OK MEDICAL JURISPRUDENCE AND TOXICOLOGY IN OWEN'S COLLEGE, MANCHESTER : EXAMINER IN FORENSIC MEDICINE IN THE UNIVERSITY OF LONDON, AND IN THE VICTORIA UNIVERSITY: PHYSICIAN TO THE SALFORD ROYAL HOSPITAL. LONDON: CHARLES GRIFFIN & COMPANY, LIMITED, EXETER STREET, STRAND. 1893. [All Rights Reserved.] T fa3 w PEEFACB This work has been written chiefly as a Text-Book for Students of Medicine; it is hoped that it may also prove useful to Prac- titioners and others who are interested in the subject of Forensic Medicine. Since Medical Practitioners in general acquire much of their expert medico-legal knowledge from the study of reported cases, no pains have been spared in the selection, from a wide field of English and Foreign periodical literature, of typical examples illustrative of the subjects dealt with. The section on Toxicology has been arranged with a view- to simplicity and convenience of reference rather than to the attainment of an ideal classification. I have to thank my friend and colleague Professor A. H. Young for valued assistance and advice on anatomical and morphological subjects. In addition to the authorities referred to in the text, the following works have been consulted : — Spiegelberg's Lehrbuch der Geburtshiilfe ; Holmes and Hulke's System of Surgery; Dixon's Law, Practice, and Procedure in Divorce; Brunton's Pharmacology, Therapeutics, and Materia Medica, and Dragen- dorff's Ermittelung von Giften. J. DIXON MANN. Owens College, Manchester, April, 189S. CONTENTS. PART I.— FORENSIC MEDICINE. ill WTKK I. — Introduction, Coroner's Court, Assizes, . H. — Medical Evidence, Oral and Documentary. III. — Legal Procedure in Scotland, IV. — Examination of the Dead Body, V. — Age in its Medicodegal Relations, VI. — Modes of Dying, .... VII.— Signs of Death, .... VIII. — Personal Identity, IX. — Blood and other Stains, X. — Identity of the Dead, XI. — Sexual Abnormalities, . XII. — Rape and Unnatural Offences, XIII. — Signs of Pregnancy and of Delivery, XIV. — Criminal Abortion, XV. —Infanticide, ..... XVI. — Birth in Relation to the Civil Law, XVII. —Life Assurance, .... XVIII. — Medicodegal Bearings of Divorce, XIX.— Modes of Death resulting chiefly from Asphyxia, XX.— Death from Extremes of Temperature and from Lightni XXI. — Death caused by Burns and Scalds, XXII. — Mechanical Injuries and Wounds, . XXIII. — Starvation, PAGES 1-7 7-ir, 15-17 17-21 •21-32 33-36 36-58 58-63 63-72 72-7S 78-88 S9-112 112-119 119-129 130-166 166-177 17S-182 182-185 185-232 233-242 242-255 256-309 309-315 PART II. INSANITY. XXIV. — Types and Medicodegal Bearings of Insanity, 316-380 PART III.— TOXICOLOGY. XXV. — Poisons in their General Aspect, XXVI. — Corrosive Poisons, . XXVII. — Metallic Irritant Poisons, XXVIII. — Non-metallic Elements, XXIX. —Gaseous Compounds, XXX.— Alcohols, .... XXXI. — Benzene and its Derivatives, . XXXII. — Alkaloids and Vegetable Poisons. XXXIII. — Animal Poisons, . 3S 1-406 407-422 423-470 476-491 491-507 507 521 522-540 540-611 612-622 PART L— FORENSIC MEDICINE. CHAPTER I. INTRODUCTION— CORONER'S COURT— ASSIZES. Forensic Medicine is a many-sided subject. A knowledge of it demands more or less acquaintance with medicine in all its branches, and with the collateral sciences. It has been said that any medical practitioner who lias a fair knowledge of his profession only requires common sense to qualify him as a medical jurist. This is a specious but fallacious statement. A knowledge of surgery, or of obstetrics, for example, limited to that required for the relief of suffering would be of little use in unravelling many of the complex questions with which the medical jurist has to deal, although the branches of medicine named may be those which are appealed to for that purpose. Much of the knowledge and skill possessed by the surgeon is useless to the medical jurist, and that knowledge of a surgical character which is important to the medical jurist is all but useless to the surgeon. Take the case of a wounded man: the surgeon examines the wound in order to determine the best treatment for its cure. To him it is of minor moment as to whether the wound was self-inflicted or not, or as to whether it might have been produced by a certain weapon, or could not have been thus produced. The attention of the medical jurist, on the other hand, is chiefly directed to these points. Something more is required for forensic purposes than a knowledge of the various departments of medicine in relation to the healing of the sick, and this additional knowledge cannot be replaced by common sense ; it necessi- tates special training. If a medical man were to commence his career as a medical jurist with no other preparation than a knowledge of medicine and surgery and the allied sciences solely as regards the art of healing, without being acquainted with the connecting links by which 1 2 FORENSIC MEDICINE. they are made subservient to forensic practice, he would inevitably overlook those features of a case which, correctly interpreted, yield the required information. A many-sided subject like forensic medicine has this disadvantage : it has no real starting-point. At whatever point the writer begins, he is conscious of assuming the possession of knowledge on the part of the reader which has not yet been imparted, and further, the sequence of subjects is determined by convenience rather than by evolution, many of them being simply grouped together without inter-relation. It is customary to commence with a description of the modes of pro- cedure in the courts of law, and of the duties, and the obligations of medical witnesses. This, in most respects the most convenient plan, will now be adopted, and, following the usual mode of procedure in criminal cases, the first court to claim attention is — THE CORONERS COURT. The office of Coroner has existed from very early times. Formerly it was of much dignity and importance, and entailed the fulfilment of many duties now in abeyance. At the present time, the chief duties of the coroner are to enquire into the cause of death in those cases in which there is reason for doubting that death resulted from natural causes. In the ordinary course of events, when death occurs from natural causes and under ordinary conditions, the medical attendant certifies as to the cause of death; this he is bound to do under a penalty of forty shillings. Such a certificate signed by a duly qualified and registered medical practitioner, together with oral evidence o-iven by a person present at the time of death, is accepted by the registrar of deaths, who issues a certificate authorising the interment of the deceased. If, however, there is reason to doubt the naturalness of the cause of death, or if death resulted directly or indirectly from an accident, or injury, the medical attendant should not certify ; the case should be referred to the coroner. A heavy responsibility thus devolves on the medical practitioner : on the one hand he is bound under a penalty to certify to the cause of death, and on the other he renders himself liable — under certain contingencies — to censure, and possibly to legal proceedings, if he does so. If a medical atten- dant has reasonable grounds for suspicion that the death of his patient did not result from natural causes, he should decline to certify, and should communicate with the coroner, or the police authorities. The second reason for declining to certify — death resulting from or after an accident — not unfrequently brings medical practitioners un- THE CORONERS COl'RT. 6 wittingly into collision with the coroner. There are two ways in which this may occur: — When death takes place at a remote period after the occurrence of the accident, especially when intercurrent dis- ease — such as an attack <>f acute bronchitis — is the ultimate cause of death. In such a case the medical attendant naturally regards the disease, and not the accident, as the cause of death, and certifies accordingly. The second way in which a medical man may inadver- tently place himself in the power of the coroner is by certifying the death of a patient who suffered from some chronic, but ultimately fatal, malady, in the course of which an accident not directly affecting life — such as fracture of one of the bones of a limb — happens to the sick person. Death may not occur for several weeks after the accident, and the medical attendant certifies as though it had not happened. In both these instances the coroner should be informed in place of giving a certificate. It frequently happens in such cases that pressure is brought to bear on the medical attendant to induce him to certify, and thus spare the deceased's family the publicity of an inquest. It is to be borne in mind, however, that a worse thing may happen to the relatives than an ordinary inquest. If a certificate is given, and it is accepted by the registrar with the result that interment takes place in due course, the coroner, on hearing of the matter, may order the body to be exhumed for the purpose of holding an inquest over it. Many coroners, on receiving information of the death of an individual under suspicious circumstances, after satisfying themselves — as a rule, by hearsay evidence obtained through their officer or other policeman — as to the absence of criminal causation, or other reason for holding an inquest, intimate to the registrar that he may authorise interment without an inquest being held. This is not strictly in accordance with the law, which provides, that, " except upon holding an inquest, no order, warrant, or other document for the burial of a body shall be given by the coroner." (50 and 51 Vict.) When a coroner is informed that the dead body of a person is lying within his jurisdiction, and there is reasonable cause to suspect that such person has died either a violent or an unnatural death, or has died a sudden death, of which the cause is unknown, or that such a person has died in prison, the coroner shall summon a jury of not less than twelve, nor more than twenty-three, men to enquire touching the death of such persons aforesaid. When it appears to the coroner that the deceased was attended at his death, or during his last illness, by any legally qualified medical practitioner, the coroner may summon such practitioner as a witness. If the deceased was not so attended in his last illness, the coroner may summon any legally qualified medical practitioner in actual practice, in or near the place where the death happened, to give evidence as to cause of death. In cither case the medical witness may be required by the coroner to make a post-mortem examination of the body, with or FORENSIC MEDICINE. without analysis of the contents of the stomach or intestines. If, how- ever, anyone states on oatli before the coroner that, in his belief, the death of the deceased was caused partly or entirely by the improper or negligent treatment of a medical practitioner, such medical practitioner shall not make nor assist at the post-mortem. If a majority of the jury are not satisfied with the medical evidence, they may require the coroner, in writing, to summon some other legally qualified medical practitioner named by them to make a post-mortem examination (whether a post- mortem examination has been previously made or not) with or without analysis of contents of stomach or intestines, and to give evidence as to cause of death. With such a requisition the coroner is bound to comply. "Where a medical practitioner fails to obey a summons of a coroner issued in pursuance of the Coroner's Act, he shall, unless he shows good and sufficient cause for not having obeyed the same, be liable to a fine not exceeding five pounds. It will be seen from the above paragraph, which is a condensed quo- tation from the Coroner's Act (50 and 51 Vict.), that no restriction is placed on the coroner as to whom he shall summon as a medical witness, beyond the definition " a legally qualified medical practitioner in actual practice in or near the place where the death happened." This con- stitutes a serious defect in the present legal mode of investigating the cause of death in suspicious cases. For the efficient performance of the duties involved, it is obvious that the medical man who gives evidence as to the cause of death in cases demanding careful and skilled investigation should be a person experienced in such duties ; to select the practitioner nearest at hand is by no means the way to secure this. A medical man occupied in general practice has neither time nor opportunity to acquire the neces- sary skill and experience. It is desirable in the interest of justice, that special pathologists should be appointed in various parts of the country, whose duty it should be to make the necessary investiga- tions on the bodies of those whose mode of death is the subject of legal enquiry. Until this is done, any medical man is liable to be summoned by the coroner to undertake this very special duty. A further defect in the Coroner's Act consists in requiring the medical practitioner to make an analysis of the contents of the stomach if necessary. This is obviously the result of ignorance on the part of the framer of the Act as to the functions of a practitioner of medicine and, probably, also as to the nature of "an analysis." The isolation and identification of a poison which is combined with a relatively large amount of organic matter, is a task sufficiently exacting for the expert chemist, and should never have been allotted to an ordinary medical practitioner. It is always understood, notwithstanding the wording of the summons, that the duty of the medical practitioner is limited to m iking the post-mortem examination, and to removing and securing magistrates' court. 5 in .appropriate vessels, with precautions which will subsequently be described, the parts selected for analysis. The coroner has it in his power to obtain the services of a chemical expert, to whom the sub- stances destined for analysis arc sent. The medical witness should remember that almost all the criminal cases which attain the notoriety of causes celebres are initiated in the Coroner's Court, and that the evidence he there gives may subsequently be subjected to the keenest scrutiny, by subtle intellects specially trained for the purpose. The fact that the majority of the cases which come before the Coroner's Court end there, too often conduces to care- lessness on the part of the medical witness in the preparation of the evidence he is about to give. Trusting to the impulse of the moment, he expresses opinions which he subsequently regrets having uttered. All statements there made are committed to paper in the form of depositions, to which the witness appends his signature; copies of these depositions are in the hands of both judge and counsel when the case comes before the assizes. The object of a coroner's inquest is to ascertain whether the indi- vidual over whose body the inquest is held died from natural causes or not. As the proceedings are not directed against any one — that is, no one is being tried — it is not necessary that a suspected person should be present. Witnesses are not subjected to cross- examination by counsel, the coroner and the jury alone have the right to interrogate them. Occasionally, as in fatal railway accidents, counsel representing the railway company, or a servant of the company who is supposed to be responsible for the occui'rence of the accident, is present at the inquest. The counsel is present in the interest of his client, but not as his defender. He has no locus standi and can only question a witness by permission of and through the coroner. The Coal Mines Regulation Act of 1887 provides for the examination of witnesses by counsel representing persons whose interests are affected, subject nevertheless to the order of the coroner. The procedure in the Coroner's Court is very simple. "Witnesses are examined on oath, their evidence is recorded, and in event of further proceedings being taken, they are bound under a pecuniary penalty to appear at the superior court to which the case is transferred. If the evidence is incomplete, and there is a prospect of additional evidence forthcoming, the coroner may adjourn the inquest. MAGISTRATES' COURT. Another preliminary court of enquiry is the Magistrates' Court of Petty Sessions. In this court the proceedings take the form of G FORENSIC MEDICINE. an investigation as to the culpability or non-culpability of a person accused of some act of criminality, or negligence of a criminal nature. As it is now ;i question <>f guilt or innocence, the accused person must be present ; for the same reason witnesses may be examined and cross-examined by counsel; if no arrest has been made the magisterial investigation cannot take place. Unimportant cases — such as simple assaults — may be dealt with summarily. In cases of suspected manslaughter or murder it frequently happens that the magisterial investigation is held immediately after the inquest, and the medical witnesses who have there appeared are called upon to repeat their evidence before the magistrates. If the evidence is deemed sufficiently conclusive of culpability the prisoner is committed for trial to a superior court, the witnesses being bound over to appear- there and give evidence. The summons to attend at the assizes is called a subpoena, which every witness in a criminal case is bound to obey when tendered with reasonable travelling expenses. The relative obligations of common and expert witnesses will be subsequently discussed. ASSIZES. The Assizes are courts in which both criminal and civil cases are tried. Usually two judges are present ; one presides over the Crown Court, where the criminal cases are tried ; and the other over the Civil Court, where suits between two individuals or parties are tried. It is with the former we are at present concerned. Before a case that has been sent up for trial from a lower court can come before the judge and petty jury, it undergoes an investigation by the grand jury. The function of the grand jury is to ascertain whether the cases brought before it are proper cases to go to trial. This the grand jurymen do by hearing the evidence of such witnesses as they think fit, without the intervention of counsel. If they are satisfied that a case should go before the judge and petty jury they find a " true bill ; " if not, they " cut the bill " — that is, they quash the proceedings and the accused is discharged. Medical witnesses under subpoena may be required to give evidence before the grand jury. The Crown Court of Assize is constituted by a judge and a sworn jury of twelve men who are called the petty jury. The duty of the petty jury is to hear the evidence, and, guided by the summing up of the judge, to deliver a verdict by which the prisoner is found guilty or not guilty. The judge receives the verdict, and when it is one of guilty, allots the punishment he deems adequate. Before Courts of Assize barristers only can plead. In the Magistrates' Courts of Petty Sessions both barristers and solicitors can plead. ASSIZES. I The evidence of witnesses in Courts of Assize is delivered in the following manner : — First comes the examination-in-chief. This con- sists of a series of questions put to the witness by the counsel who represents the side on which the witness appears. Previously in- formed by the statements contained in his brief, which consists of a full account of the case prepared by the solicitor who has charge of it, the counsel interrogates the witness so as to place before the court a clear account of all that the witness knows with regard to the case. Frequently many successive questions are so couched that they can be answered by simple negatives or affirmatives. "When the examination-in-chief is concluded, a counsel for the opposite side cross-examines the witness. The object of the cross-examination is to lessen the value of the previously given evidence so far as it is adverse to the cross-examiner's client. Evidence is rarely, if ever, of uniform value. It is like a chain, some of the links of which are strong, others are weak. The object of the examiner-in-chief is to place the strong links in a high light and to keep the weak ones in obscurity. The cross-examiner re- verses the process, placing the strong links in the back ground, and bringing out to the fullest the unreliability of the weaker links. Proportionally to his success is the force of the evidence reduced. After the cross-examination, the counsel on the same side as the witness may re-examine him. The object of re-examination is to put straight any part of the evidence that has been distorted by cross- examination, and to clear up doubtful points. An observant counsel will have noticed any answers given by the witness during cross- examination which were inconclusive or ambiguous, and will put such questions as will enable the witness fully to explain his meaning. In the re-examination the counsel may not introduce any new matter unless by permission of the judge, and, if allowed to do so, a supple- mentary cross-examination on the new matter may be made. It is competent for the judge and the members of the jury to question witnesses. The procedure in the other higher courts of justice are conducted on the same lines as those described. CHAPTER II. MEDICAL EVIDENCE ORAL AND DOCUMENTARY. Evidence may be of two kinds: — (1) Evidence as to facts that have come under the observation of the witness; (2) evidence as to the 8 FORL.NSIC MEDICINE. interpretation of facts, founded on a knowledge possessed by the witness of a sp< ciaJ subject. Witnesses of the first kind are called "common witnesses;" those of the second are known as "expert witnesses." The Common Witness, or witness to facts.— A medical man acts as a comm. in witness when he gives evidence as to the condition of a wounded person examined by him. In such a case his duty is to describe the nature of the wounds, the general condition of the patient, and other circumstances that he observed at the time he made the examination. A common witness is obliged to give evidence if legally summoned to do so. The Expert Witness.— When giving evidence solely as an expert, the witness acts as an interpreter of facts without having personal know- ledge of them. Usually, a medical witness acts both as a common and as an expert witness, his skilled or expert opinion being founded on facts that he himself has observed. To continue the illustration above given of the duties of a common witness :— After describing the actual condition of the wounded person he may be asked if the wound was of such a nature as to be dangerous to life. In answering this question the witness is no longer giving evidence to facts; he is acting as an expert, and thus combining the functions of a common and an expert witness. Before giving purely expert evidence — that is, evidence founded on facts of which he has no personal cognisance —it is necessary that the witness should have heard the facts on which he expresses an opinion stated on oath before the court. The obligations of the expert witness are not so easily defined as those of the common witness. Hypothetically the knowledge possessed by an expert, who has no personal acquaintance with facts relating to a given case, is his own property, and, therefore, he ought not to be obliged to part with it against his will. This view has been taken by more than one judge. Lord Campbell ruled that a scientific witness was not bound to attend on being served with a subpoena. Justice Maule ruled that an expert is under no obligation to give evidence before a court of law. Unfortunately for experts the difference of opinion with which they are proverbially accused pervades the judicial bench. Other judges have ruled that wilful neglect of a properly served subpoena constitutes contempt of court. In the face of decisions so adverse it is difficult to determine what the law on the subject really is. It is probable that an expert who had no personal acquaint- ance with a case might neglect a subpoena without rendering himself liable to attachment for contempt of court, but he might render himself liable to an action for damages. Such an action, though futile so far as obtaining a verdict goes, would subject the defendant to much trouble and to some pecuniary loss in defending it. Having regard to MEDICAL EVIDENCE. U the uncertainty of the results the safest course would be to obey the subpoena under protest. Previous personal knowledge of the facts of a case preclude a witness from taking any possible advantage of the status of an expert witness. There is no doubt as to the obligations of a witm situated;- he must obey a subpoena in his capacity as a common witness, although the evidence he is going to give may be of an expert character. Professional Secrets. — It is an honourable law of the medical pro- fession that confidential statements made by a patient to a medical adviser are held to be inviolable secrets. In a court of law this i n \ i( liability is overruled; a medical witness, if asked, is bound to reveal any secrets that have come to his knowledge whilst in atten- dance on a patient. However repugnant it may be to the feelings of a medical man to violate the confidences of the consulting-room, he has no option. If, when in the witness-box, he refuses to answ er a question involving the betrayal of a secret which is really the property of his patient — it having been revealed to him in trust and under the conviction of absolute confidence — he renders himself liable to com- mittal for contempt of court. It is conceivable that a medical man might feel the obligation to secrecy so great as to compel him to decline to answer a question involving betrayal of the confidence of his patient. Such a step, however, should not be taken without a pro- found conviction of duty. A good citizen obeys the law, although he may have scruples in doing so; therefore, a witness should not set his private judgment against authority without very searching self inquiry; an obstinate conviction must not be mistaken for a sense of duty. In the majority of cases it will probably be com- patible with his sense of duty, if the witness enters a protest against answering the question and then bows to the requirements of the law. When giving evidence, the witness may refresh his memory by referring to notes made by him at the time of, or immediately after, the events or proceedings to which he is testifying. Such notes must have been written by himself and must be the original copy; he must not copy the original notes and use the copy in the witness-box, or, if he does so, he must keep the rough copy so that it may be compared with the transcript, the two must agree word for word. It is much better to use the original notes, and thus save explanation and discussion. In using notes in the witness-box, the witness is only allowed to refer to them from time to time in order to refresh his memory for figures, dates, names of persons, or of places, &c. ; he may not read his notes in consecutive sentences. The law requires 10 FORENSIC MEDICINE. that the evidence tendered by a witness in court, should be oral and not documentary. In the course of a trial it is not unusual for a counsel to quote from a text-book on forensic medicine, or from some other book containing matter germane to the question at issue. If the witness disagrees with the quotation it is well for him to ask to be allowed to look at the book ; possibly by reading the context he may find that the difference of opinion is only apparent; in any case, before accepting or denying a quotation, the meaning of which he does not fully com- prehend, it is advisable for the witness to read the passage himself. A book should not be quoted if the author is living. The objection is founded on the principle that evidence should be oral and delivered on oath in the witness-box, so that the giver of it may be cross- examined; this of course is impossible if the author is dead, and, therefore, his writings are admissible. The witness himself should not quote authorities to substantiate his opinions unless asked ; the opinions he expresses are supposed to be the outcome of his own knowledge and experience. Medical and expert witnesses are usually allowed to be present in court whilst the trial in which they are going to give evidence is proceeding. It is often absolutely necessary for the expert to become acquainted with the evidence tendered by the witnesses to fact seeing that the opinions he forms are founded on this evidence. Merely having a transcript of the evidence delivered by the witnesses to fact read to him, in place of hearing it delivered, is liable to lead to error of inter- pretation on the part of the expert. Further, if the evidence to a certain fact is lacking in some detail which is necessary to be brought out in order to arrive at a correct conclusion, the expert witness, if in court, has the opportunity of communicating with his counsel so that questions may be asked and the doubtful point cleared up. A few words as to the giving of evidence before courts of law will be of assistance to the inexperienced medical witness. One of the most important points to remember is that, although the medical witness to a great extent deals with technical matters, he is addressing an audience which may be regarded as ignorant of technical terms. The judge and the counsel, although men of the highest intelligence and education, are not for the most part versed in the technical expressions by which medical men are accustomed to describe anatomical and pathological details. The medical witness has only to listen to lawyers discussing some point of law to appreciate the difficulty interposed to members of another profession by the use of technical words and phrases. If the judge and bar are not in a position to follow medical evidence couched in technical terms, much less are MEDICAL EVIDENCE. 11 the jury — men of very ordinary intelligence and education— able to do so. The description of an injury which would be perfectly suitable if given before a medical society might be just as unsuitable if delivered in the witness-box. The avoidance of technical terms necessitates a good deal of paraphrasing, as such terms are u< sarily the most concise in which the speaker can convey his thoughts. It is obviously more convenient to speak of the "peritoneum' 3 than to say "the membrane that covers the bowels;" but the latter ex- pression would, and the former would not, convey information to the occupants of the jury-box. It may be received as an axiom that it is absolutely necessary for a medical witness so to express himself that anyone of ordinary intelligence can understand him. Next in importance to the avoidance of technical expressions is the avoidance of superlatives and hyperbole. All evidence should be given with exactitude and without any attempt at dramatic effect : the stj Le to aim at is a matter-of-fact style. Every object or condition should be described in the simplest terms consistent with perspicuity. As already stated, many of the questions asked require simply affirmative or negative responses. When a long string of such questions is asked there is often a tendency on the part of the witness to anti- cipate one or more of the succeeding questions which he divines are coming. This draws upon him a sharp reproof from the counsel, who has planned his interrogations and means to follow them out in his own way. If a witness is doubtful about the answer to a question it is better to say frankly that he does not know than to seek to escape the diffi- culty by giving an ambiguous answer. When a counsel insists on "yes or no" to a question that the witness feels cannot be properly so answered, he should ask to be allowed to qualify his answer, always avoiding such appeals unless the obligation of the oath he lias taken to tell "the whole truth" is in danger of being violated. No witness is required to answer a question if the answer would incriminate him. All answers should be uttered in a sufficiently audible voice as to reach the judge and the jury, and sufficiently slowly as to enable the former to take notes. A witness should avoid a reserved or defiant manner, as though giving evidence under protest. Questions relating to facts should be promptly answered, those involving interpretation of facts demand caution. Too ready acquiescence should not be given to an apparently careless inquiry which half assumes the answer. A guarded reply to a question the answer to which involves a certain amount of discrimination is equally desirable as is a frank and open reply to a question relating to a fact observed by the witness. FORENSIC MEDICIXK. FEES ALLOWED TO MEDICAL WITNESSES. Coroner's Court.— The Coroner's Act states that the fees for medical witnesses attending an inquest shall be: — For attending to give evidence at any inquest whereat no post-mortem examination has been made by the witness, one guinea. For making a post-mortem and attending to give evidence, two guineas. No fee shall be paid to a medical practitioner for making a post-mortem without the previous direction of the coroner. No extra fees are provided for if the inquest is adjourned. When an inquest is held over the body of a person who has died in a lunatic asylum, or in a public hospital, infirmary, or other medical institution, whether supported by endow- ments or by voluntary contributions, the medical officer of such institution shall not be entitled to any fee. It has been recently decided that workhouse infirmaries are included in this classification. If the dead body of a person is brought into a hospital or other public institution, and the medical officer of that institution is summoned to give evidence, he is entitled to the usual fee. The Act provides that immediately after the termination of the inquest the coroner shall pay the medical witness his fee. Magistrates' Court.— If the witness resides within three miles of the Court, ten shillings and sixpence ; if at a gi-eater distance, one guinea. Assize Court. — One guinea per day, with two shillings for every night away from home, and second class railway fare, or threepence a mile each way if there is no railway. Sundays are not counted. Court of Probate and Divorce. — One guinea per day if resident within five miles of the General Post Office ; if at a greater distance, two or three guineas per day, with expenses out of pocket in coming and l'eturning. Court of Appeal. — One guinea if resident in London ; two or three guineas if from a distance, with reasonable travelling expenses. In civil cases an arrangement is usually made with the solicitor as to the amount of fee before accepting the subpoena. In default of this, if the witness has not received what he deems a reasonable fee, he may appeal from the witness-box before being sworn; after taking the oath objections are futile, he is bound to give evidence. It is well to have a written agreement from the solicitor binding him to pay the fee, otherwise he is not responsible, and may refer the witness to his client, which often means loss of the fee. If a witness is summoned to attend at two Courts at the same time, he must obey the summons to the higher Court. If one summons is for a Criminal Court and the other for a Civil Court, that for the Criminal Court must have the preference. A. DOCUMENTARY EVIDENCE. 13 DOCUMENTARY EVIDENCE. Documentary evidence includes dying declarations and medicodegal reports. A dying declaration is a record of the evidence given by a person | who is dying, or who believes that he is dying, from the results of an injury sustained, or a poison administered, at the hands of some person or persons. For a dying declaration to be valid it is necessary that the person who makes it should feel convinced that he is about to die. It is further necessary that this should be definitely stated in the written declaration. As the individual is incapable of writing down his deposition it is taken by a second person, and this duty may devolve on a medical man. If the condition of the patient, thouerh critical, is such as to permit of a short delay, the police should be in- formed ; it is their duty to secure the attendance of a magistrate, who will take down the declaration. In such a case all that the medical practitioner has to do, if required, is to pronounce as to the mental fitness of the deponent to make the declaration. Should the condi- tion of the dying person be such that there is not time to procure the attendance of a magistrate, the medical attendant himself must write down the declaration. In doing this the following rules should be observed : — If possible, the attendance of one or more intelligent per- sons should be procured to act as witnesses ; this is not necessary, but when important issues are at stake it is advisable to omit no precau- tions that can possibly be taken. The medical man should then satisfy himself that the person making the declaration is convinced that he is about to die, and the declaration should commence with a state- ment to that effect. Such a statement must be unqualified ; on one occasion the addition of two words was sufficient to invalidate a dying declaration, thus : — " No hope of my recovery at present ; " the last two words destroyed the expression of certainty that death was imminent, and the declaration was rejected at the trial. The exact n-orih uttered by the dyiny person should be written down. No questions should be asked, except such as are necessary to clear up any obscurity. The declaration should be limited to a statement of what was done to the deponent at the time the injuries were inflicted, his own actions are not relevant. When completed, the declaration should be read over to the deponent ; and, if possible, he should then append his signature. In any case, the witnesses pre- sent, together with the writer of the declaration, should sign it. In some cases death occurs so rapidly, that even the medical attendant may not be able to take down the dying man's words in writing before he dies. The duty of the medical man in such cases is 14 FORENSIC MEDICINE. to listen to anything voluntarily said by the patient, and to take an early opportunity of writing down the exact words, and signing the statement. If others were present when the words were uttered, the statement should be read over to them, and their signatures should also be appended. Considerable responsibility devolves upon medical men who are in attendance on persons who have been criminally injured and are in danger of death. No time should be lost in communicating with the police, as, apart from the occurrence of unexpectedly rapid death, the patient may become delirious or comatose. If a person who has made a dying declaration recovers, the document ceases to have any legal force. The law only admits evidence when tendered on oath : in the case of a dying person an exception is made. It is believed that an individual who is convinced that he is about to die, will feel himself equally under an obligation to tell the truth, as though he was in the witness-box, and had taken the oath. If, after making a dying declaration, the deponent recovers, he reverts to his normal condition as regards the law and must tender his evidence before the court in the usual .way. Dying declarations are not admissible in civil cases. Medico-legal reports in criminal cases are more used in Scotland than in England. A medical report is divisible into two sections : — (1) The result of the examination of the case, or, in other words, the facts that have been observed. (2) The deductions drawn from a consideration of such facts. It is absolutely necessary in a well ordered medical report that this division should be rigidly adhered to. Every fact should be recorded before the inferential part of the report is begun. Short of absolute inaccuracy, nothing vitiates a medical report so much as the mixing of facts with deductions ; first state the facts and then the conclusions drawn from them. The legal authorities for whom the report is made may know nothing of the case, and they require to become acquainted with all the facts before they are in a position to appreciate the deductions drawn from them. The facts to be observed in the l iving are limited to those which fall within the scope of medical observation. A good report, while con- taining all that is necessary, will be free from extraneous matter. Nothing should be included in a report that does not come under the personal observation of the reporter ; indirect or hearsay evidence is as much out of place in a report as in the witness-box. To avoid error of reading, all dates should be written in full. Every detail that can possibly have a direct bearing on the case should be noted ; it is impossible to foresee what questions may subsequently arise. When LEGAL PROCEDURE IN SCOTLAND. 15 making- a report concerning a dead body, everything, both as regards the body and its surroundings, should be scrupulously noted. When the autopsy is completed, and, consequently, all the available facts are, obtained, the inferential part of the report is to be undertaken. If the report refers to a living person a careful study of the facts is to be made in order to arrive at a conclusion as to the way in which an injury has been inflicted, whether the statements of the wounded person are or are not borne out by the actual condition of the injured parts. If it refers to a dead body the questions are: — How was death caused 1 Did it immediately follow the infliction of the injuries'? If not, what interval intervened? Were the injuries of such a nature as to incapacitate the deceased from moving after they were inflicted'? — with other observations to which attention will be directed when the mode of conducting a post-mortem examination for medicodegal purposes is described. The advice previously given as to oral evidence is equally applicable to documentary evidence. The language in which a report is drawn up should be free from technical terms and exaggerated expressions. The report should not be too long ; when giving oral evidence in court the judge and the counsel will take care that the witness does not err in this respect, when writing a report he has unlimited scope, and is sometimes apt to be verbose. It is to be remembered that the writer of a report has not done with it when he has despatched it to its destination. Copies are placed in the hands of counsel] who will insist on an explanation of every ambiguous phrase; the longer the report, the more likely are ambiguous phrases to occur, for it is in the inferential part that verbosity asserts itself. CHAPTER III. LEGAL PROCEDURE IN SCOTLAND. There are certain differences with regard to legal proceedings in Scotland as compared with England. Public prosecutors are appointed by the Crown, who conduct criminal prosecutions in both higher and lower courts. The Lord Advocate and the Deputy Advocates take charge of cases which come before the High Courts of Justiciary ; the Procurator Fiscal appears before the lower courts. 16 FORENSIC MEDICINE. The first step in a criminal prosecution is taken by the Procurator Fiscal, who, on information supplied by the police or by private persons, makes such inquiries as satisfy him with regard to the necessity or not for legal proceedings. Any person who is supposed to know anything about the case is interrogated privately before the Sheriff, or, to use the legal term, is "precognosed." The examination is not made on oath, unless the witness is suspected not to be telling the truth. The evidence obtained is written down and forms the precognitions. The counsel for the accused, as well as the counsel for the Crown, has the power of precognosing the witnesses. The Sheriff or Justice, before whom the preliminary examination has been conducted, liberates the accused, or commits him for trial in accordance with the nature of the evidence obtained. Jf the accused is committed, the precognitions are forwarded to the Crown Counsel in Edinburgh, who have the power either to stop the proceedings, or to send the accused before the High Court, or one of the Circuit Courts of Justiciary, or before the Sheriff with or without jury. The Courts of Justiciary correspond to the Courts of Assize in England. Should the case be sent for trial, the persons who have been precognosed, or such of them as the Crown Counsel select, are summoned by writ as witnesses. Neglect of such citation, unless sufficient cause be shown, is punishable by a fine of £5, and also by imprisonment from which the offender is only released on expressing his regret before the Court and tendering bail to appear to give evidence. Common witnesses are not allowed to be in Court except when giving evidence : this applies to medical witnesses also, who appear as witnesses to fact. Expert witnesses are generally allowed, by mutual consent of the opposing counsel, to remain in Court. When an expert is giving his evidence, the other experts are usually required to leave the Court. An expert witness who has been in Court during the delivery of evidence by common witnesses, cannot be examined as a witness to facts. The Procurator Fiscal performs the duties undertaken by the Coroner in England, but without a jury. If a dead body is found, or a case of suspicious death occurs, the Procurator Fiscal, on being informed, has the power of directing a medical man to make an examination of the body, and to forward him a report dealing with the case, all such reports being certified by the reporter " on soul and conscience." If the medical examiner is satisfied with an external examination, he may certify to the Procurator Fiscal without making an internal examination. If a complete examination is requisite, the Procurator Fiscal issues a warrant to the medical practitioner who has already seen the case, and usually associates with him another EXAMINATION OF THE DEAD EODY. 17 practitioner of experience. The warrant is countersigned by the Sheriff or Justice, and empowers the holders of it to take charge of the body, and to make such examination as the law requires. The warrant also enables the inspectors to exclude improper persons from the room where the examination is being made. If, notwithstanding this authorisation, the relatives of the deceased refuse to allow the examination to take place, the authorities granting it (on being informed) will take steps to remove opposition. To ensure complete- ness of examination, the Crown Office in Scotland issues a form of instructions to medical inspectors, which contains elaborate directions for making the necropsy. A medical practitioner, whether previously acquainted with a given case or not, cannot refuse to be precognosed if duly cited to that effect. Refusal is met by a further warrant, and, in case of contumacy, by imprisonment. The fee for attendance at High Courts of Judiciary, or the Sheriff Criminal Court, is a guinea per day, if the court is held in the town in which the medical witness lives. If the witness comes from a distance, he is allowed two guineas per day, both for the actual attendance at court and also for each day occupied in travelling to and fro, with a guinea per day for travelling expenses. CHAPTER IV. EXAMINATION OP THE DEAD BODY. Post-mortem Examinations for Medico-legal Purposes.— There are several important points to be observed when making a medico-legal necropsy over and above the requirements of ordinary pathological investi- gations. External Inspection. — The examination should be made in daylight; colour changes are often invisible by artificial light. If the body is seen on the spot where it was first discovered, attention should be paid to the following points: — The exact posture in which it lies, the expression and colour of the face, the position of the hands whether clenched or not; if clenched, they should be examined for any substance possibly grasped by them. The fingers should be examined for cuts or wounds. The condition of the dress : if disordered, indicating a struggle, or if it is soiled or stained with blood. Attention should IS FORENSIC MEDICINE. be directed to the ground on which the body lies and to that im- mediately around it for signs of struggling and for objects that may have dropped, as fragments of clothing, &c. Any discovery should at once be recorded in writing. The presence or absence of body heat, •r of cadaveric rigidity, or of putrefactive changes are to be observed. When an exhaustive investigation of the body in sitd has been made, it may be removed to some place convenient for further examination. The clothes are now to be removed and any cuts or injuries sustained by the clothing carefully compared with the underlying surface of the body. Marks resembling bruises should be sponged so as to make sure that they are not due to dirt or other external stain. Indications for identification are to be sought for in surface marks: — naevi, moles, tattoo-marks, cicatrices; external abnormalities or loss of fingers or limbs ; absence of natural, or presence of artificial, teeth ; colour of the hair; height, weight, sex, age, state of nutrition, and indications of social position, or of occupation. In women and female children the presence or absence of the hymen, any signs of recent violence to the genital organs, together with the presence of foreign substances in any of the natural apertures of the body should be ascertained. If there are wounds, examine them carefully as to their length and depth and the structures divided or injured ; whether they could have been self inflicted, and the kind of weapon that could have produced them. Examine the neck for marks of strangulation. If there is a gunshot wound, look for blackening or tattooing of the surrounding skin, and also for blackening of the hand. The internal inspection must be complete ; all the cavities of the body should be opened, even though sufficient cause for death is found in the cavity first opened. If this is not done, the counsel for the defence may assume the presence of disease in an important organ which has not been investigated, or it may be necessary to have a second examination made to clear up a doubtful point which ought to have been settled by the first examination. The cavity supposed to be implicated in the cause of death should be opened first. In cases where there is no reason for selecting one cavity before another, the order from above downwards may be followed. If there are any penetrating wounds produced by cutting instruments or by firearms, ascertain their direction, and, in case they are not self-inflicted, try to form an opinion as to the relative position of the deceased and his assailant. When bones, cartilages, or intervertebral substances are injured, it is well to remove the injured parts and preserve them as evidence. Look carefully for any acute or chronic morbid changes in the organs, especially in cases of suspected poisoning, or when there is no cross traumatic lesion which would account for death. When the EXAMINATION OF THE DEAD BODY. 19 head has heen injured the use of the chisel and hammer to open the cranium is to be avoided for fear of producing a fracture of the skull, or of causing one already existing to spread : -the saw only should be used. The vagina and the uterus are to be examined for signs of recent delivery and for mechanical injuries, or for injuries produced by the introduction per vaginani of caustic or irritant substances. The vertebral canal should be opened and the condition of the cord ascertained. Cases of suspected poisoning.— Several large glass jars, preferably new, but in any case thoroughly cleansed, should be provided. If they are furnished with glass stoppers so much the better, if not, some bladder or gutta-percha tissue should be obtained which may be secured by string over the mouths of the jars. It is convenient to have a large dish — a photographer's square porcelain dish is the best — for placing the stomach in when opening it. Before opening the body, examine the mouth and lips for injuries caused by a corrosive, and ascertain if there is any peculiar odour given off from the mouth. After making the primary incision through the abdominal parietes, again try if any special odour can be distinguished, and if so obtain corroboratory evidence from those who are present ; the same proceeding should be adopted when the stomach and intes- tines are opened. When the abdominal cavity is opened, look for signs of inflammation of the peritoneum or of any of the viscera, especi- ally of the peritoneal aspect of the stomach. Then place a ligature round the lower end of the oesophagus, and a double one at the com- mencement of the duodenum. Divide the oesophagus above its ligature, and the duodenum between the two, and remove the stomach. On a dish, as already described, open the stomach along the lesser curvature, taking care that none of the contents are lost. The contents may be poured into one of the jars, and the inner coat of the stomach examined forthwith, its colour when first opened being noted. Search should be made with the aid of a lens for crystals, fragments of leaves, berries, and other parts of plants, and for particles of pigments, (such as indigo) which are mixed with certain poisons — as arsenic when sold in small quantities, and strychnine in the form of vermin-killer. Any suspicious substances found should be carefully collected and examined under the microscope. The intestines, large and small, separately ligatured, are to be removed and treated in the same way. In the case of corrosive and irritant poisons, the oesophagus should also be removed, opened, and its internal appearance noted, the effects of the poison being traced from the mouth down the digestive tract as far as any can be observed. The presence or absence of solid motions in the lower bowel is to be recorded. 20 FORENSIC MEDICINE. The colour of the blood, its condition as regards fluidity, and the colour of the solid organs generally, should be observed. Indications of fatty degeneration in liver, kidneys, and heart, of injection, especially of the kidneys, and of ecchymoses must be looked for. In addition to the stomach and intestines with their contents, the liver, kidneys, spleen, as much of the blood as can be collected, with the contents of the urinary and gall bladders, should be severally removed and placed separately in appropriate vessels for analysis. It is well to remove the brain with any fluid that is present within the cranium, especially in the case of volatile poisons, and to preserve it as above described. All vessels should be closed so as to be as nearly air-tight as possible, and the mouths finally covered with paper securely tied, the knot of the string being well covered with sealing-wax impressed with the private seal of the medical man who makes the examination. Labels should be attached to the jars and bottles, on each of which a description of the respective contents, with the name of the individual from whom they were derived, and the date of the necropsy, should be clearly written. Two lists of the jars and contents should be made ; one being forwarded along with the jars to the analyst, or to the authorities who take charge of them meanwhile, the other being retained by the sender. The jars should pass through as few hands as possible ; when feasible, the person who makes the post-mortem should himself deliver them to the analyst. They should be kept in a cool place, but no preservative should be added to their contents. It is convenient and advisable that two practitioners should con- jointly make the post-mortem examination. In case of doubtful or of obscure indications, the advice and countenance of a colleague is advantageous, and the division of labour— one practitioner making the section, and the other recording the results — adds to the com- pleteness of the investigation and to the facility with which it is made. Every step should be accurately recorded at the time, or in event of the examination being made by one medical man only, immediately after its completion. If the notes are made by a colleague they should be read over on the spot by the operator, and then signed by both medical men. No other persons than those concerned in making the necropsy should be present. If a medical man is implicated, he must not be permitted to be present; he may depute another medical practitioner to represent him at the necropsy, but his representative must not take any active part in the proceedings. In all cases_in which a legal inquiry is likely to take place, the medical practitioner in charge should refrain from making an examination until he re- ceives an order from the coroner to do so. When an inquest is going AGE IN ITS MEDICO-LEGAL RELATIONS. 21 to be held, the dead body is technically in the possession of the coroner until he has issued his order for burial, and, consequently, it may not be interfered with without his permission. In other cases the Anatomy Act of L832 (2 & 3 Wm. IV., c. 75, sec. 7 , pro vides that the executors, or other partj having Lawful possession of the body, may permit an anatomical examination to be made. Exhumation.— When suspicion of foul play arises after the body of the supposed victim has been interred, the coroner and the authorities at the Home Office may order the body to be exhumed and a medical inspection made. The medical man deputed to examine the body should be present at the exhumation, and should previously see thai adequate provision is made for making a full investigation. A relative or friend of the deceased should be present at the exhumation in order to identify the body. When the interment has been recent an ordinary post-mortem examination can be made, but if the body has lain long underground decomposition will be more or less ad- vanced and the usual post-mortem appearances destroyed. In such cases injuries to the bones, especially those of the skull, and in women the uterus (which resists putrefaction longer than the other soft organs) may afford valuable evidence. Most frequently, exhumations are undertaken in cases of suspected poisoning; in such cases, the stomach and intestines are to be removed— if recent, they should be ligatured as described in the directions for the ordinary examination. and placed in clean glass vessels well secured. The liver, spleen, and kidneys should also be removed. When the presence of a metallic- poison is suspected, as mercury or arsenic, some of the bones should also be taken, the shaft of the femur, for example. If the interment was remote, so that the coffin is decayed, it is advisable in cases of mineral poisoning to remove a little of the surrounding earth for ' chemical examination. However far putrefaction is advanced, neither preservative fluid nor disinfectant must be used when making the post-mortem, nor added to the parts removed. The stage of the putrefactive changes in relation to the length of time the body has been interred should be noted. CHAPTER V. AGE IN ITS MEDICO-LEGAL RELATIONS. The question of age in the living may tome under the notice of the medical jurist in relation to criminal responsibility, marriage, fecundity, 22 F0REN8IC MEDICINE, viability, rape, and personal identity. In the dead, in relation to infanticide, criminal abortion, and personal identity. A child u nder seven years of age is held by the law to be incapable , of committing a crime, and, consequently, is exempt from punishment. Above thai age, but below fourteen years, a child is stili deemed irresponsible, unless proof of such a degree of intelligence is forth- coming as to show that he understood the criminal character of the act committed by him. An "infant" under the age of fourteen years is presumed by law to be incapable of committing a rape, and, there- fore, cannot be found guilty of the crime, nor of an attempt to com- mit it. At and after the age of fourteen a youth is held responsible for his actions, but he does not attain the full privileges of an adult until he reaches the age of twenty-one years. It is not until he attains his majority (twenty-one years) that he can make a valid will (1 Vict., 26). The day of birth is included in computing the age, and, therefore, a valid will may be made on the day before the twenty-first "birthday," as the law does not recognise a division of time less than one complete day. The obligation to serve on a jury does not affect a man until he has reached his majority. In courts of law evidence may be given irrespective of age, provided that a sufficient degree of intelligence is manifested by the child when interrogated by the judge as to his or her capacity to understand the necessity of speaking the truth. The marriageable age in this country is fourteen years for the male sex, and twelve years for the female. In determining age in the living, no reliable criteria are available after adult life is reached. In the young, the teeth yield evidence up to the thirteenth or fourteenth year. General indications, of course, exist, but their variability — from idiosyncrasy, mode of life, personal attention, &c. — is so great, that to estimate the age of a living person between the two extremes of life is little more than guess-work. In the dead, the case is different. There are developmental signs which, when found, limit the age of the individual in both directions sufficiently narrowly to enable a fairly accurate estimate to be made. No single sign, as a rule, is determinative ; but when several are found to be in accord the expert is warranted in giving a decided opinion. The most reliable information in the later foetal months, and in the earlier years of life, is afforded by the ossification of the bones. The length and weight of the body during intra-uterine life afford impor- tant data, as do also the degree of development of the nails on the fingers and the toes, the size of the external ear, the presence or absence of meconium in the intestines, of lanugo on the skin, and of the pupillary membrane in the eye, and, in the male, the position of the testicles. It is not necessary for our present purpose to go further DEVELOPMENT OF THE FCETUS. 23 back than the sixth month of intra-uterine life; at this period viability may be said to begin. The dead body of a fetus that can be proved not to have reached the sixth month of utero-gestation, may be regarded as having been still-born, which would, of course, negative the charge of infanticide. Concealment of birth, apart from i nf a ntic i d e, is a crime independent of the age of the foetus. To avoid error, the period of utero-gestation in the follow Lng tabula- tion is stated in complete months ; for example, of six months duration, not in the sixth month. The latter mode of expression is ambiguous. Gestation of six months' duration means that the full period named has been accomplished. Gestation in the sixth month means any time from the commencement to the end of the sixtli month, and, therefore, may mean five months and one day. DEVELOPMENT OF THE FCETUS FROM THE SIXTH MONTH TO THE FULL TERM OF UTERO-GESTATION. Six Months. — Length, 9 to 13 inches. "Weight, 1 to 2 pounds. The head of the foetus is large in proportion to the body. The insertion of the funis is considerably below the middle of the body. The skin is red and wrinkled, the underlying fat, which subsequently imparts rotundity to the body and limbs, is only now commencing to form. The body is covered with downy hair or lanugo, and also with a thin layer of vernix caseosa — a white substance consisting of sebaceous matter derived from the skin, mixed with epithelium and lanugo. The bones of the head are widely separated at the sutures, the anterior and posterior fontanelles being open. The s ylvian fissure is forme d. The precentral, inferior frontal, and intra-parietal sulci of the cerebral cortex appear. 1 The eyebrows and the eyelashes are beginning to form. The eyelids are adherent. The pupillary membrane, which is formed in the third month, is present. The external auricle measures 1G to 24 millimetres. 2 The finger-nails are forming, but are quite- soft; the toe-nails are less developed. The scrotum is smooth and empty. The testicles are on the psoas muscles, below the kidneys. In the small intestine there is a little mucoid secretion, which may be coloured with bile-pigment. Centres of ossification are present in the os calcis, the manubrium, and in the bodies and laminae of the sacral vertebrse. Seven Months. — Length, 12 to 15 inches. Weight, 2 to i pounds. The skin is rather paler, and is well covered with lanugo and vernix 1 Cunningham, Contribution to the Surface Anatomy of the Cerebral Hemi- spheres, 1S92. 2 von Troeltsch, Die Anatomie des Ohres. 24 FORENSIC MEDICINE. caseosa. The lanugo is beginning to disappear from the face, that of the scalp is taking on the character of hair and is becoming darker. The superior precentral and the superior frontal sulci appear. The eyelids are not adherent. The pupillary membrane, which reaches its highest development during this month, begins to disappear. The external auricle measures 26 millimetres. The finger-nails do not quite reach the ends of the fingers. The testicles are near the abdominal ring. Meconium is found in the large intestine. Examined microscopically, this substance is seen to consist of mucous corpuscles, epithelium from the intestine, small crystals of bilirubin (very like hsematoidin crystals), crystals of stearic acid, and vernix caseosa. Centres of ossification are present in the first piece of the body of the sternum and in the astragalus. Eight Months. — Length, 15 to 17 inches. Weight, 4 to 5 pounds. The insertion of the funis is only slightly below the mid-point of the body. The skin is a little paler, and is more filled out by increased amount of fat beneath it. The face retains a wrinkled appearance. The lanugo is disappearing. The pupillary membrane has generally disappeared. The external auricle measures 26 to 28 millimetres. The nails feel harder, and have reached the ends of the fingers, but probably not the ends of the toes. The testicles are in the inguinal canal, or they may have reached the upper part of the scrotum, especially the left testicle. Valvule conniventes are formed in the small intestine The kidneys are now larger than the adrenals, and the bladder may contain urine. A centre of ossification is present in the second piece of the body of the sternum. Nine Months, at term. — Length, 18 to 20 inches. Weight, 5 to 8 pounds. The head measures transversely 3f to 4 inches ; sagittally, 4 J to 5 inches. The shoulders measure 4| inches across; the hips, 4 inches. The umbilicus is only three-quarters of an inch below the mid-point of the body. The skin has lost its rosy tint, and resembles more in colour that of the adult. The limbs and body are plump, and the face has lost its wrinkles. The lanugo has almost disappeared. Vernix caseosa is only. present in quantity on the back and on the flexor aspect of the limbs. The hair on the head is mostly dark and is about an inch long. Along the lines of the sutures the bones of the skull are close together, but the parietal and occipital bones are only united by membrane and are freely movable. The posterior fontanelle i s close d; the anterior fontanelle is not closed. The secondary sulci of the brain appear, and the surface is more highly convoluted. The eye- lashes and the eyelids are well-formed. The external auricle measures 33 to 36 millimetres. The cartilages of the nose and the ears feel hard. The nails project beyond the tips of the fingers, and they reach the DEVELOPMENT OF THE FCETCS. 25 tips of the toes. The testicles are in the scrotum, which is well corru- gated. Meconium is present in the large intestine only. The breasts in both sexes are well-formed, and contain some secretion. In the lower end of the femur there is a centre of ossification which measures 02 inch in diameter. This centre of ossification is of great importance to the medical jurist when investigating the development of the foetus in cases of infanticide. It appears with tolerable constancy about a fortnight before full term, the epiphysis in which it is developed being the only one in which ossification begins before birth. Centres of ossification are also present in the cuboid, in the first coccygeal vertebra, and in the third piece of the body of the sternum. The above criteria of the stage of development of the foetus are subject to considerable variation, and consequently a decided opinion should not be given unless, in a given case, several of the most impor- tant reasonably coincide. As regards dimensions and weight, it. is to be remembered that male children usually exceed female children in both respects. The variation in weight of children at term is consider- able. Ortega 1 delivered a woman of a still-born child which measured 27 inches in length and weighed 24f pounds ; it measured 7£ inches across the shoulders. Play fair 2 quotes the case of a child born of parents of gigantic stature — the mother being 7 feet 9 inches in height, and the father 7 feet 7 inches. The child was still-born; it measured 30 inches in length and weighed 23f pounds. The weighi of the foetus at term being more influenced by the state of nutrition is less constant than the length. Rickets retards ossification, and thus inter- feres with the closure of the fontanelles and with the development of the various centres of ossification normally existing at term. In the newly-born, putrefactive changes take place with great rapidity and seriously interfere with the indications afforded by the weight, the condition of the skin, hair, nails, cartilages of the nose and ears, and by producing opacity of the cornea, with evidence afforded by the pupillary membrane. It is to be observed that the absence of the pupillary membrane does not in itself determine the maturity of the foetus, nor is the absence of the testicles from the scrotum to be accepted as an indication of immaturity : they not unfrequently remain in or above the inguinal canal until or beyond puberty. The presence or absence of the centre of ossification in the lower epiphysis of the femur, although not infallible, is perhaps the most reliable means of enabling an opinion to be formed as to the maturity or otherwise of a foetus, even when putrefactive changes are so far advanced as to render other indications valueless. It is to be remembered that the difference 1 Xouvelles Arch. d'Obstit. et de Gyntcol., 1S91. 2 Science and Practice of Midwifery. 26 FORENSIC MEDICINE. between a foetus at eight months and one at full term is not sufficiently pronounced as to enable a positive opinion to be given. This, however, does not affect the issue in the greater number of cases that come before the medical jurist, seeing that in either case the child might have been born alive. The following table shows the more important developmental changes which take place in the foetus from six months to full term : — Table of Developmental Changes in the Fcetus. Months. Length in Weight in Nails. Pupillary Testicles. Centres of inches. pounds. membrane. ossification. 6 9-13 1-2 Forming. Present. Eyelids ad- herent. On psoas muscles below kid- neys. Os calcis. Manu- brium. Bodies and lamina? of sacral vertebrae. 7 12-15 2-4 Not reached Partly pre- About ab- First piece of endsof fin- sent. Eye- dominal body of ster- gers. lids open. rings. num. Astraga- lus. Second piece of 8 15-17 4-5 Ends of fin- Disappeared. Inguinal gers, but canal; may body of ster- probably be in scro- num. not of toes. tum. Left often be- fore right. 9 17-20 5-8 On fingers perfectly for m ed : not neces- sarily on toes. Usually both in scrotum which is corrugated. Cuboid. Third piece of body of sternum. First coccygeal ver- tebra. Lower epiphysis of femur. After birth, the circulation soon becomes of the adult type. The epiderm begins to desquamate about the third day. The skin, at first hypersernic and red in colour, subsequently acquires a yellowish tinge. When desquamation is finished — the time occupied varying from one to two weeks or more, according to the vigour of the child — the skin assumes its permanently normal colour. During the first three days the child loses weight. A few hours after birth the intestines relieve themselves of the meconium which accumulated during intra-uterine life. At birth, the normal umbilical cord is plump, spiral, and of an opal colour ; in weakly children it is flaccid and is much thinner. After division of the cord, the portion attached to the child becomes flabby and begins to shrivel up on the first or second day : desiccation com- mences at the free end, advances towards the point of insertion, and is completed about the third or fourth day. The cord is then flattened, and has a parchment-like, translucent appearance, exhibiting the DEVELOPMENT OF THE FCETUS. 27 arteries and vein as red lines. If a cord that has undergone mum- mification is soaked in water, it dors not return to its previous condition. About the fourth or fifth day the cord separates by ulceration close to the abdominal wall. Around the point of detachment is an inflam- matory zone, which persists some time after separation. The usual purulent secretion which accompanies ulcerative processes is more or less present. The degree of, and the time occupied by, the inflammatory processes which attend separation of the cord vary with the developmenl and vital activity of the child: the feebler the child, the longer the pro- cess of detachment. Cicatrisation of the navel is usually completed in aboul eight to twelve days. After separation of the finds and completion of desquamation of the epiderm, the progress of dentition and the development of the various centres of ossification that form after birth afford the most reliable criteria of age. There are, however, other indications which may be of use. The capacity of the stomach rapidly increases after birth. Ashby and Wright 1 estimate the rate of increase as follows :— At term, ...... about 2 fluid ounces. Fourth week, ..... ,, 3-4 ,, Three months, ..... ,, 5 ,, Twelve months, . . . . . >> 1') ,, The cubic capacity of the skull at term equals 500 cc. In the second year, it has increased to 1000 cc. In adult life, it averages 1500 cc. The increase in the child's weight during the first twelve months of its life is very pronounced. Pfeiffer gives the following table (abridged) : — In the first month, „ third ,, ,, sixth ,, , , ninth , , twelfth ,, Pounds. Oun s 5 11 L5 1G 3 20 1 22 7 The weight does not increase so rapidly after the end of the first year. It is again doubled at the end of the sixth year, and also at the end of the fourteenth year. These figures obviously presuppose that the nutrition of the child is progressively maintained. The average length of a child at the end of the fourth year is double the average length at term. At birth, the angle formed by the ramus and the body of the lower jaw is obtuse, being equal to about 140°. The body is almost semi- 1 Diseases of Children, 1S92. 28 FORENSIC MEDICINE. circular in form; it is shallow and chiefly consists of the alveolar portion ; the basal part is but little developed. The permanent teeth Fig. 1. — The lower jaw at puberty. being more numerous than the temporary teeth require additional space; this is provided by growth of the body of the jaw posteriorly, Fig. 2. — The lower jaw of adult age. which changes its form from a semi-circle to that of a horse -shoe. Coincident with its increase in length, the body becomes deeper and Fig. 3. — The lower jaw of old age. THE TEETH. 29 thicker. The ramus lengthens, and the angle formed by it with the body becomes less obtuse, so that in adult life it approaches a right angle. In advanced old age the teeth are lost, and the alveolar por- tion of the jaw atrophies, consequently the body is again shallow, and the angle formed by it with the ramus is once more obtuse. It will be seen from this description that the shallow jaw of infancy and that ' of old age are anatomically complementary the one to the other : the b ody o f the infantile jaw is almost exclusively alveolar, that of old age is exc lusively basal. This is demonstrated by the position of the ! ini-.-nn.-M in tin- infaiilil.- aii v 4«^ to the temporary set ; if there is a sixth, it belongs to the per- manent set. The rest of the permanent teeth replace the tem- porary teeth in the same order in which the temporary teeth ap- peared. The permanent molars appear at intervals of about six years. A child, nine years of age, will have twelve permanent teeth ; at thirteen or fourteen, it will have twenty-eight — that is, all except the four wisdom teeth. In advanced life, the bones of the head tend to become thinner from absorption of the diploe. The long bones become lighter and more fragile, the inorganic components being in excess. Many of the teeth are absent, and those which remain are worn down and discoloured. The following Tables are arranged (mostly from Quain's Osteology by Thane) with the view of showing the probable age of a body or skeleton up to puberty, from the presence of the principal centres of ossification, and to later adult age from the union of epiphyses with bones, or of one bone with another : — a 4-13-1° .tlt-ye* 1 " v ■IS- 30 th -Year W Fig. 5. — Permanent teeth. (Macalister's Human Anatomy). POINTS OF OSSIFICATION*. 31 Table Showing the Periods at which Points of Ossification Appear after Birth. Tears of Life. Boxes in which the Ossific Points Appear, 1st Fourth piece of the body of the sternum. Coracoid process of the scapula. >) Head of the humerus. 51 Os magnum (carpus). 5J Head of femur. ) J Upper end of tibia. 3) External cuneiform (tarsus). 2nd Lower end of radius. j> Unciform (carpus). ,, Lower end of tibia. j> Lower end of fibula. 3rd Great tuberosity of humerus. )) Patella. ^ s Internal cuneiform (tarsus). 3rd to 4th Upper end of fibula. 4th Great trochanter (femur). ,, Middle cuneiform (tarsus). 4th to 5th Scaphoid (tarsus). ?) Lower end of ulna. 5th Lesser tuberosity (humerus). J5 Internal condyle (humerus). )) Trapezium and semilunar (carpus). 5th to 6th Upper end of radius. 6th • Scaphoid (carpus). 7th Trapezoid (carpus). 10th Upper end of ulna. 12th Pisiform (carpus). 13th to 14th External condyle (humerus). " Small trochanter (femur). 32 FORENSIC MEDICINE. Table Showing the Periods of Union of Epiphyses with Shafts of Bones, and of Bones with each other. Years of Life. 1st or 2nd 2nd 7th or Sth 17th >) 17th to ISth 18th 19th 20th 21st n 24th 25th 40th Epiphyses and Boxes. Symphysis of lower jaw. Frontal snture ; unites from below upwards : may persist. Anterior fontanelle filled up. Rami of ischium and pubis. Epiphysis of upper end of ulna. ,, small trochanter (femur). ,, condyles (humerus), upper end of radius, great trochanter (femur). , , lower end of tibia. Lower sacral vertebra:'. Portions of acetabulum united. Epiphysis of head of the femur. humerus, lower end of radius. ,, ulna, upper end of tibia. ,, lower end of fibula. ,, upper end of fibula. Second and third pieces of sternum. First and second sacral vertebras. Epiphysis of clavicle. „ lower end of femur. Manubrium with body of sterum. ASPHYXIA. 33 CHAPTER VI. MODES OF DYING. It is customary and convenient to speak of death as beginning in one of the three essential organs concerned in the maintenance of life — the brain, the lungs, and the heart ; failure of action on the part of any one of these organs speedily interferes with the functions of the other two. If the blood is insufficiently aerated in the lungs, the vaso- motor centres are irritated, and consequently the heart's action is impeded by the narrowing of the blood-channels, the musculature of the heart itself being enfeebled by impure blood-supply. If the heart does not propel the blood with sufficient activity through the lungs, the respiratory centres are ultimately paralysed. Again, if a blood- clot presses on the centres in the medulla, both heart and lungs succumb. If the final obvious indications of life are to be accepted, the heart and the lungs are the organs which, by cessation of function, actually bring about somatic death. From this aspect the mention of death beginning in the head may be regarded as unnecessary; it is convenient, however, to retain Bichat's classification. It is to be borne in mind that, chiefly, the medical jurist is only concerned in the investigation of deaths which have resulted from violence; but not unfrequently he is called upon to investigate cases in which death was the result of disease — the manner of death, or the circum stances under which it took place, being suspicious of foul play. The three modes of dying are — Asphyxia, Si/ncojje, Coma. ASPHYXIA. When the respiratory function is arrested beyond a certain limit asphyxia is the resul t. There are various ways in which the inter- change may be interrupted which normally takes place in the lungs between the blood and the air, viz. : — The nervous supply to the respiratury muscles may be abolished either centrally (medulla), or peripherally (pneumogastrics or phrenics). Fixation of the respiratory muscles (tetanus or strychnine); mechanical pressure on thorax; collapse of lungs (pneumothorax); foreign bodies in the air passages, or closure of them by external compression 3 34 FORENSIC MEDICINE. (strangulation); drowning; respiring air deficient in oxygen; spasm of glottis from mechanical irritation (particles of food), or from irritant gases (CI, S O.,), are each capable of producing death from asphyxia. Symptoms. — The phenomena of asphyxia may he divided into three stages. In the first, the respirations are deeper, more frequent, and more laboured than in the normal condition. The extraordinary muscles of respiration are called into action, and the struggle for air becomes more and more severe. The blood becomes more venous, and stimulates the respiratory centres, evoking violent attempts at respi- ration. In the second stage, the inspiratory muscles are less active, whilst the expiratory muscles contract energetically, as do also almost all the muscles of the body, producing g eneral convuls ions. In the third stage, the respiratory centres are paralysed. The pupils are widely dilated, consciousness is abolished, and the reflexes are absent. A few gasps at long intervals, and all is over. Hughlings- Jackson 1 directs attention to absence of the knee-jerk when the blood is highly venous. In the earlier stages of asphyxia the knee-jerks are ex- aggerated, but when the third stage is reached they are entirely lost. Post-mortem Appearances. — The right side of the heart, the pul- monary artery, the vense cavse, and the veins of the neck are gorged with dark venous blood. The left side is comparatively empty from post-mortem contraction (see under " Cadaveric Rigidity "). The blood, nearly black, contains a large amount of C 0. 2 , and, therefore, coagu- lates slowly. The haemoglobin is almost entirely reduced ; ordinary venous blood contains a considerable amount of O., Hb as well as reduced Hb. (Landois and Stirling.) SYNCOPE. "When the circulation suddenly fails, syncope is the result. The circulation may fail from cessation of the heart's action, the result of disease (aortic regurgitation, fatty heart, &c), of inhibition (psychical shock, blow on the head, or reflexly from blow on epigastrium). The circulation may also fail from loss of blood (wounds of the large blood- vessels, or of the heart itself, profuse hsematemesis, Arc.) or from sudden withdrawal of blood from the circulation without loss (blows on the abdomen by paralysing the splanchnics may enlarge the vascular area of the abdomen to such an extent as to deplete the rest of the system). Symptoms. — Pallor of the face, including the lips, dimness of vision, cold clammy sweat, sense of impending dissolution, craving for more 1 British Med. Journ., 1892. COMA 35 air, great restlessness, gasping for breath, nausea, possibly vomiting, rushing sounds in the ears, momentary delirium quickly passing on to insensibility, followed by convulsions precede death. The whole of these symptons are not always present. In simple fainting there may be only immediate loss of consciousness with cold surface and sighing respiration. In all cases the pulse is weak, irregular, or imperceptible. The condition called collapse, though attended by failure of the heart's action, differs from syncope inasmuch as the patient retains conscious- ness. Post-mortem Appearances. — When death lias resulted from insuffi- cient supply of blood to the heart, that organ has been found conj racted and empty. When the cause of death has been heart-paralysis both sides have been found to contain blood. (See " Cadaveric Rigidity.") COMA. When from any cause affecting the brain insensibility is produced which terminates in death, the individual is said to die from coma. Increase of intra - cranial pressure, or dynamic disturbance of the cerebrum or of its circulation, may produce coma (concussion, haemor- rhage, tumour, abscess, embolism, thrombosis, depressed fracture of the skull). Inflammatory processes (meningitis, &c). Abnormal con- dition of the blood circulating through the brain (uraemia, certain poisons, as opium, alcohol, and that which produces the complication attending diabetes known as diabetic coma). Symptoms. — The symptoms produced by many of the causes of coma above enumerated may take the initial form of stupor, from which the patient may be partially roused for a few seconds or more. This condition subsequently deepens into profound insensibility, from which the patient cannot be rouse d. Some of the causes enumerated produce sudden coma without any antecedent stupor. In stupor the reflexes may be retained or even exaggerated, in coma they are usually diminished or lost. Power to swallow fluids is consistent with stupor, but not with coma. A comatose person is utterly insensible to all external impressions; he lies powerless, breathing heavily, with stertor from paralysis of the soft palate. The surface is usually covered with a cold sweat, the temperature being at or below normal, except in lesions of the pons and a few other conditions. The pulse may vary, but is often full and laboured. The breathing becomes more and more embarrassed from diminished activity of the respiratory centres, and mucus collects in the airq)assages, causing the form of breathing known as "the death rattle." The pupils, either dilated or contracted, are in- sensitive to light, and the conjunctival reflex is lost. oG FORENSIC MEDICINE. Post-mortem Appearances. — In some of the conditions which produce coma, examination of the brain reveals the cause. From what has been already said it will be apparent that the condition of heart and lungs is not constant. As a rule, they resemble more or less the con- dition found in death from asphyxia. CHAPTER VII. SIGNS OF DEATH. The movements which accompany respiration and circulation are the two most obvious indications of the existence of animal life. If signs of movement of the lungs and of the heart are present, it is clear that death has not yet occurred. If the lungs cease acting, the heart may continue to beat for many minutes, which, also, is conclusive that death has not yet taken place. When both heart and lungs have ceased to act, the tissues retain " vitality " for some time, during the continu- ance of which it cannot be truly asserted that the individual is dead. To this lingering " vitality " of components is due the potentiality of resuscitation of the entity they compose, after temporary cessation of the main functions by which life is sustained. If the heart persistently ceases to beat, the vitality of the tissues progressively diminishes, until at last a point is reached when death is absolute and universal ; when this point is reached, but not before, resuscitation is impossible. It is very necessary for the medical jurist thoroughly to appreciate the importance of the distinction between systemic or somatic death, and death of tlie tissues or molecular death. In profound syncope, for example, there is every external appearance of death ; but, if the heart resumes its function, the patient recovers. Hence the necessity of careful study of the phenomena which succeed death, in order to be able to distinguish between real and apparent death. Auscultation, carefully conducted and repeated if necessary at intervals, will enable an opinion to be formed as to whether the heart and lungs have or have not ceased to act. Absolute silence should be maintained during the investigation, which should be conducted with all deliberation. Error on the part of the practitioner, should he wrongly pronounce that death has taken place, is so obviously capable of refutation that his reputation is damaged, and, what is of infinitely greater importance, such an error might lead to CESSATION OF RESPIRATION" AND CIRCULATION. 37 that most ghastly of all blunders — the treatment of a living being as though he were dead. After the occurrence of somatic death — that is, after permanent cessation of respiration and circulation — certain phenomena occur in definite order. The time occupied by many of these phenomena, although variable, is limited, and consequently, by ascertaining the stage at which they have arrived, an opportunity is afforded of approximatively estimating the interval that has elapsed between death and the period of investigation. These phenomena are manifestations of the occurrence of molecular death. The rapidity of their onset is, to some extent, determined by conditions which exercise an influence on the amount of vital energy with which the tissues are endowed immediately before somatic death. Such conditions comprise disease, poison, violent exercise, and other exhausting influences. If the tissues are depressed in vitality at the moment of somatic death, they rapidly succumb to molecular death, and the course of the succeed- ing phenomena is hastened. If, on the other hand, they are in full activity when somatic death takes place, they resist the advent of processes which are really the antecedents of decomposition. CESSATION OF RESPIRATION AND CIRCULATION. At the moment of somatic death, the skeletal muscles lose their tonus and become flaccid. When death takes place whilst the body is in the recumbent posture, the loss of tonus is immediately manifested by dropping of the lower jaw ; the eyelids remain open, or partially so, and the limbs are flexible. The pinched look of the face — facies hippo- cratica — that frequently manifests itself at the time of death, changes to a more or less peaceful expression, often — in the case of persons above middle age not much emaciated — evoking the comment from the by- standers that the deceased now resembles the appearance he presented in youth. This alteration in facial expression is due to relaxation of the muscles smoothing away the sharp contour of the features. The eyes lose their lustre and acquire the peculiar ghastly stare so charac- teristic of death. The pupils dilate at the time of death, and do not respond to light. Marshall l states that contraction of the pupils subsequently takes place for a period varying from one to forty-eight hours after death ; that atropine dilates the pupils after death, in some instances as long as four hours after ; and that esserine contracts the pupils, but not for so long after death. The surface of the body, includ- ing the lips, becomes pallid; people of florid complexion often retain 1 The Lancet, 1SS5. 38 FORENSIC MEDICINE. their colour for several days after death. Ten or twelve hours after- death, the eyeballs sink in the orbits and become flaccid, so that the cornea retains the dint caused by pressure of the finger-nail or other- hard substance. Death abolishes the distinction between living and dead matter, and, consequently, the human body after death becomes subject to the laws which govern inanimate matter. That remarkable property with which man in common with other animals is endowed— the power of main- taining an equable internal temperature, whatever may be the tem- perature of the surrounding air— is now lost. The consequence is, that the body yields up its heat and slowly but progressively cools down to the temperature of the surrounding media. POST-MORTEM COOLING. From fifteen to twenty hours is the time usually required for the body to cooTto the temperature of its surroundings. It is obvious that this can only be accepted as a general statement. The actual time taken by a cadaver to become cold is determined by conditions, some of which are of internal and others of external relation. Conditions of Internal Relation.— At the time of death resulting from some diseases, and from certain other modes of death, the body-heat greatly exceeds the normal. This has been observed in cholera, acute rheumatism, poisoning by strychnine, tetanus, and some forms of apoplexy. After death from cholera, yellow fever, and some other diseases, post-mortem elevation of temperature has been observed. Under like external conditions, a cadaver having at the moment of death a temperature 8° or 10° F. above normal, would take longer to cool than one at the normal temperature. Certain modes of death, without necessarily causing any elevation of temperature, retard the rate of cooling : death from suffocation, and some other kinds of sudden death from violence may have this effect. The state of nutrition at the time of death also exercises a considerable influence; bodies loaded with fat do not cool so rapidly as those which are ema- ciated. The bodies of persons in the prime of life do not cool so rapidly as those of very young or of very old people. Those who have died from lingering or wasting diseases cool rapidly, the temperature pro- bably being subnormal before death. Conditions of External Relation.— The temperature of the surround- ing media and their capacity for heat-conduction exercise an important influence ; a body submerged in water will cool more rapidly than in air, because water is colder and is a better conductor of beat than the air above it ; a body lying naked on the flags will cool quicker than one pro- POST-MOItTEM STAINS. 3'J tected l>y clothing and lying on a bed. Without particularising further, it may be accepted that the greater the difference of temperature between the dead body and the surrounding media, the more rapidly is its heat lost in a given unit of time ; therefore, the rate of post-mortem cooling is not uniform, but is proportional to the difference in temperature existing at any given period between the body and its surroundings. From this it follows that the cooling rate will be quicker in the earlier than in the later hours, because in the later hours the temperature of the body more nearly approximates to that of its surroundings ; during the first few hours it may average 2° or 3° F. per hour, sub- sequently it will not exceed 1° F. per hour. The longer of the two periods — twenty hours — stated as sufficient in ordinary cases to allow the body to cool, may be accepted as practically, but not absolutely, correct. For the reason just given, the cooling-rate is exceedingly slow when the temperature of the body differs but slightly from that of its surroundings ; therefore, the last few degrees of body-heat take a long time to disappear, the body in the meantime being cold for all practical piirposes. POST-MORTEM STAINS. Coincident with cooling is the formation of certain discolorations on the dependent parts of the body. Various terms are used to indicate these stains, as— cadaveric hypostases, cadaveric ecchymoses, post-mortem lividities, sugillations. When the subject of giving evidence was dealt with, the necessity of avoiding technical terms in the witness-box was emphasised; in furthei'ance of this advice it is recommended that the words which head this section should invari- ably be used when discussing the subject, as conveying a clearer idea of what is meant to the ordinary hearer than any of the synonyms. Post-mortem stains are produced by_ gravitation of the still iluid blood into the capillaries and the venous radicles of the lower part s of the body which are obviously determined by the position in which it rests. If the body is lying on its back the lobes of the ears, the shoulders, the lumbar region, the buttocks, and the posterior parts of the legs and arms will constitute the lower parts. If the body is in the prone posture, the face, chest, abdomen, and the anterior parts of the legs and arms will be the lower parts. In addition to the results produced by gravity, are those due to loss of tonus of the walls of the capillaries which occurs at the time of death. The effects produced by the gravitation of the fluid blood are not limited to the surface of the body, the internal organs are also subject to them. As the formation of post-mortem stains is dependent on the fluidity 40 FORENSIC MEDICINE. of the blood, the question arises — how long does the blood remain fluid within the body after death 1 Coagulation within the dead body- commences later, and takes place much more slowly than is the case with blood withdraw]! from the living organism. It is impossible to state with exactitude the time that elapses between death and the commencement of coagulation : about four hours is the period allotted. Clots may form within the large veins at this interval after death, but the progress of coagulation is so slow — especially in the smaller veins — that the great bulk of the blood is probably still fluid for many subsequent hours. This being the case, the exact period after death when the blood begins to coagulate is of little importance. The time occupied in coagulation may be further prolonged by the condition of the blood at the time of death. The presence in it of excess of carbon dioxide retards coagulation ; therefore, the blood of persons who have died from suffocation coagulates very slowly. The salient features of slow coagulation outside the body are distinguishable in the blood-clots formed within the cadaver. These features are sinking of the red blood corpuscles to the lower stratum before solidification takes place, and the consequent formation of a more or less colourless layer at the upper part of the clot. This division of the clot into two layers is of importance to the medical jurist. On examination of a dead body in which coagulation has taken place, the clots ought to correspond with the position of the body, the coloured layer being furthest from the upper surface of the body. If this is not the case — if the colourless part of the clot is found at the undermost part of the body — proof is afforded that the position of the body has been reversed after coagulation took place. The blood-clot formed within the body after death is not nearly so firm as one formed from blood withdrawn from the circulation during life. Apart from death from suffocation, it does not appear that the reluctance of the blood to coagulate within the vessels depends upon the presence of C 2 , as blood which has remained fluid within the body for some hours after death will coagulate when received over mercury without exposure to air. To return to post-mortem stain s. They begin to appear on the undermost parts of the body from four to twelve hours after death; not unfrequently they may be seen earlier than the first-mentioned period. They consist of patches of a dull red, or they may be of a bluish-slate colour. At first they impart a mottled appearance to the skin, later on the individual patches coalesce and form large areas of discoloration. The outline of the patches is irregular but is well- defined, the margins stand out in bold relief against the neighbour- ing uncoloured skin. The stained portions are not elevated above FOST-MORTEM STAIN'S. 41 the level of the surrounding skin. Although post-mortem stains occur on the undermost parts of the cadaver, they arc absent from those 7 parts which are in contact with the substance on which the body lies. If a body lies in the ordinary position — on its back — the shoulders, buttocks, calves, and heels will be unstained. The reason for this is that the compression of the parts named, caused by the body-weight on the one hand and the resistance of the unyielding surface which supports the weight on the other, prevents the gravitation of the blood into the vessels of the skin. An amount of compression much less than that produced by the weight of the body is sufficient to exclude the blood from the part thus compressed. A tight collar or necker- chief may act in this way. and so produce a mark round or partly round the neck that might resemble to some extent the mark left by a cord after death by strangulation. Post-mortem stains continue to form so long as the blood, or a part of the blood, remains uncoagulated. Whilst the blood remains fluid, the post-mortem stains are only per- i manent provided the position of the body at the time of their formation remains unaltered. If post-mortem stains have made their appearance on the posterior part of a body which lies on its back, and whilst the blood is still fluid the position of the body is reversed, the stains on the back part will disappear and fresh ones will be formed on the now de- pendent parts in front. Permanency of position in post-mortem stain s is only secured by coagulation of the blood; after it has taken place, any alteration in the position of the body produces no effect on them, nor are new ones formed. For this reason, if the position of a body is materially changed after coagulation, it will be found that the post-mortem stains do not correspond with the altered position, and consequently afford evidence of the body having been interfered with. Casper states that they are invariably present after death from haemorrhage; other authorities have found them absent, or but feebly indicated in such cases, and also when anaemia from disease was the cause of death. The distinction of post-mortem stains from bruises made during life is of great importance. Mistakes in this relation may be, and have been, the cause of doing serious injustice to innocent persons. The difference is very marked and easy of recognition. In post-mortem i Stains the blood which produces them is still within the blood-vessels — it is contained in the flaccid, dilated venous radicles and capillaries of the rete, above the papilla?. The surface is uninjured : if examined in an oblique direction, or with an oblique light, no trace of disturbance of the epiderm is found. The parts stained are not elevated, they are practically on the same level with the surrounding skin. The stains are always on the most dependent parts of the body, 42 FORENSIC MEDICINE. with the exception of such parts as are subject, or have been subjected, to compression. The margins of the stains are well defined, they do not fade away into the surrounding skin. The depth of colour of the patches of stain is uniform, or nearly so. The stains when in patches (such as might, by the ignorant, be mistaken for bruises) rapidly increase in size, mostly in a direction determined by gravity. In bruises made during life, the discoloration of the skin is caused by extravasation of blood in and under the papillae of the true skin from vessels which have been ruptured by violence. The surface of the skin will generally be found disturbed, the result of impact with the object that produced the bruise. Except in the case of very slight injuries, the bruised part will be found more or less elevated. The position of the mark of a bruise is not determined by gravity, it may be on any part of the body, and instead of having a well-defined irregular outline, it will correspond somewhat in shape with the causal agent, or with that part of it which came in contact with the surface, and the margin will be ill-defined, fading away into the surrounding- skin. The colour of a bruise is not uniform ; if the injury has existed for a day or two a zone of yellow or green may be seen round the outer parts. Such are the differences observable on the surface between post- mortem stains and bruises. The critical distinction is made by incising the part. In a post-mortem stain no blood escapes except from a few minute points which represent the divided vessels of the rete pre- viously distended with blood. On the other hand, an incision into a bruise reveals the presence of effused blood, either clotted or fluid, below the rete, or when the bruise has been the result of great violence, still deeper down. So far for external post-mortem stains. The same conditions that produce the stains on the skin influence the internal organs. When the body has been lying on the back, the veins of the pia mater at the posterior part, and the lateral and occipital sinuses will be found filled with blood. This is even the case after death from haemorrhage, a fact to be borne in mind lest the presence of so much blood in the highest part of the body (during life) should be regarded as inconsistent with that cause of death. The posterior fourth of each lung is almost invariably filled with blood, here ;ilso is some risk of attributing the condition to pathological causes. The posterior parts of the stomach and of the intestines, especially those in the pelvis, are also stained. The absence of inflammatory exudation, and the fact that on stretching out the bowels the colouration will be found absent at parts lying between the discoloured portions, is suffi- cient to prevent error of interpretation. The posterior halves of the CADAVERIC RIGIDITY. 43 kidneys are usually gorged. The veins in the pia of the cord often present an appearance not unlike that resulting from meningitis. The heart is free from staining, but fibrinous clots — the so-called cardiac polypi — are common. CADAVERIC RIGIDITY. The flaccidity of the muscles which occurs immediately after death gives place to an opposite condition of extreme hardness. So Long as the muscles remain flaccid they retain their irritability, and respond to electrical stimuli in the same way that they do in life. This is due to the persistence of molecular or tissue life after the cessation of somatic life. At a variable period after death, the muscles of the lower jaw begin to stiffen; this is the first indication of the onset of cadaveric rigidity or, as it is also called, rigor mortis. Under ordinary circumstances, the skeletal muscles begin to stiffen in from four to ten hours after death. The stiffening spreads from the muscles of the jaw to those of the face, neck, and trunk, and lastly to the limbs. It is f ully developed in from two to three hou rs, when the entire body is firm and stiff. The limbs cannot be flexed at their joints without considerable force, and the body when moved behaves as though it was devoid of articulations. This condition lasts for a period varying from a few hours to six or eight days. Twenty-four to forty-eight hours may be regarded as the average duration of cadaveric rigidit y. In addition to the hardness, a certain amount of contraction of the muscles takes place during the onset of cadaveric rigidity. The muscles become shorter and thicker, and the limbs, if left to themselves, stiffen in a position of partial flexion. Experimentally it is found that a muscle in the act of stiffening will lift a weight, showing that a ctual cont ract \> m takes place. This question will be fully discussed later on. When cadaveric rigidity is present, the muscular electrical current is either abolished, or there is a feeble current in the opposite direction to the normal. The muscles have also lost the power of responding to electrical stimuli. The chemical reaction of the living muscle at rest is neutral or slightly alkaline; that of muscle doing work is acid. Muscles in which cadaveric rigidity is present have a strongly acid reaction, said to be due to the p resence of sarcolactic ac id, and, p ossibly, also of glycero- phosphoric acid; in addition, a large amount of carbon dioxide is set free. The actual cause of the muscles becoming hard and still' is the coagulation of the myosin within the sarcolemmas of the muscular fibres (Kiihne). Rigidity does not occur in the body of a foetus of under seven months.^ Preyer 1 doubts this generally accepted statement. 1 Specielle Physiologie des Embryo. 41 FOKEXSIC MEDICINE. The rigidity seems to exist in two conditions, the first passing on to the second by simple lapse of time. In the first condition, it is sup- posed that the myosin is only partially coagulated, being of a jelly-like consistence; in this stage the muscle has not yet lost its irritability. If, whilst the muscle is in the first state of rigidity, fresh arterial blood is transfused into the blood-vessels, the semi-coagulated myosin is dissolved, and it is then found that the muscles are still irritable and respond to electrical stimuli (Brown-Sequard). 1 When the second stage is reached the coagulation of the myosin is complete, and the irritability of the muscles has permanently disappeared. This coincides with the period of death of the muscular elements, and of the tissues of the body generally. When cadaveric rigidity is fully developed, if one of the limbs is forcibly flexed at a joint, the rigidity does not return, the joint remains supple, and the limb in the position in which it is left. In this way post- mortem rigidity may be distinguished from ante-mortem rigidity as occasionally met with in hysterical or cataleptic subjects. In the latter condition, if the limb is forcibly bent it tends to return to its previous position, and again becomes rigid. In the first stage of cadaveric rigidity, however — when the myosin is only partially coagulated — a certain degree of stiffening again occurs after a joint is forcibly flexed. The conditions which hasten the onset of cadaveric rigidity are those which have an exhausting or depressing influence on the muscles immediately before death; hence, after violent muscular exercise, death is speedily followed by rigidity. It has been observed that the bodies of soldiers killed at the commencement of a battle, before they have under- gone much fatigue, do not become rigid so soon as those of their fellow- combatants who succumb at a later period, after many hours' arduous fighting. After death from diseases or poisons, which depress or exhaust the system (especially if attended with clonic spasm of the muscles) rigidity comes on early. Finlayson 2 records a case of chronic Bright's disease in which cadaveric rigidity exceptionally commenced within fifteen minutes after death. Animals that have been hunted for some time before death stiffen almost at once, and within a few minutes may be held out by the hind legs perfectly rigid. On the other hand, in speedy death (with exceptions presently to be mentioned) occurring to in- dividuals in vigorous health the onset of cadaveric rigidity is delayed. Even in those who are in full vigour, if death is immediately preceded by convulsions, rigidity comes on early, because the vital energy of 1 See also Heubel on "Die Wiederbelebung des Herzens nach dem Eintritt vollkommener Herzmuskelstarre." Pfliiger's Archir, 1889. - Brit. Med. Joum., 1S84. CADAVERIC RIGIDITY. 45 the muscles is lowered. It has been found that the muscle-currents disappear, and the electrical irritability of the muscles is diminished before the development of rigidity. All these facts point to one conclusion: that cadaveric rigidity is a consequence of death of the muscles, that it creeps on as the muscles are dying, and is, therefore, partially present before they arc dead, but it is not fully developed until molecular death has taken place. It may be asserted as a general proposition that the sooner rigidity comes on after death, the sooner will it pass away. The converse is equally true : the longer it is in appearing, the longer will it last. An unexhausted condition enables the muscles, within limits, to resist disintegration when deprived of further aid from the nutrient supply and the eliminative agencies by which their vigour was maintained during systemic life. A high state of vigour is resistant of change, not only up to the period when change commences, but for a time after. Hence it is, that both the onset and the duration of cadaveric rigidity (other conditions being equal) are dependent on the store of vitality possessed by the muscles at the moment of somatic death. Heat -Stiffening. — The rigidity of a cadaver that is fully under the ! influence of ordinary cadaveric rigidity may be increased by sub- ! iecting the body to a temperature of 75° C. The explanation is, that other albuminates present in the muscles besides myosin are thus coagulated. Myosin coagulates (in mammals) about 50° C, another albuminate coagulates at 47° C, and serum-albumin coagulates at 73° 0. If, therefore, either before or after the full development of cadaveric rigidity, the body is subjected to a temperature exceeding 73° C, but short of causing disintegration, all these albuminates are coagulated, and a higher degree of rigidity is produced than that dependent on natural causes. The Involuntary Muscles are a lso aff ected by cadaveric rigidity; the only internal organ necessary to consider in this respect is the heart. I Very soon after death, before the skeletal muscles begin to stiffen, the I heart-muscles become rigid. It has long been observed that when the heart is in the condition of cadaveric rigidity, the ventricular walls, especially the left, are firm and contracted, and present an appearance totally different to that which obtains after rigidity has passed off. It has also been observed by physiologists that certain changes in the condition of the heart-muscles take place during the development of cadaveric rigidity. The heart, like the skeletal muscles, not only stiffens but it undergoes contraction sufficient to entirely alter the relative capacity of its cavities after death. This fact is of great im- portance to the medical jurist, since a decision as to the mode of death 4G FORENSIC MEDICINE. is not unfrequently based on the condition of the heart as found at the necropsy. When the post-mortem appearances of death from syncope were described, the condition of the heart was represented as being con- tracted, which is often the case at a necropsy <>n the body of one who has died from syncope, the result of want of blood to supply the heart. The question arises — is this the condition of the heart at the time of death; or, in other words — did death take place with the heart in systole? Strassmann's : experiments are very instructive in relation to this question. In a number of animals which had been killed by sudden paralysis of the heart, he opened the thorax as soon as circulation and respiration had ceased. In some the heart was examined immedi- ately; others, after superficial investigation, were covered over and left until the next day. When the heart was examined immediately after death, the left ventricle was found to contain more blood than the right. When the examination was made on the following day, the left ventricle was almost invariably found firmly contracted, and its con- tents for the most part, or entirely, expelled either into the left auricle or into the aorta. In animals that had been killed by rapid suffocation, when the heart was examined immediately after death, the right ventricle contained on the average twice as much blood as the left ; at a subsequent examination, the left ventricle was found contracted and empty, or nearly so. In all cases, when the heart was examined immediately after death, even after death from strychnine, both right and left ventricles were found in diastole, relaxed and filled with blood; in no case was the heart found to have stopped in systole. Strassmann directs attention to the extremely early development of cadaveric rigidity in the heart: in animals poisoned with hydrocyanic acid it was observable one hour after death. Even so early as this, the left ventricle did not contain nearly so much blood as it did immediately after death. Post-mortem contraction of the right ventricle is much feebler than that of the left ; only in cases where haemorrhage has taken place is it found empty. These investigations indicate that the condition of the heart at the necropsy affords no certain proof of its condition at the moment of death. Only when left and right sides are both found to be filled with blood can it be said that the original condition has been maintained. In post-mortem examinations on the human subject, it is usual to allow an interval of at least twenty-four hours to elapse before the examination is made. During this time the heart will have become rigid, and whether examined whilst in this state, or subsequently when the rigidity has departed, it is dangerous to assume that the organ is then in the condition which existed at the moment of death. 1 Vierte 7 jahrsschr. f. ger. Med., 1S89. CADAVERIC RIGIDITY. -17 The post-mortem condition of the heart is by no means BO plainly indicative of the mode of death as is frequently taught. The subject of post-mortem contraction of the heart leads to further consideration of the cadaveric contraction of the skeletal muscles previously mentioned. Coagulation of the myosin alone is not sufficient to .account for all the phenomena which accompany the development of cadaveric rigidity ; the shortening undergone by the muscles indicates something more than mere stiffening. 31 any physiologists are of the opinion that after- death rigidity is accompanied by, if not caused by, a true muscular contraction. L. Hermann 1 points out that the chemical processes in vital muscular contraction and in cadaveric rigidity are analogous, with the exception of the formation of myosin from myosinogen. In both, CO,, sarcolactic, and other acids are formed, heat is evolved, and the muscle-current is reversed. He holds that cadaveric rigidity is a contraction of the muscles, occasioned by some unknown stimulation, the contraction lasting- longer and passing off much more slowly than an ordinary contraction. Bierfreund 2 divided one ischiatic nerve in recently killed animals, and invariably found that rigidity was delayed on the injured side. Hemisection of the spinal cord below the pyramidal decussation was also followed by delayed rigidity of the side on which the cord was divided. The effect of cutting off the communication with the nerve-centres was strikingly displayed in a dog in which the left cerebral cortex was stimulated during life, producing right-sided convulsions ; the right half of the cervical cord was subsequently divided, and the animal was then killed. The effect of the convulsions would have been to hasten the onset of rigidity on the side on which they occurred, if no subsequent steps had been taken. The result of cutting off the communication with the brain on that side, however, Avas that, on examining the extremities four and a-half hours after, the left side was pronouncedly stiff, whilst the right side was almost as movable as at the time of death. Two hours later there was si ill a marked difference between the two sides. The body of a man who died forty-eight hours after an attack of apoplexy, also showed delayed rigor on the paralysed side. It was formerly asserted (Nysten) that in hemiplegia there was no difference in the cadaveric rigidity of the two sides so long as the nutrition of the affected muscles had not suffered. "We are now in a position to consider that abnormal occurrence of cadaveric rigidity to which the designation Cadaveric spasm, or Instantaneous rigor, has been given. 1 Lehrbuch der Physiologic. - Arch, fur die \ electrolysis or by the injection of some fluid, one or more of the papillae under the rete is injured, a corresponding depression will be produced on the surface, which, though small enough to escape the unaided eye, will probably be visible if examined, as described, with a lens. Larger or deeper-seated mevi, or moles, may be removed by excision, but for the reasons already given, a scar will remain, although different in shape from the original mark. Tattoo-marks. — It is a favourite habit of sailors and soldiers, and also of others, to have various devices tattooed on the skin of the chest, arms, or other parts of the body. The procedure consists in pricking out the device, or a portion of it, with needles, and then rubbing in some colouring agent, the operation being repeated until PERSONAL IDENTITY OF THE LIVING. 61 the design is complete. A good deal of swelling and inflammation is produced, and on its subsidence the design is found to be more or !■ permanently depicted. The durability of tattoo marks depends on two factors- -the character of the colouring-matter, and the depth to which it is carried. The colouring agents used arc carbon in various conditions— as gunpowder, soot, Indian ink, or lamp black— and vermilion, indigo- blue, writing-ink, and other substances. Carbon is permanent as a colouring agent ; it is insoluble in all fluids, and its colour does not fade. The other substances named are less likely to be permanent, although they may be so. I have seen a tattoo-mark which was produced forty vears ago with ordinary writing ink, and which is still visible. The tattooing in which carbon is used is not black, but is blue-black. The position in which the colouring matter is located is equally important as regards permanency. If it is superficial, there is the possibility of its removal in time by wear and tear or by artificial means. The reported cases in which tattoo-marks have 1 o erased without leaving any trace, were most probably of this clas-. a. shown by the mode in which the obliteration was effected. The application of acetic acid, dilute hydrochloric acid, cantharides, and the like, would remove the epiderm, and dissolve out the colouring-matter, or, if it was insoluble, would cause it to be washed out with the exudation from the cutis. Another mode of obliteration of superficial tattoo- marks is to pick out the coloured particles with a needle. In the case of superficial tattooing, it might be possible to obliterate the mark in some such way without leaving any or but very little trace of its former existence. If, on the other hand, a permanent colouring-matter is carried down to, or into, the papilla, it will remain undisturbed for an indefinite period, and cannot be removed without leaving indelible sear-. Any attempt to obliterate such a mark by means of acetic acid, or of blistering fluid would be futile, and removal with a needle (if practicable) would injure the papilla', and so lead to depressions on the surface of the skin, which would betray what had been done. Of course, a tattoo-mark, of however permanent a nature, may be removed by excision, <>r by the application of caustic substances, or of a red-hot iron, but a depressed cicatrix of a size larger than the tattoo will result; in the Tichborne case (1ST-")) some such attempt at obliterating a tattoo-mark above the left wrist had been made. It may be accepted that when tattoo-marks disappear in the lapse of time, or when they can be artificially removed without leaving a trace, either the tattooer, or the colouring agent, or both, are in fault. The colour Of the hair may be changed either to a darker or to a lighter shade. Hair dyes are usually composed of a solution of a -alt of 62 FORENSIC MEDICINE. silver, lead, or bismuth; when a speedy result is desired, sulphuretted hydrogen is subsequently used to produce a black sulphide. The metals may be tested for by digesting the hair in nitric acid with the aid of beat, dri\ ing off the acid, and then adding the appropriate reagent to a solution of the nitrate in water. Hair may he bleached by means of chlorine, but those who habitually assume light coloured hair usually resort to an aqueous solution of peroxide of hydrogen. Any mode of bleaching the hair causes it to become lustreless and brittle. The indications by which an opinion may be formed in regard to the naturalness or otherwise of the colour of the hair are — that artificially coloured hair has an unnatural hue whether dark or light, and the colour is not uniform, as may be seen by turning the hair over. On careful scrutiny of the hair towards its roots, there will generally be found a difference in tint, especially if the dye has not been applied for a few days. A comparison between the colour of the hair on the head and that on the rest of the body may help in deciding ; but too much confidence must not be placed on this, as there is often, naturally, a considerable difference. If no decision can be arrived at for the moment, a day or two passed without the opportunity of apply- ing a dye will place it out of the power of a suspected person, to keep up the imposition. Sudden complete blanching of the hair from grief or dread is reported to have occurred, but the evidence is scarcely con- clusive. The hair that grows subsequently, however, may be devoid of pigment. When one or more hairs are found on the person of the accused which resemble the hair of the victim, or vice versa— hair on the victim resembling that of the accused— a careful comparative examination has to be made. The points to observe are the tint, diameter, length, and any peculiarities such as are caused by the use of pomade or dye. Hair from the head of a woman is slightly thinner than that from the head of a man. The hairs from different parts of the body vary in thickness. Those from the axilla and from the pubes of both sexes are respectively stouter than from other parts of the body, except from the beard. Hairs that have never been cut, as those of the eyelids and eyebrows, taper to a point ; hairs that have been cut are either stumpy at the ends, or are split into several branches. The student is strongly recommended to examine microscopically, hairs from the commoner domestic animals — the cat, the dog, the horse, the cow, and the sheep, so as to become familiar with their appearance. The same advice applies to fibres from various fabrics — cotton, wool, silk, linen, Arc. Footprints sometimes afford evidence of identity. The impression may be that produced by the naked foot, or by the boot or shoe. In the case of the bare foot, the evidence afforded is rarely conclusive, HL00D AND OTIlliK STAIN'S. G3 unless there is some distinct peculiarity or deformity. Nevertheless, if the impression is sufficiently well-marked, a cast should be taken, or in the case of a foot-stain on a hard surface— as when an individual treads with the naked foot into a pool of blood, and then produces a print on the neighbouring unstained pari of the floor — a tracing should be obtained by laying a piece of traei in;- paper over the dried stain, and carefully going over the outline of it with pen and ink. If possible, the hoard or flag with the print entire should be removed, as affording still more direct evidence. More reliable is the evidence obtained from the impression produced by the tread of a foot wearing a hoot or shoe. Even in this ease it is only when the identical 1 t or shoe is forthcoming that convincing proof is afforded. Conclusions drawn from comparison between the impression and a boot belonging to the accused other than the one that produced the impression are open to serious objections. If the impression is sufficiently distinct as to yield a cast one of two methods may be adopted. The impression may be carefully smeared with a flexible feather dipped in oil, and then filled in with plaster of Paris mixed with water to the consistency of cream. Ample time must be allowed for the plaster to set before attempting to remove the east. The other method is to hold a large piece of red-hot iron (a cook's salamander is convenient) over the impression, without touching it, until it is well warmed, and then to gently sprinkle the impression with paraffin wax chopped up into a coarse powder. The hot iron should be re-applied after each addition of paraffin, so as to render it riuid, until a sufficiently thick cast is obtained. When the paraffin is set, which takes place almost immediately, the cast is carefully removed and any adhering soil gently detached with a soft brush. The marks on an accused person resulting from scratches, cuts. &c, will be dealt with when discussing the question of homicidal violence. CHAPTER IX. BLOOD AND OTHER STAINS. In medico-legal investigations it is frequently of the greatest import- ance to determine whether stains on the clothing of the accused, or on a knife or other weapon found in his possession, are or are not due to blood. The question may have to be solved under difficulties, such as result from the stain being very small, very old, or on foul linen. The 64 FORENSIC MEDICINE. opinion of the expert only becomes necessary when the stain is of ambiguous appearance, or of microscopic dimensions; the appearance of a fabric which has been drenched with blood is usually sufficiently characteristic as to need little critical examination. For this reason the medical jurist has to select, from the methods used in the physio- logical laboratory, those which yield the most reliable results with mere traces of blood : the intention is not to demonstrate all the properties of blood, but simply to identify it. Blood-stains may be examined by three methods — Microscopical, Spectroscopical, and Chemical. MICROSCOPICAL EXAMINATION OF BLOOD-STAINS. If a blood-stain is recent it will present a bright red, or redd ish- brown colour, and the fabric on which it exists will be stiffened. The stain should first be carefully examined with a short focus lens, or with the low power of the microscope. The fabric will be found to have red filaments, and minute clots interspersed in bhe meshes of its fibre s, which present all the outward appearances of coagulated blood. In old blood-stains no coloured substance is seen lying on the fabric as in recent stains : the appearance under the lens is simply that of a fabric that has been stained by some dye. If a small piece of recently stained fabric is cut out and placed in a watch-glass with a few drops of glycerine and water (1 to 10), the colouring matter will rapidly tinge the solution, and in a short time a few drops may be squeezed out of the cloth on to a microscope slide, covered with a thin glass, and examined under a power of 300 to 400 diameters. lied corpuscles will be seen in various conditions in accordance with the age of the stain. If quite recent, many of them will present a fairly normal appearance ; others will be contracted and out of shape, irregular in outline, or milled at the edges like coins. With increasing age of the stain the Mood corpuscles shrivel up, and become more difficult of recog- nition, until at last they are completely disintegrated. The distinction of human blood from that of animals is a question that has long exercised the minds of medical jurists. The blood of birds, fishes, and reptiles presents sufficiently marked differences as to> render differentiation between it and human blood possihle. The red corpuscles are larger than those in human blood; they are oval in shape, and are nucleated. The only mammals which have blood corpuscles characteristically different in shape from those of man belong to the camel tri be, which also have oval red corpuscles, but they are not nucleated. The difference in size between the red corpuscles of man and those of the commoner mammals is so slight MICROSCOPICAL EXAMINATION OF BLOOD-STAINS. 65 that even with fresh blood a witness would not be justified in deposing positively that a given specimen was derived from a human being, and not from one of the lower animals; much less when the corpuscles have been dried, and subsequently immersed in an artificially prepared substitute for serum. Of the commoner animals the sheep presents the most marked difference in size of red corpuscles as compared with those of man : the proportion is as 5 to 7-7. Differences in size, which may be of considerable interest from the histological standpoint, are not necessarily sufficiently distinctive for medico-legal purposes. In questions where the life of a possibly innocent man is at stake, all expert evidence must be free from doubt; it may, therefore, be stated in the witness-box that, with the exceptions mentioned, it is impossible positively to distinguish human blood from that of the lower animals. The same attitude is to be taken when the subject of menstrual blood is under discussion; such blood, although possessing certain character- istics as regards coagulability, and reaction to indicators of alkal inity or acidity, is not capable of being differentiated absolutely from blood derived from other parts of the body. Whether the result of the microscopical examination is in favour of the stain being clue to blood or not, further investigation is to be made. It is convenient in the first place to have recourse to what is known as the Guaiacum Test. If the suspected stain is on a fabric, a fragment should be cut off and placed on a colour-slab, or other white non-absorbent surface. To it add one or two drops of a freshly-prepared solution of guaiacum in alcohol and promote admixture by manipulation with the point of a glass rod. Then drop on a little ozonic ether, or aqueous solution of pei-oxide of hydrogen. If the stain consists of blood, a blue colour is produced ; if not, no colour-change takes place. When the stain is on dark-coloured cloth — e.g., from a black coat — the blue colour may be seen on the white surface around the fabric, or a piece of white filtering paper may be superimposed and pressure applied, in winch case the paper will be tinted blue. This test is only to be accepted when it yields a negat ive react ion — that is to say, when no colour- change results, blood is not present. In its positive phase — the production of a lilue colour— the indication is only to be accepted pro- visionally : the substance tested may be blood, but corroboration is required before a decision is given. Other substances than blood possess the property of striking a blue colour with guaiacum and peroxide of hydrogen, therefore on no account must a positive opinion be expressed from the indications obtained by this test. Even a negative result with this test must not be considered final. It is an axiom in forensic medicine that every detail demands every possible 5 GG FORENSIC MEDICINE. corroboration. The guaiacum test, therefore, is only a preliminary test which is easy of application, and requires but a fragment of material. Its use is to pave the way for further inquiry. The next step is to cut out a portion of the stained fabric close round its margin, and to place it in a watch-glass with a few drops of distilled water. The colouring matter from a fresh stain will be readily dissolved out. If the stain is old the colouring matter will have been converted into hamiatin and will be much less soluble. The appearance of the stain, if it is on linen, or other light-coloured fabric, will afford an indication of its age. Fresh stains are of a more or less bright red, with the lapse of time the colour becomes browner, but retains a trace of red in its composition for years. The rapidity with which the colour of a blood-stain undergoes this change depends on the freedom with which it is exposed to the air, and upon the presence or absence of chemical impurities in the air, such as the oxides of sulphur, hydrochloric acid, ozone, and the like. For this reason blood-stains change more, rapidly when exposed to the air in large manufacturing towns than in agricultural districts. It is futile to attempt to infer the age of a blood-stain from its appearance, since it is due to external conditions of unknown activity. If the stain appears old, the watch-glass with the portion of fabric covered with water should be protected by an inverted watch-glass, so as to retard evapora- tion, and left for half an hour or more ; it may be preferable to use a test-tube instead of the watch-glass. Some amount of manipulation with a glass-rod may be resorted to in order to facilitate solution of the colouring matter, but it is well to avoid mechanical interference as much as possible, lest the resulting solution is rendered turbid. Fil- tration will remedy this, but if the quantity of coloured fluid is small, the loss from absorption by the filter paper is of importance. Decanta- tion, after allowing the matter in suspension to subside, is open to the same objection — loss of fluid; moreover the suspended matter is often reluctant to subside. Should the stain resist the solvent action of water a saturated solution of borax in cold water may be used, and if very insoluble a few drops of ammonia water may be added, in which case the solution obtained will be one of hsematin. Alkalies convert hemoglobin into hsematin, but if the blood colouring-matter is in- soluble in water, it has already undergone this change. SPECTROSCOPICAL EXAMINATION OF BLOOD-STAINS. The fluid thus obtained (after filtration, if necessary) is placed in a small test-tube, or, preferably, in a glass cell with parallel walls, and examined with the spectroscope. A small direct-vision spectroscope is SPECTROSCOPICAL EXAMINATION OF BLOOD-STAINS. G7 convenient, but more exact results are obtained with a single prism table-spectroscope. Should the amount of fluid for examination be very small, the adaptation of the spectroscope to the microscope, known as the micro- spectro scope, must be employed. In this ease, it is best to use one of Sorby's cells, which consists of a short Length of barometer tubing— about half or three-quarters of an inch — ground to parallel surfaci the end-, one of which is cemented on to an ordinary microscope slide. A couple of dro ps of the fluid to be examined will till the cell, and thus expose a layer of half or three-quarters of an inch in thickness between the source of light and the prisms. It is well completely to fill the cell with the fluid to be examined, and to slide a thin cover- on to the upper end of it, avoiding air-bubbles. The cell is then placed on the stage of the microscope, the eye-piece of the instrument being replaced by a direct-vision spectroscope with focusing arrange- ment. The spectroscopic eye-piece is furnished with a reflecting prism at one side, so that a solution containing blood colouring matter in a known condition can be made to throw its spectrum alongside that of the blood under examination for the purpose of comparison. When using the microspectroscope, the mirror of the microscope is so adjusted as to project the rays of light through the tubular cell into the instrument, as in ordinary microscopic work. A bright source of artificial light is preferable to daylight, as the presence of Frauenhofer's lines may be embarrassing. The position of the D line can readily be ascertained by bringing a platinum wire, which has been previously dipped in a solution of a sodium salt, into the flame. The spectra of hamioglobin and its derivatives are so characteristic that, when obtained, their evidence may be considered conclusive of the presence of blood. For this assertion to hold good, it is essential that the alterations about to be described in the position of the absorption bands should be produced; a final opinion must not be given from an examination of blood colouring matter in one condition only. There are other substances which yield spectra closely resem- bling the spectrum of oxyhemoglobin, but no substance other than blood will give in addition the bands of reduced haemoglobin, and of reduced hsematin. If all these spectroscopic reactions are produced from a single specimen of colouring matter, that colouring matter is derived from blood without the possibility of doubt. The spectrum of oxyhemoglobin is characterised by the presence of two absorption bands between the 1) and E lines of the solar spectrum. The first band commences at the D line, and extends towards E. The second band commences after a slight gap, and terminates at the E line. Some absorption also takes place at both ends of the spectrum, 68 FORENSIC MEDICINE. especially at the violet end. It is to be remembered that the appear- ance of the spectrum, as to breadth of bands and general amount of absorption, varies with the concentration of the solution under examination. A good plan is to begin with a strong solution, and gradually to dilute it until the best results are obtained. The spectrum described is the one met with in recent blood-stains. As before stated, the " age " of a blood-stain is not entirely determined by the time that has elapsed since the blood escaped from the body. It may be prematurely aged by the presence of acid vapours in the air, or it may retain its freshness in a pure atmosphere for a considerable time. It is important to bear this in mind. Very frequently the blood colouring matter will have passed from the condition of oxyhemoglobin into that of methaemoglobin before the stain comes to be examined. The exact constitution of methenio- globin has not yet been determined. Perhaps the prevailing view is that it consists of hemoglobin in combination with the same amount of oxygen as that of oxyhemoglobin, but that the combination is closer. A current of neutral gas — as hydrogen or nitrogen— will not disassociate the oxygen of methemoglobin as it does that of oxyhemoglobin. When the stain has passed into the condition of methemoglobin, it will have acquired a brownish hue, and will probably yield an acid reaction. The solution obtained from a stain in this state is less red and more brown than one obtained from a fresh stain, there is, however, no great diminution in solubility. The spectrum of metliEemoglobin for all practical purposes may be said to resemble that of 2 Hb with the addition of a thin band in the red, nearer the line than the D. There is also more absorption of the violet end of the spectrum than is the case with 2 Hb. The methemoglobin spectrum then consists of three bands— two in the same position as those of 2 Hb but paler, and one thin band in the red. If to a solution of either oxyhemoglobin, or of methemoglobin, a reducing agent, such as Stoke's reagent [an aqueous solution of ferrous sulphate with a little tartaric acid, alkalised with ammonia], or, what is preferable, ammonium sulphide is added, the spectrum of reduced hemoglobin is obtained. This spectrum consists of a broad, ill-defined band, occupying very nearly the same position as the two bands of Oo Hb— that is to say, covering almost all the spectrum between the D and E lines. The absorption of the violet end of the spectrum is about the same as with 2 Hb ; the red end is rather more absorbed. After identifying hemoglobin in its two states — in combination with oxygen and deprived of it— some of it is to be converted into hematin. Hemoglobin is decomposed by acids and alkalies into two SPECTROSCOPICAL EXAMINATION OF BLOOD-STAINS. 09 substances : h^matin — acid or alkaline — which retains the iron of haemo- globin; and globin. Acid haematin has a spectrum not unlike that of methaemoglobin ; it is not so easily seen as some of the other spectra of blood, and for its recognition requires a good instrument and a solution of a definite density. Alkaline hsematin also has a spectrum of its own, more difficult to obtain than that of acid hsematin. It is not necessary for the identification of blood colouring matter that the two last-mentioned spectra should be examined. It is sufficient if, in addition to the spectra of haemoglobin or methaemoglobin and of reduced haemoglobin, the spectrum of reduced haematin, or as some prefer to call it hsemochromogen, is obtained and identified. To a little of the original solution of haemoglobin or methaemoglobin add a few drops of a 20 per cent, solution of sodium hydrate. A change in colour is seen and the original spectrum disappears. Then add a few drops of ammonium sulphide to the solution of alkaline haematin thus obtained, a further change of colour is at once apparent, the solution becomes somewhat claret-coloured. On examining with the spectroscope the spectrum of reduced haematin the most pronounced of all the blood-spectra is seen. It consists of two bands slightly nearer the violet end of the spectrum than the bands of 2 Hb. The first band is dark and is exceedingly well defined at the edges ; it is situated about midway between the D and the E lines. The second and broader band, not quite so well defined, commences before the E line and extends as far as the b line ; the violet end of the spectrum is more absorbed than is the case with Oo Hb. The reducing power of ammonium sulphide is not so active as that of Stokes' fluid, and in consequence, when ammonium sulphide is used, the second band of reduced haematin is not, as a rule, fully developed for some time (5 or 10 minutes) after the first, which appears at once. Reduction may be hastened by gently warming the solution after the addition of ammonium sulphide. If the colouring matter of the blood-stain has been converted into haematin before the fabric is submitted to examination, the first solution obtained from it will yield the spectrum of acid haematin. The resemblance between the bands of methaemoglobin and those of acid haematin has already been pointed out. The addition of a reducing agent at once distinguishes the one from the other — the methaemoglobin spectrum changes to that of reduced haemoglobin, the acid haematin spectrum to that of reduced lueniatin. When acid haematin has been produced by natural causes (without the addition of acid), the use of ammonium sulphide, as reducing agent, obviates the necessity of previous alkalisation. Both haemoglobin and haematin after being reduced can again be 70 FORENSIC MEDICINE. oxidised by shaking up the respective solutions with air. To enable this to be done easily, the smallest quantity of the reducing agent must be used that will effect its purpose. CHEMICAL EXAMINATION OF BLOOD-STAINS. If there is sufficient material at command the most conclusive of the chemical tests for blood may be resorted to — the production of Hsemin crystals. Cut out a piece of the stained fabric about the size of a postage stamp; much less is sufficient with skilful manipulation. Divide this piece into three equal sized slips and place them one over the other on a microscope slide. Add a minute crystal of sodium chloride, and sufficient glacial acetic acid to thoroughly saturate the fabric and then a few drops more. Roll a glass rod backwards and forwards over the fabric for a minute or two, so as thoroughly to incorporate the acid with the colouring matter. A dirty brown fluid can now be pressed out of the fabric by a final passage of the rod, the fabric itself being at the same time withdrawn with a pair of forceps. Bring the fluid to the middle of the slide by stroking it up at each side with the shaft of the rod, and drop on a thin cover-glass. Hold the slide by one end, and pass the centre of it to and fro over the flame of a Bunsen burner ; continue until active ebullition, manifested by bubbles rapidly forming under the cover, takes place, Then allow the slide to cool gradually. When cold examine under a power of 300 diameters. In the production of haemin crystals there are one or two precautions to be observed. The amount of sodium chloride must be very small — a crystal the size of a small pin's head is sufficient ; if more is added the field, when examined with the microscope, is seen to be covered with cubes of sodium chloride crystals. Plenty of acid must be used. The boiling demands care : it must be thoroughly done, but if heat is too suddenly applied the glass will probably crack ; if excess of caution is observed — the heat being applied very gradually — the fluid round the circum- ference of the thin glass will be evapor- ated, and the dried up residue will seal in the fluid beneath the cover, so that when ebullition takes place the cover-glass will be projected to a distance. Haemin crystals { r Iei<>lir)tv's crystals) are composed of hydrochlorate of hsematin. They are insoluble in water, alcohol, and Fig. 6.— Ha?min crystals, dilute acetic and hydrochloric acids. They are soluble in boiling acetic and hydrochloric acids, and in the caustic STAINS OTIIEK THAN BLOOD. )]] alkalies. They yield the blue reaction with the guaiacuru test, and when incinerated, and the ash is treated with a drop of hydrochloric w acid and a solution of potassium sulphocyanide, the presence of iron !is demonstrated by the red colour produced. Under the microscope they appear as brown or claret coloured crystals which have a steely- blue (watch-spring) lustre by reflected light. They usually take the form of rhombic plates which are frequently superimposed so as to form crosses or stars. The size of the crystals varies: sometimes they are exceptionally Large and well formed, at others they are scarcely recognisable with a power of 300 diameters. When small they occasionally resemble the so-called whetstone crystals of uric acid, but are much smaller. Crystals obtained in the manner described, and possessing the above-mentioned physical and chemical characteristics, afford conclusive proof of the presence of blood. Blood-stains on knives, or other steel weapons, are frequently very difficult to deal with if the stain is not quite fresh; the colouring matter has a tendency to combine with the oxide of iron, and thus become very insoluble. The saturated borax solution with a few drops of ammonia water will dissolve out sufficient hannatin for spectrum analysis. The deposit is scraped off the weapon, and digested with a little of the solution, and then decanted or filtered off the iron oxide. Fresh blood stains on metal are easily dealt with, except when the stain is very thin and in small patches, as after a knife that has been used for homicidal purposes has been wiped with a cloth. Careful pencilling of the stained portions with a small camel-hair brush dipped in distilled water, or borax solution, will generally procure enough colour- ing matter for recognition by the microspectroscope. If a clasp-knife is undergoing investigation, special attention should be paid to the joint, and if on examination with a lens it appears to contain colouring matter, the pivots must be withdrawn, and the parts of the knife separated; in this way ample evidence may not unfrequently be obtained. When blood has been projected from a divided small artery, it may reach a neighbouring wall, or article of furniture. The appearance will probably be that of small splashes or spots; sometimes they take the form of notes of exclamation when the jet falls obliquely on the surface. Distinction between arterial and venous blood found on clothing, or on furniture, cannot well be made except when a verj small artery has sprinkled its contents to a distance in a fine spray. STAINS OTHER THAN BLOOD. Rust-stains on knives, but more especially stains produced by then- use in cutting fruit, as oranges or apples— the stain then consisting of 72 FORENSIC MEDICINE. citrate or malate of iron respectively— often present a strong resemblance to blood-stains. Rust-stains are insoluble in water, and the solutions obtained from the stains produced by vegetable acids on steel yield none of the reactions of blood. Fabrics may be stained with vegetable, mineral, or anilin colouring matters. Most fruit stains that resemble blood are altered by ammonia water to a greenish tint; other vegetable stains are made crimson by the same reagent; some, as logwood, are turned to a bluish-black. Dilute acids often alter the colour of vegetable stains. Mineral stains are often due to the oxide, or some of the salts of iron. Ammonium sulphide usually blackens such stains, but as the ammonia of this reagent darkens some vegetable stains, as archil and logwood, it is necessary to make a control experiment with ammonia- water alone. In the case of the oxide, or of ferric salts, a drop of H CI, followed by a drop of potassium ferrocyanide solution, will yield Prussian blue. Most of the anilin stains resembling blood when treated with dilute HN0 3 become yellow, or tinge the excess of acid yellow. In addition to these tests, the absence of haemoglobin and its derivatives must be proved. CHAPTER X. IDENTITY OF THE DEAD. The identification of the dead is required when the body of an un- known person who has died from violence, starvation, or disease is found in the open air, or in an out-house, or other uninhabited premises; after a fire in an inhabited house or hotel where strangers are tem- porarily residing, or after the occurrence of an explosion, or of a railway accident. The difficulties of the investigation are increased if the body is much mutilated, or is far advanced in putrefaction. Perhaps the most diffi- cult cases are those in which dismemberment and mutilation have been effected with the special object of preventing recognition of character- istics that might lead to identification. There are certain points to which attention must be directed, which constitute the basis of an investigation having for its object the identi- fication of the body of an unknown person. The stature, age, sex, general state of nutrition, colour of hair, scars, skin-marks of any kind, THE STATURE. 73 deformities, indications of past injury to the bones, and the presence of false teeth, with absence of the natural teeth, all claim attention. In the unmutilated fresh body most of these points can be cleared up, the age, as a rule, being the most difficult. When an opinion has to be founded on an Investigation of fragments of a bod} r , with the flesh and skin remaining, much depends on tin- nature of the parts. An entire hand, for example, would convey more information as to the social condition and occupation than afoot. If the body has been very much mutilated, and but a few fragments are forthcoming, a part of the thorax or abdomen would probably reveal the sex of the victim. Close attention to details is necessary to secure success in all inquiries of this kind. When fragments of a body are examined, special attention should be paid to the parts where separal ion from the rest of the body has been effected. An exact description should be written down at the time, and if possible a photograph taken, or a drawing made, so that at a future time, if other fragments are found, it may be ascertained whether they belong to the same body or not. The presence of scars, however small, should be noted. It may subsequently turn out that the individual whose body is under exam- ination had been bled from the arm, or had received a small wound, the scar of which was known to have been present up to the time of his disajipearance. It has been recommended in cases where there is suspicion of the previous existence of tattoo-marks, to take out the neighbouring lymphatic glands, and to examine them for traces of the colouring matter. THE STATURE. Within somewhat wide limits, the stature may be determined from the measurement of single limbs, or even of some bones. The length of the arm multiplied by two, with six inches added for each clavicle, and an inch and a half for the width of the sternum, gives the distance between the tips of the middle fingers when the arms arc stretched out, and approximative^ the height of the body (Taylor). The femur equals about -275 of the body height (Quain). Calculations have been made, and tables drawn up with the view of establishing a relation between the length of some of the long bones, and the stature of the individual to whom they belonged, but the mean ratio is obtained from measure- ments ranging over extremes too widely apart to permit of its general application. Estimations of stature from the measurements yielded bv •one or two bones are very unreliable; if they are given at all it must be in a qualified manner, as they partake largely of the nature of guess- /4 FORENSIC MEDICINE. work. When the entire skeleton is available, li inches is to be added to its length to represent the soft structures. Criteria for the estimation of age have already been given. If the body is entire, but in an advanced stage of putrefaction, there may be difficulty in ascertaining even the sex. The points to be noted are the hair of the head, that of the pubes, and the development of the breasts. In women the hair of the head is, as a rule, longer and finer than in men. The pubic hair does not usually advance so near the umbilicus in women as in men. The breasts are fuller in women. In female children all but the first indication will be absent. The clothing will help identification, even if only fragments remain attached to the body. Metallic articles, as rings and other ornaments, may afford a clue. The resistance offered by the uterus to putrefactive changes is to be borne in mind. If the soft parts have disappeared, the bones will afford indica- tions as to age and sex. When isolated bones, or fragments of bones only, are forthcoming, the first question to be answered is : — Are they human, or do they belong to one of the lower animals? A bone that is intact does not usually present insuperable difficulty ; a due acquaintance with human osteology will enable a satisfactory conclusion to be arrived at, for or against. If a bone is not human, it is by no means easy for an ordinary medical man to determine the animal from which it is derived ; unless well versed in comparative osteology, it is best for a witness to content himself with the statement that the bone in question is not a human bone. Fragments of the shafts of the long bones may present great difficulties, and demand corresponding cautiousness on the part of the witness. The fragment may be so small and anomalous in appearance, that the question becomes — Ts it bone or not 1 The microscope will determine the question by demonstrating the presence or absence of the structural characteristics of bone. From time to time collections of bones are discovered under circum- stances which give rise to suspicion that a murder has been perpetrated. If such a collection is referred to the expert for a rej)ort, the first step is to determine whether they are human or not. If they are human, they should be arranged in order, so as to build up a skeleton as com- pletely as possible. It sometimes happens that duplicate bones are present, which, of course, indicate the dual nature of the remains. A full report should be drawn up, and a drawing or photograph taken when the arrangement is complete. Any abnormality or trace of injury should be noted, taking care not to include under this head the results of violence produced by the implements used in the process of disinterment. The questions to be answered are : — What was the age, SEXUAL CHARACTERISTICS OF THE SKELETON'. 75 stature, and sex of the individual or individuals to win mi the bones belonged, and are there any indications of the cause of death? I. question must be considered separately. The age is to be inferred from the condition of the teeth, and that of the epiphyses of the long bones, together with the other indications previously tabulated. The stature can only be arrived at approxi- matively, especially if the skeleton is ao1 complete. The question of sex, as regards the skeleton, remains to be considered. SEXUAL CHARACTERISTICS OF THE SKELETON. The female skeleton is smaller and of slighter build than that of the male, the individual bones weighing less than the corresponding bones <>f the male. The following account of the chief distinctions between the bones of the male and female skeleton is taken from Macalister's Human Anatomy : — The male skull is larger, heavier, and more ridged than the female, with more prominent mastoid processes, occipital protuberance, zygo- matic and superciliary ridges, and a larger capacity (11 : 10), especially in the frontal and occipital regions. The female skull preserves a look of immaturity, and such characters of immaturity as the pre- ponderance of temporal length over frontal, the prominence of the parietal tubera and the concomitant narrowness of the base. The average maximum length from the glabella (the smooth spot between and below the superciliary arches) to the most prominent point of the occiput is 19-6 cm. in the male, and 18-.3 cm. in the female. The capacity of the skull — ascertained by filling it through the foramen magnum with No. 8 shot (the other foramina being plugged with cotton wool) and then measuring the shot in a graduated vessel — averages, in the European male, 1570 cc, the European female 1378 cc. The female lower jaw has a less prominent chin, and a weaker, shorter coronoid process than the male, the angle formed by the ramus and body is greater. The thorax is shorter and wider in the female when not distorted by stays. The ribs are more oblique. The twelfth male rib averages 103 mm. in length, that of the female 83-8 mm. The meso sternum (body) is more than twice the length of the presternum (manubrium) in the male, but less in the female. The lumbar curve in the female vertebra] column i^ of greater length, and the lumbo-sacral angle is greater than in the male. The normal adult male sacrum is about 105 mm. high and about 117 broad, the female about 101 high and 118 broad; these relations are expressed by the . . n breadth x 100 sacral index . . feacra, such as those of Europeans, in 76 FORENSIC MEDICINE. which this index exceeds 100, are called platyhieric, those under 100 are dolichohieric, as is the case in most of the black races. The sacral index of British males is about 1124, of females 116. As a rule, all females are platyhieric. Fig. 7. — Male sacrum. Fig. 8. — Female sacrum. Ward 1 gives the following characteristics of the curve of the male and female sacrum respectively : — The curvature of the female sacrum occurs chiefly at the lower half of the bone. The upper half is nearly straight. The male sacrum is on an average more curved than that Fig. 0. — Male pelvis (from Macalister's Anatomy). of the female, and its curvature is more equally distributed over its whole length. The male sacrum, in many instances, approximates in 1 Outlines of Human Osteology. SEXUAL CHARACTERISTICS OF THE SKELETON. 77 form to that of the female, hut the female sacrum rarely presents tin- characters proper to the male. Thus it is much more common to find a straight sacrum in a male subject than one that is very much curved in a female. The pelvis, as a whole, is the mosl characterisi ic part of the skeleton in the two sexes respectively. The male pelvis is deeper, rougher^ with deeper iliac fossae and symphysis, a smaller pubic angle, a vertically ovate obturator foramen, and indexed fcubera ischii. The female pelvis Fig. 10. — Female pelvis (from Macalister'a Anatomy). is shallower, wider, smoother, with shallower symphysis, and wider pubic arch, everted ischia, and a triangular obturator foramen. These sex characters are discernible at birth. The sagittal diameter of the brim from sacral promontory to upper edge of symphysis pubis is 100 mm. in the male, 116 in the female. The transverse, 124 in male, 135 in female. The oblique from the sacro-iliac joint to the ilio-pubal eminence, 110 in the male, 12G in the female. The index of the , . , . sagittal x 100 ,.„ _. „ ,, pelvic brim, — r . — , varies in different races. Ihe neck of the transv. diam. femur has a lower angle in the adult female than in the male, averaging 118°, the male being 125°. The skeleton may bear traces of violence inflicted during life. Injuries to the skull caused by firearms are usually too obvious to escape notice. Fractures, especially of the base, might be overlooked except a careful examination is made. Injuries to the cervical vertebrae, from excessive violence due to death by strangulation or by hanging, are to be looked for, also fractures of the ribs. If such injuries have been produced immediately before death there will be no evidence of attempt at repair. The presence of callus shows that an interval elapsed between the receipt of the injury and death. Indica- tions of old fractures should be sought for. The remains of the 78 FORENSIC MEDICINE. African traveller Livingstone were identified by the presence of an old ununited fracture of the humerus, the existence of which was known to his friends. SUBJECTS INVOLVING SEXUAL RELATIONS. CHAPTER XL SEXUAL ABNORMALITIES. The subject of sex is one that frequently comes under the notice of the medical jurist. Questions relating to it may arise in regard to newly-born children, as when a woman gives birth to an infant whose sex is doubtful, but which, if a male, is heir to an estate. Later in life sexual development or capacity has to be considered in relation to impotency, rape, impregnation, and allied subjects. In order that an infant shall be capable of inheriting an estate the law demands that it shall have "the shape of mankind," if the estate is entailed on male heirs the question of sex is added. It is impossible to define the limit at which deformity is so excessive as to deprive the subject of it of the right to be considered a human being. The various types of monsters which may be born alive are so diverse that although they may be capable of scientific classification each case has to be separately considered. The law leaves the question open without determining the degree of deviation from the normal which would constitute absence of human shape. Under these circumstances it is useless to attempt any abstract differentiation, all that the expert can do is to make a very careful and detailed examination of the infant, and to report what he has found to the court. It may be observed parenthetically that, contrary to popular opinion, it is criminal to hasten the death of an abnormally formed foetus or monster, although it may obviously be incapable of long survival. The question of sex in an infant is sometimes equally impossible of determination. Here, however, the morphology of the sexual organs serves as a guide to interpretation. In a living infant, the external generative organs only are available for examination. As an aid to the interpretation of abnormal appearances a glance at the condition of matters at the period of development when the sexes differentiate will SEXUAL CHARACTERISTICS OF THE SKELETON. 79 be of service. The accompanying two figures diagrammatic-ally re- present the male and female external organs in this stage. In Fig. 11 the genital tubercle (c) forms the clitoris, the genital fol< become the labia minora, and the cutaneous folds of the cloaca! lips (X) remain separate and form the labia majora. The urogenital sinus remains as the vestibule. In Fig. 12 the genital folds have approxi- mated and united in the median line, closing on the urethra as far as the glands of the penis, /'. Those cutaneous folds of the cloaca, which in the 1'eina le remain separate as the labia majora, coalesce and by their union form the scrotum (S). If the genital folds do not unite, the urethra remains open at tiie raphe (Ji), producing the condition called hypospadias. The conditions which obtain in the fully developed external organs of the female are approximatively those which exist before differentiation of the sexes. j Further growth and development in a new direction is required to form the male organs, and during its progress m< ist of the conditions arise which cause ambiguity of sex. It is easy to see that hypospadias may be so extensive as to cause the male organs to appear like abnormally formed female organs. If the testicles have not descended, and the scrotum is cleft, there exists a condition resembling that before differentiation. In such a case it would not be easy to determine the sex from external inspection only. If one or both testicles can be found and identified the sex of the infant is thereby determined — it is a male. The detection of an ovary is equally determinative of the female sex. If a glandular organ is accessible it must be carefully examined by the touch, t he harder it is the more li kely it is to be an ovary. The virgin ovary is largely composed of fibrous tissue, hence it is hard— more so than the testicle. In the adult, compression of the glandular body, if the subject is a male, pro- duces the peculiar sickly, faintly feeling which is experienced when the testicles are thus treated. The representative of the penis may or may not be perforate ; its prepuce may be free, or it may be continuous w it li the genital folds or labia minora, the two last-named conditions being in favour of the female sex. If the opening of a cul-de-sac exists below the mouth of the urethra and in front of the bowel, it will probably represent the Mullerian ducts or vagina, and, therefore, is indicative of the female sex, a similar opening, however, may exist in the masculine type of hermaphrodism being that of the vesicula prostatica — the homologue of the uterus. Epispadias consists in the < s FORENSIC MEDICINE. existence of an opening on the dorsal aspect of the penis which is often- accompanied by genera] malformation of the other external genitals. It maybe associated with extroversion of the bladder. After puberty indications may be afforded by the occurrence of functional activity of the sexual apparatus. If periodic discharges of blood take place, they are indicative of the female sex ; seminal discharges indicate the male sex. The bodily conformation may be taken into consideration — the growth of hair, the general contour, the mammary development together with the vocal intonation. Moral characteristics are not of much value as determinatives, since long custom exercises a powerful influence as regards the sexual proclivities and the habits of the individual. Developmental malformations of the internal as well as of the external organs of generation are also met with. Individuals so deformed are often, though improperly, called Hermaphrodites. The union of the sexes in one being is an old myth having for its basis the assumed power of self reproduction. In this sense hermaphrodism has no existence ; but so far as the linking together in one person of the male and female generative organs, or of parts of them is concerned, a goodly array of examples are to hand. It is customary to speak of cases of simple malformation of the external genitals which impart a false or ambiguous sexual identity, as cases of spurious or false her- maphrodism. Such cases have already been described. A few words remain to be said on the subject of so-called true hermaphrodism. The normal sequence in the male subject is for the Wolffian ducts to persist, whilst the Mullerian ducts almost entirely disappear; in the female the converse takes place. It happens from time to time that this order is not followed, and in place of it both the Wolffian ducts with the primitive reproductive gland, and the Mullerian ducts, develop in one and the same individual, into the organs of which they are the antecedents in the embryonic state. Watson x tabulates the sexual homologies thus : — Female. Sinus uro-genitali3. Male. Urethra. Upper part of urinary Upper portion of prostatic pedicle. urethra. Vestibule. Lower part of urinary Lower portion of prostatic pedicle. and membranous urethra. Glands of Bartholini. Blastema. Glands of Co wper. Crura and corpus Corpora cavernosa. Crura and corpus penis. clitoridis. Clans clitoridis and Corpora spongiosa. Clans penis and corpus vaginal bulbs. spongiosum urethra?. Labia majora. Genital ridges. Scrotum and raphe. 1 Journ. of Anat. and Physiol., 1S79. SEXUAL CHARACTERISTICS OF THE SKELETON. 81 Sir J. Y. Simpson 1 classified the so-called true hermaphrodism into : Lateral. — Testicle on one side, and ovary on the other. Transverse. — External organs male and internal female, or the reverse. t (a) Ovaries with combined male and female passages. Vertical, or double.— I (b) Testicles with combined male and female passages. ' (c) Ovaries and testicles coexisting on one or both sides. Watson considers the lateral to be the only true kind of hermaphro- dism, and thinks that the others ought to be included in the class of spurious hermaphrodism, except (c), which ought probably to be placed in the category of double monsters. The following are examples of different forms of hermaphrodism : Schmorl - describes a case of lateral and transverse hermaphrodism in which the external organs had a general resemblance to the male form : there was a well-developed, but imperforate penis. The scrotum was divided : in the right half there was an organ of the same structure as the testicle ; the left half was empty. The internal organs were of the female type :— a vagina, which did not open externally, a uterus with cervix and Fallopian tubes, and an ovary on the left side. Hutchinson, Junior, 3 dissected the body of a full grown foetus, the subject of transverse hermaphrodism. The penis was well formed but for a slight hypospadias, the raphe of the scrotum was very well marked. The bulb and prostate extremely well developed; into the latter opened a vagina, above which were perfectly formed uterus, ovaries, and Fallopian tubes. Heppner 4 examined the body of a child two months old, which presented the appearance of vertical hermaphrodism. The external organs were of the male type ; there w T as a hypospadic penis with glans and prepuce ; an empty scrotum with raphe, and a prostate gland, but no vasa deferentia nor vesicula seminalis. A vagina, a uterus with arbor vitse in the cervical canal, round and broad ligaments, well-formed Fallopian tubes and ovaries existed on both sides. Under each ovary was a testicle, and near each testicle was an organ resembling the parovarium. Ceccherelli 5 describes a living example of vertical hermaphrodism, the subject being fourteen years of age. The mammae were well developed. There was a hypospadic penis. The scrotum was divided and contained only one testicle ; between the folds of the split scrotum, or labia, the neck of the uterus could be felt. The female organs appeared complete. Menstruation had occurred regularly since the twelfth year of age, and the individual had copulated as a woman. From the opening in the penis semen was ejected, a specimen of which was examined by Yirehow and found to contain spermatozoa. 1 Todd's Cyclopaedia of Anatomy. - Virchow's Arch., 1S:S. 3 The Lancet, 1SS5. 4 Du Bois-Eeymcmd'a Arch., 1S70. 5 Lo sperimenlale, IST-f. G 82 FORENSIC MEDICINE. Abnormalities of the Male Organs. — Individuals in -whom one testicle only is in the scrotum, are known as monorchids. This condition, whether the result of imperfect development, or of operative inter- ference, is no bar to procreation. Non-descent of both testicles does not necessarily deprive the individual of procreative power, although it probably lessens it, and may be a positive barrier ; the subjects of this abnormality are called cryptorchids. Many post- mortem examinations of individuals labouring under this defect have demonstrated the absence of spermatozoa in the spermatic fluid, but a number of cases in the living have been recorded in which procreative power has existed, so that the positive evidence outweighs the negative. Even absence of both testicles — at least for a time after removal — does not entirely destroy fertility. This however can only be due to im- perfect ablation, or to the existence of a reserve of speimiatic fluid after the organs which secreted it had been removed. Absence of the penis, or of the whole of the external genital organs, may occur either from defective development, injury, or disease. In some cases the penis is united in its whole length to the scrotum ; if the organ itself is fully formed, the abnormality is capable of being remedied by surgical operation. The female external organs may be wanting, with or without absence of the internal organs. Sometimes the vulva jn*esents a normal appear- ance, but there is no vagina. The vagina may be either congenitally deficient, or it may have been closed by inflammatory processes, not unfrequently from diphtheritic disease in childhood. Surgical pro- cedure can only be resorted to when structures representing the vagina are present. The external organs may be complete, the ovaries and the uterus — one or both — being wanting. The capacity of the vagina may be inadequate for the reception of the penis ; usually this condition is capable of being remedied by appropriate treatment. The condition named Vaginismus, especially if associated with pronounced hysteria, may as effectively bar sexual intercourse as structural atresia of the vagina. Large hernias in both sexes may prevent intercourse. IMPOTENCE AND STERILITY. By impotence is meant incapacity for sexual intercourse, by sterility incapacity for procreation of children. The first term is usually used in reference to the male sex, the second to the female sex; they are, however, respectively referable to both sexes : a man may be sterile as well as a woman, and a woman may be impotent as well as a man. A man may be incapable of procreation, either in consequence of impotence, or, though competent for intercourse, in consequence of SEXUAL DEFECTS IN MALES. 83 absence of the impregnating elements of the semen. A woman may be sterile from absence of the external generative organs rendering her incompetent for sexual intercourse, or, with the presence of these organs, from absence of the ovaries or uterus; in the Litter case she would be sterile without being impotent. It will be necessary to discuss the subject with respect to the two sexes separately, and, for convenience, to take impotence and sterility together. In medico-legal practice the subject of impotence and sterility arises in relation to cases of divorce, legitimacy, and criminal assaults. SEXUAL DEFECTS IN MALES. Impotence and sterility in the male may be due to organic defect or to functional disorder, the organs being anatomically perfect. Age, malformation, and constitutional causes may severally be causal factors. Age. — The two extremes of life may render the individual incom- petent for sexual intercourse; no limits can be stated, however, when this occurs. Extreme Youth. — At the age of puberty, which is usually about the fifteenth or sixteenth year, the sexual powers normally begin to develop, capacity for intercourse preceding procreative power. Considerable latitude occurs in this respect. The earliest recorded 1 age at which the power for procreation existed in the male is thirteen years ; a boy at this age impregnated a young woman. Many cases are recorded of boys becoming fathers at fourteen years of age. Puberty does not consist in a change that takes place at a certain fixed period of life; it is dependent for its early or late occurrence upon hereditary influence, and upon the conditions which surround the individual, morally ami physically. For this reason, when examining a case of reputed sexual capacity, the medical man should not be influenced so much by the age of the individual as by his physical and moral development. There are boys of fifteen or sixteen who are sexually mere children, whilst at a much earlier age other boys have the powers and the instincts of adults. The presence of hair on the pubes, and of a developed penis, with or without the general conditions which indicate incipient manhood — as the tone of voice' and bodily conformation — are strongly indicative of sexual capacity. It is to be noted that, although advanced corporeal development is found in most cases of hereditaiy sexual precocity, when premature puberty has been brought about through evil example and vicious habits, the bodily appearance is often the reverse of manly. In addition to observing the development of the penis, the condition of the prepuce is to be noted : in boys accustomed to sexual grati- ^Brit. Med. Journ., 1SS7. 84 FORENSIC MEDICINE. fication in any form, the glans will be more or less uncovered, unless the prepuce is abnormally long. Advanced age is no barrier to procreative power. It is true that the sexual capacity diminishes with age, and, consequently, an old man is less likely than a youth to impregnate a woman; this however is only stating probability, the medical jurist has to depose to possi- bility. Active spermatic filaments have been found in the seminal fluid of men of 70 and 80 years of age, and even older; numerous instances have occurred in which men who have married at this time of life have had children. So long as there are active spermatozoa present in the seminal fluid, the possibility of impregnation must be admitted. It may therefore be stated that advanced age is not imcompatible with the possible retention of procreative power. The imaginative faculties occasionally completely inhibit the sexual emotions. A man from this cause may be utterly unable to have intercourse with one woman although quite competent with another ; a perverted sentiment causes the mental attitude to be one of extreme disgust at the idea of coitus with the woman towards whom this sentiment is entertained. Debility clue to disease may produce temporary or permanent loss of the sexual functions; most acute diseases of a severe type — as fevers, pneumonia, and the like lead to temporary loss. Of chronic diseases diabetes is one that commonly abolishes sexual energy. Diseases of the nervous system have a special tendency to derange the sexual functions. Tabes at first increases capacity and later on abolishes it. In chronic myelitis the sexual power is usually impaired at an early period, it diminishes more or less rapidly and is finally lost. Ross 1 states that in incomplete paraplegia the sexual power may be preserved for a long time. In the many toxic conditions producing peripheral neuritis, the virile power is more or less impaired, and in some there is complete impotence. Mumps sometimes results in metastatic inflammation of one or both testicles, which may lead to atrophy and consequent abolition of procreative power. A common nervous disorder of anomalous character to which the term neuras- thenia is applied is frequently accompanied by sexual debility, and those who suffer from this complaint often attribute the origin of their troubles to loss of virility. This tendency is caused or increased by previous habits of masturbation. Blows on the head have been followed by temporary or even per- manent loss of the vii'ile power. The malformations of the male sexual organs, described in the previous section, may or may not produce impotence or sterility in 1 Diseases of the Nervous System, 1SS3. SEXUAL DEFECTS IN MALES. 85 accordance with their character and degree. The first consideration is — does the condition prevent the secretion of normal spermatic fluid] and, secondly, if not, is there any absolute mechanical impediment to its being conveyed to the vagina 1 Complete absence of both testicles renders a man sterile. If they are removed whilst the individual is in full sexual activity, it is possible that one or more fruitful intercourses might take place after- wards, but the power of impregnation is eventually lost. Massazza, 1 experimenting on animals, found that castration does not immediately abolish procreative power; active spermatozoa were discovered in the spermatic ducts nine days after removal of the testicles. The removal of the testicles does not necessarily render a man impotent although it deprives him of procreative power. History relates that the ladies of imperial Rome were in the habit of taking advantage of this fact by indulging in illicit pleasure with eunuchs as the act entailed no risk of impregnation. In more recent times the male sopranos (castrati), who as a class are barely extinct, have often given rise to scandal. When the testicles exist, although not in their normal situation, the condition imposes no absolute barrier to fertility. Cryptorchids have been known to be fruitful. Malformations of the penis are the chief cause of mechanical im- pediment to impregnation. Epispadias almost invariably makes a man sterile, because the condition renders it next to impossible that the seminal fluid can reach the vagina. Hypospadias is or is not a barrier to impregnation in accordance with the degree of malformation and its position ; if the penis and scrotum are cleft, or even if the penis only is open at the root, the difficulty is insurmountable by natural means ; artificial transference of the semen to the vagina has resulted in impregnation. Since impregnation may result from deposition of semen on the vulva, without propulsion of it into the vagina, great reticence must be observed in expressing an opinion as to the 'possibility of impregnation under adverse conditions on the part of the male. Cases of hypospadias have to be considered on their individual merits; the malformation itself is not a fixed condition, and therefore it may or may not render a man sterile. Binding down of the penis to the scrotum is another impediment of varying significance. The same question obtains as with hypospadias— is the deformity of such a character as to totally forbid the possibility of the deposition of semen within the vulva? A curious anomaly may occur with respect to the question of impotence and sterility in the male : the rule is that the former includes the latter, but that the converse is not the case. If a man, by accident or disease, loses the whole of the 1 Riforma Medica, 1891. 86 FORENSIC JIEDICINE. penis, the testicles remaining, he is obviously impotent, hut from what has just been said, he is not necessarily sterile; cases have occurred in which a man thus mutilated has succeeded in effecting impregnation. SEXUAL DEFECTS IN FEMALES. Impotence and Sterility in the female may also be due to organic defect, or to functional disorder. Age. — In the female sex puberty usually occurs in this country at fourteen or fifteen years of age. At this age a change takes place in the bodily conformation — the girl becomes more womanly. The com- mencement of menstruation is the index by which the advent of puberty is recognised, showing that the individual has arrived at the period of life when the capacity for procreation exists. As the development of the virile power in the male may be accelerated or retarded, so in the female may the menses appear early or late. Cases of abnormally early menstruation are not unfrequently recorded, but, as pointed out by Cullingworth, 1 all discharges of blood from the genital organs of young children are not to be regarded as instances of precocious menstruation. In many cases the discharge is not periodic, and there are no corresponding signs of abnormally early development of the breasts and external genital organs. Exceptionally, however, puberty commences at a very early age, and the reality of the condition is vouched for by the occurrence of pregnancy. The earliest recorded age at which pregnancy occurred in this country is reported by Dodd. 2 A girl began to menstruate at the age of twelve months, became pregnant when eight years and ten months old, and was delivered of a living child which weighed seven pounds. Allen 3 reports a case in which a girl commenced to menstruate at eleven years of age, and at the age of thirteen years and six months gave birth to a fine healthy boy weigh- ing nine pounds ; the father of the child was only fourteen years old. In another case, reported by Dobson, 4 a girl began to menstruate when only eleven years old ; she became pregnant at twelve years and nine months, and gave birth to a male child at the age of thirteen and a half. Lefebvre 5 records the case of a girl who was born fully developed with hair on the pubes ; she began to menstruate at four years of age, and became pregnant at eight by a man aged thirty-seven, the pregnancy terminating by the expulsion of a mole containing a well characterised 1 Liverpool and Manchester Med. and Surg. JReports, 1876. - Lancet, 1881. 3 Brit. Med. Joarn., 18S5. * Brit. Med. Joxirn., 1SS4. 5 Gaz. Hebdom, 1S78. SEXUAL DEFECTS IX FEMALES. 87 human embryo. Curtis 1 records a case and after inquiry vouches for the facts, in which a girl became pregnant (by a boy of fifteen) twenty four days before she was ten years old ; she was delivered at the age of ten years eight months and seven days of a healthy child at full term. These cases illustrate the necessity for the medical jurist to determine the presence or absence of puberty by the degree of sexual development attained by the individual rather than by the age. The condition of the breasts, the presence or otherwise of hair on the pubes, and the general contour of the external sexual organs are the indications by which an opinion is to be formed. Advanced Age. — Unlike men, women, with few exceptions, are limited in the duration of their procreative capacity. The menopause is usually an indication that the period of fertility is at an end. The average age at which menstruation ceases is forty-five years, it may cease earlier, or it may be prolonged to fifty ; exceptional cases of still later menstruation are recorded as far as and beyond seventy. It is to be observed, however, that as in preternaturally early menstruation, all haemorrhages from the vagina in advanced life are not to be accepted as evidence of the existence of the monthly function. Uterine polypi and malignant disease of the uterus are conditions which may give rise to haemorrhage occurring with more or less periodicity. A most extraordinary case of delayed menstruation is recorded by Marx 2 : — A woman forty-eight years old, who had been married twenty years, had never menstruated; at that age she was treated for oophoritis In- periodic local abstractions of blood, and subsequently she commenced menstruating at monthly intervals. When the account was published she was fifty-two years old and continued to menstruate regularly. "Women rarely have children after about forty-live years of age, but exceptions to this rule, and also to the rule that the procreative powers cease at the menopause, are occasionally met with. Davis* relates the case of a woman who was delivered at fifty-five years of age; the baptismal certificate of the woman was seen, and her state- ment of age thus corroborated. Underbill 4 delivered a woman in her forty-ninth year who had not menstruated for two years. Lavasseur records the case of a woman, aged fifty, who had ceased to menstruate for two years, and who gave birth to a living child at full term. Depasse 6 relates the case of a -woman wdio had ceased menstruating nine years previously, and who had a married daughter forty years, old. At the age of fifty-nine years she was delivered of a healthy 1 Boston Med. and Surg. Journ., 1863. - Przeglad leharski, 18S9. 3 Lond. Med. Gaz., 1S47. 4 American Journ. of Obstet., 1S79. 5 Gaz. Hebdomadaire, 1873. 6 Gaz. de Gynecol, 1S91. S8 F0REXSIC MEDICINE. child which she suckled, weaning it on her sixtieth birthday. Priou 1 states that a woman who had ceased menstruating at the age of forty- eight years, recommenced twenty-four years after and menstruated regularly at monthly intervals for six periods, and then ceased; two months afterwards she gave birth to a two months' foetus. The woman waSySeventy-two years old when this took place ! The form of impotence in men due to psychical causes has its com- plementary condition in women. In men the state is negative — one of pure passivity : in women the impediment is of an active character. It arises from a highly emotional type of hysteria which is associated with vaginismus. A woman in this condition is incompetent for the sexual act ; the slightest approach evokes a paroxysm of dread, and of consequent resistance which defies all efforts. Anaesthetics have been used to enable intercourse to be effected, sometimes with permanent success. In other cases the irritability of the vaginal orifice is so intense that the least contact throws the sphincter vaginae into such powerful contraction as to prevent the introduction even of the finger. In such cases the condition may be more local and physical than general and psychical, and is consequently amenable to surgical treat- ment. As intercourse may be accomplished if the woman is entirely passive, it follows that general disease — paralysis and the like — does not pro- duce impotence in the female, as it does in the male sex. Extreme bodily deformity is not necessarily a barrier to intercourse, as' women with limbs ankylosed in positions that apparently would forbid all approaches have born children. The local abnormalities previously mentioned may or may not pre- vent intercourse. Absence of external genitals, excessive narrowing or absence of the vagina, the presence of a very firm hymen with small aperture, or quite imperforate, adhesion of the labia, tumours filling the vagina, large incarcerated hernias, and other analogous con- ditions will impede or entirely prevent coitus in accordance with their character and degree. Absence of uterus and ovaries, the external organs being complete, w T ill not prevent intercourse, though it will obviously prevent conception. A not infrequent cause of sterility is the so-called chronic uterine catarrh ; in this condition the mucous membrane of the uterus is spongy, and secretes an abnormal amount of clear mucus which may be blood-stained. Some vaginal discharges by their marked acid reaction render impregnation difficult ; sperma- tozoa are rapidly killed in fluids having a very acid reaction, and also in those which have a very alkaline reaction. 1 Bulletin de la Socicle de Med. d'Anrters, 1SG5. RAPE AND UNNATURAL OFFENCES. S3 CHAPTER XII. RAPE AND THNnsrATURAL OFFENCES. Rape may be defined as carnal knowledge of an individual by one of the opposite sex without consent ; in practice it is understood to refer to carnal knowledge by a male of a female of adult age against her will, or of a girl under a certain age with or without her consent. As the law at present stands : — " Any person who unlawfully and carnally knows any girl under the age of thirteen years shall be guilty of f elony . Any person who attemp have unlawful carnal kuowledge of any girl under the age of thirteen years shall be guilty of a misdemeanour. Any person who unlawfully and carnally knows or attempts to have unlawful carnal knowledge of any girl being of or above the age of thirteen years and under the age of sixteen years ; or unlawfully and carnally knows, or attempts to have unlawful carnal knowledge of any female idiot or imbecile woman or girl, under circumstances which do not amount to rape, but which prove that the offender knew at the time of the commission of the offence that the woman or girl was an idiot or imbecile, shall be guilty of a misdemeanour. Provided that it shall be sufficient defence to any charge under sub- section one of this section" [referring to the age of the girl being above thirteen and under sixteen] "if it shall be made to appear to the Court or jury before whom the charge shall be brought that the person so charged had reasonable cause to believe that the girl was of or above the age of sixteen years. Provided also that no prosecution shall be com- menced for an offence under sub-section one of this section " [referring to the ages between thirteen and sixteen] " more than three months after the commission of the offence."— Criminal Law Amendment Act, 1SS5 (4S and 49 Vict,, ch. 69). It is to be noted that the cpuestion of age, parenthetically explained, does not refer to idiots nor imbeciles, also that between the ages of thirteen and sixteen an accusation of rape must be made within three months after the alleged offence was committed. Although not stated, it is probable that this time-limit is intended to apply to all ages above thirteen. A definition of the term "carnal knowledge" is necessary for a full comprehension of the above quotation from the Act. By carnal knowledge the lav.- includes any degree of sexual intercourse from mere introduction of the penis within the vulva, with or without 90 FORENSIC MEDICINE. emission, to complete penetration with emission. If this is done to an adult woman without her consent and against her will, or to a child under any circumstances, it constitutes rape. Formerly both penetration into the vagina and emission were required, and sub- sequently (24 and 25 Vict., ch. 100) penetration only, with or without emission, was deemed sufficient to constitute the crime. It has been decided by the Courts that introduction of the penis within the vulva, without causing any injury to the hymen, constitutes rape under the conditions above stated. The relation between age and volition is to be noted : — If a girl of or above the age of sixteen years consents to the act, rape is not committed. If a girl of or above the age of thirteen and under the age of sixteen consents or not, the act on the part of the man is neverthe- less criminal, and he is liable to imprisonment for misdemeanour, with or without hard labour, for a term not exceeding two years. If a girl under the age of thirteen years consents or not, the aggressor is guilty of felony if he effects his purpose, and of a misdemeanour if he attempts only. In the former case the allotted punishment ranges, at the dis- cretion of the Court, from imprisonment for a term not exceeding two years to penal servitude for life ; in the latter case the imprisonment must not exceed two years. Therefore, below the age of sixteen years, consent or even solicitation on the part of the girl does not do away with the criminality of the act. The same statement applies to women who are idiots or imbeciles ; consent on their part does not absolve the accused — he is guilty of a misdemeanour. The restrictions of the law apply to prostitutes as well as to women of chaste life : if a man has forcible intercourse with a prostitute against her will, he is guilty of rape, and is liable to be punished accordingly. If a man, by personating the husband, has intercourse with a married woman with her free consent, he is guilty of rape (48 and 49 Vict., c. 69). Formerly this question was left to the judgment of the court in each case, the consequence being that some judges pronounced the act to be rape; others held that the consent, although obtained by fraud, did away with the criminality of the act. To obviate this want of uniformity the law definitely decides the question as above. Cases have occurred from time to time that have given rise to the question — Can rape be committed on a woman without her knowledge during sleep 1 According to the present interpretation of the law, an affirmative answer must be given. The mere introduction of the penis within the vulva would not necessarily cause pain enough to awake a sound sleeper; the act, however, would constitute rape according to the definition of the crime above given. The question was originally propounded when penetration was necessary to establish rape, and at the KAPE AND UNNATURAL OFFENCES. 91 present time it usually arises in respect to cases in which intromission is alleged to have taken place ; when this is the case a qualified answer is required. It would be quite possible for a woman accus- tomed to sexual intercourse to be violated with complete intromit"!! during sleep. Instances have occurred in which this has taken place; one such is reported in the Edinburgh Monthly Journal, 1S62. Guy 1 mentions the case of a married woman who slept so heavily that her husband frequently had connection with her during sleep. The conditions are quite different, however, when the victim is alleged to have been a virgin up to the time the violence was used. It may lie confidently stated that an adult man of average sexual development could not fully penetrate a woman who was a virgin, without her knowdedge, during natural sleep. Cases in which it is alleged that this has taken place, are ipso facto to be treated with grave suspicion, if not with absolute incredulity. In abnormal states of sleep, or stupor, as for example post-epileptic coma, it is not impossible that a virgin might be ravished without being conscious of the violence at the time. It is to be expected, however, that on recovery of consciousness she would experience sore- ness in the private parts, and most probably would find that her underclothing was stained with blood. In Casper-Liman's Handbuoh a case is narrated of a girl who was subject to epileptic seizures which always left her unconscious for some hours after. A man who was acquainted with this fact on one such occasion took advantage of it, and had intercourse with her without her cognisance. The probability of the occurrence of violation under these conditions would greatly depend on reliable evidence being obtained that the alleged victim was subject to epilepsy followed by stupor. Hysteria or catalepsy, as causes of unconsciousness, or of a condiiiiin of subjugation to the will of the person accused, are to be received with much caution. It is to be admitted that a girl, or a woman, of a certain neurotic type may for a time be deprived of volition by so-called hypnotism, and whilst in such a condition might be violated without offering eii'ective resistance, or even any resistance whatever. All such accounts, however, are very suspicious, and are — without convincing evidence to the contrary — to be regarded as plausible excuses for non- resistance rather than genuine statements. In giving an opinion respecting such a case, the possibility of the occurrence of hypnotic sleep, or of mental and bodily subjugation induced by suggestion, is to be admitted hypothetically, but great reserve should be maintained in accepting any such condition as accounting for the absence of resistance. or of outcry, whilst the act was being perpetrated. 1 Forensic Medicine. 92 FORENSIC SIEDICIN'i:. Extreme terror may undoubtedly deprive a girl or woman for the moment of the power of offering effective resistance to her violator ; volition and physical energy may he temporarily paralysed by the outrageously violent demeanour of an assailant, so that he may accomplish his purpose without any opposition. It is not necessary that the threatened general violence should be directed to the intended victim. In one case recorded by Maschka, 1 the ravisher seized the infant of the woman he desired to violate, and threatened to dash its brains out unless she submitted; the terror thus induced by the appeal to her maternal instincts made the woman submit. In this case, although no physical force was resorted to, the woman was effectively constrained by moral coercion. The law makes no distinction between moral and physical coercion, intercourse against the victim's will, effected after passivity produced by a blow on the head or by threats, is equally criminal. It must be quite clear, however, that the alleged mental and physical paralysis through fright was actually experienced by the woman, and not feigned as an excuse for offering no opposition. If a woman in the act of illicit intercourse only begins to cry out and struggle when she becomes conscious of the approach of a third person, and states that the reason she did not do so before was because she was paralysed by fear, the probability is that she was a consenting party, and that her outcry was prompted by the desire to save her character when detection seemed inevitable. Amos 2 relates a droll case, in which a man was charged with violating a girl who gave as the excuse for not screaming, that she was afraid of wakening her mother, who slept in the next room. Narcotics or anesthetics are occasionally used, and probably much more frequently alleged to have been used, with the object of rendering a woman unconscious and thus placing her at the mercy of her would- be ravisher. The substances usually resorted to for this purpose are — alcoholic beverages, chloroform, and opium, or some of its preparations. It is probably much more common than is publicly known for women to be intentionally intoxicated with wine or spirits, which may be dru^'ed with opium or not, in order to deprive them of consciousness and power of resistance, with the object of facilitating violation. A woman profoundly intoxicated would be quite incapable of effective resistance, even if she retained sufficient perception as to be aware of what was taking place. In forming an opinion respecting a case of this kind, the difficulty is to determine whether the woman was as much under the influence of the intoxicant as she professes to have been. A woman who voluntarily drinks an alcoholic beverage until discretion is i Handbuch, Bd. 3. - Lond. Med. Gaz., 1831. RAPi: AND UNNATUF.AL OFFEXCES. 93 vanquished by desire, and then yields to the embraces of her male companion, on return to her ordinary state of mind may regret her fall to such an extent as to attempt to visit him with the entire culpa- bility of the act, and so exonerate herself— at least in the e;. the world— from all fault. In such a cas. its for consideration are :— The previous character of the woman, her age (a young woman would be more likely i this curse than one of middle age), the kind and amount of intoxicant, together with accidental evi- dence, such as a too clear and detailed account of the transaction being given by th<- at with a progressively increasing Loss of consciousness. For the reason \a>i named, the time that the man and woman S] I ' gether, if ascertainable, might be suspiciously short for an intoxicant of the kind partaken of to produce profound unconsciousn- With regard to the administration of chloroform vapour for the purpose of rendering a woman incapable of to be observed that there are probably only two ways in which this could be done. The first is when a woman volunt the vapour (which for this purpose includes all anesthetics capable of being thus administered; for a proper object — as the extraction of a tooth — and when under the influence of the anaesthetic is violated by the adminis- trator. The other way is when the vapour is administered to a woman who is A case of the first kind is quoted at length by Wharton and Stille. 1 A young lady went to a dentist to have a tooth filled; the operation being painful, ether was administered, and, according to the deposition of the prosecutrix, violation was effected whilst she was under its influence. The peculiarity of the case consists in the state- ment made by the prosecutrix that though unable to resist she was sious of what occurred to the minutest detail, and moreover could see the disordered state of her clothes when she opened her eyes after the offence had been committed, the dentist having for a moment retired to another part of the room. The young lady discreetly closed her eyes before the dentist returned, and allowed him to re-adjubt her clothing; a few minute 3 after she was sufficiently ( as to discuss the advisability of having the offending tooth extracted on being informed that it was too far decayed to be filled; more ether was given, and the extraction performed. When the effects of the jthetic had passed off, she left the house without reproaching the dentist, and did not mention the occurrence until some hours after. To complete the story, the dentist was sentenced to four and a-half (!) years' imprisonment, but was subsequently released on representation being made to the authorities that it was quite possible that the whole 1 Medical Jurisprudence. 94 FORENSIC MEDICINE. affair was an hallucination. On reading the detailed account, it is difficult to determine the exact degree of admiration relatively due to the presence of mind displayed by the young lady on the one hand, and the nicely adjusted sentence of the court on the other. This case has been narrated with the object of emphasising a rule that has been many times urged — that a medical man, or dentist, should never administer an anesthetic to a female patient without the presence of a third person. This should be one of those rules that has no excep- tion. It is well known that a partial degree of unconsciousness produced by an anesthetic is not unfrequently attended by delusions, and in the case of females such delusions occasionally take an erotic type. The vividness of the subjective impression is so great that the person on whom the impression is made thoroughly believes in its objectivity. On an occasion, which it is to be hoped will be unique, such an impression was apparently transferred to a second person. A married lad\ T , to whom a dentist administered chloroform, afterwards accused him of violating her whilst under the influence of the anaes- thetic, and her husband, who was present during the whole time she was unconscious, testified that his wife was under the strongest impres- sion that she had been violated. The jury found the dentist guilty of an attempt to commit a rape, with a recommendation to mercy ! l The administration of chloroform to sleeping persons in order to prepare them for surgical operations has been tried on many occasions ; in some instances the individual passes into the condition of chloro- form narcosis without awakening from natural sleep; in others, in spite of very gradual administration, the vapour produces such irrita- tion of the glottis that the subject of the experiment awakes. Dolbeau 2 records some experiments made by him in relation to a case in which it was alleged that a girl had been chloroformed during sleep and afterwards violated. Out of twenty-nine attempts to bring sleeping persons under the influence of chloroform, he succeeded in ten and failed in nineteen. There is no doubt that a woman once under the influence of an anaesthetic is at the mercy of any one who chooses to take advantage of her helpless condition. The two ways in which a woman might be thus rendered insensible— by voluntary inhalation and by sur- prising her whilst asleep — probably comprise all the cases in which violation has been effected with the aid of anaesthetics administered in the form of vapour or gas. Those cases of alleged chloroform narcosis effected by waving a pocket-handkerchief impregnated with an odorous substance before the face, the proceeding being followed by 1 Boston Med. and Surg. Journ., 1S5S. 2 Annates d 'Hygiene, 1874. RAPE AND UNNATURAL OFFENCES. 95 sudden insensibility, are from the nature of things untrue. It is a matter of common experience that the chloroformist at a surgical operation frequently requires the aid of an assistant during the earlier Stages of the administration, to restrain the struggles of a patient who submits voluntarily. Except in the case of a weakly person, it would be no easy matter to administer chloroform single handed to a woman against her will ; the difficulty would probably be quite as great as to commit the rape without the aid of the anaesthetic. A practitioner who is called upon to examine the prosecutrix in such a case should carefully examine the face, neck, shoulders, and wrists for finger-marks or bruises, which would be very likely to be produced (in a genuine case) in overcoming the attempts made by the victim to evade the .-uiresthetic. The use of other narcotics to facilitate violation is not common, but the drugging of alcoholic beverages with opium or morphine has been recorded. The following case of alleged administration of chloral hydrate came under my cognisance two years after the trial. A married man, in consequence of the absence of his wife who was a monthly nurse, was left in his house one night with a servant girl, fourteen years of age. The girl's statement of what happened was that in the evening she complained of toothache, and her master dropped something that tasted like peppermint out of a bottle on to a little cotton- wool, and applied it to the tooth ; she then went to bed and immediately fell fast asleep. At daybreak she awoke and found her master in bed with her, but he at once got up and left the room. She discovered that she was bleeding from her private parts, which felt painful ; she went to sleep again, awoke at the usual time in the morning, got up and did a hard day's work at washing clothes. Although her mistress returned in the morning she made no •complaint until evening, when she told her sister the above story. No medical examination was made for five days after the alleged violence had been perpetrated. The following is copied verbatim from the deposition before the magistrates of the medical man who examined the girl : — " There had been penetration, and the nymphse (!) had been destroyed. There was some inflammation of the private parts. She winced on my touching her. There must have been violence. Chloral would taste like peppermint and would produce a deep sleep such as would enable any one to commit an act of this sort without the girl knowing." Unfortunately for the accused no rebutting medical evi- dence was forthcoming. The trial took place, at the Manchester Assizes at a time when the public mind was greatly agitated with regard to criminal assaults on young children, an agitation which led to the passing of the Criminal Law Amendment Act of 1885. In spite of 96 FORENSIC MEDICINE. the utter improbability of the girl's tale, and of the self-contradictory nature of the medical evidence, the prisoner was sentenced to ten years penal servitude. Two years after, in consequence of repre- sentations from several medical men to the Home Secretary, the convict was released. This case admirably illustrates the value and importance of reliable expert medical evidence, and the necessity for every medical witness to know what he is talking about when he is in the witness-box. Any well-informed medical man would at once have made it clear to the jury that a few drops of a solution of chloral hydrate on cotton wool could not possibly have produced immediate and profound insensibility, lasting for hours, which would enable an adult man to fully penetrate a young girl of fourteen (presumably a virgin) without her knowing. In this way the medical evidence would have served its proper purpose as intended by the law, especially in cases of criminal assault— to corroborate that which is true, and to confute that which is false in the evidence relating to technical subjects given by the prosecutrix. By Yict. 48 and 4 9, the administration of any drug, matter, or thing to a girl or woman with intent to stupefy or overpower, so as thereby to enable any person to have unlawful carnal connection with such woman or girl, constitutes a misdemeanour. It has been doubted whether a man unaided could fully consummate sexual intercourse with a woman against her will, the woman not being disabled by blows or other violence nor by drugs. The fact that a woman by continued movements of her body could effectively prevent intromission, has led some to deny the possibility of an adult female being violated without aid other than the directly applied physical strength of the man. The question is one which depends on the relative physical strength of the two individuals. A strong man would be likely to succeed with an old or weakly woman, or with a, child : a puny man, on the other hand, could be held at bay by a vigor- ous woman without much difficulty. When the respective muscular developments of the man and woman are more nearly balanced, some discrimination is required in giving an opinion. There is one point with respect to this subject that is often lost sight of— the social position and habits, and the temperament of the woman. Women of the lower classes are accustomed to rough play with individuals both of their own and of the opposite sex, and thus acquire the habit of defending themselves against sportive violence. In the majority of cases such a capacity for defence would enable a desperate woman to frustrate the attempts of her intentioned ravisher. A delicately nurtured woman, on the other hand, is so appalled by the unwonted violence that her faculties may be partially benumbed, and her powers of resistance cor- respondingly enfeebled. THE PHYSICAL SIGNS OF VIRGINITY. 97 Under exceptional circumstances the woman's movements may be so hampered as to make her an easy victim. Casper 1 mentions the case of a strong well -developed woman who was rendered powerless by having her dress thrown over her head, and whilst thus enveloped was violated by a man single-handed. It was formerly a matter of debate as to whether rape could be followed by pregnancy. The question needs no discussion, as the impregnation of an ovule is not influenced by volition — it may be accomplished without the participation and against the will of the woman. Another question has arisen : may injuries to the genital organs produced by rape be sufficient to cause death 1 An affirmative answer is unfortunately afforded by the occurrence from time to time of cases in which death was directly due to mischief inflicted on the immature sexual organs of young girls by brutal attempts to effect intromission of the penis, apart from injuries otherwise inflicted. Colles 2 reports the case of a girl aged eight years who was violated by an adult. She died from peritonitis in six days. At the autopsy the perineum was found torn and the vagina gangrenous. As a result of the early age at which marriage is consummated in India, death of immature girls has not unfrequently occurred from attempts at marital intercourse. THE PHYSICAL SIGNS OF VIRGINITY. In the young adult virgin the breasts are hemispherical in form, and are firm and elastic to the touch. The nipples are small, and are surrounded by areolae, which are rose-coloured in blondes and darker in brunettes. Occasionally a slight secretion of a fluid having some of the characteristics of milk may be found in the virgin breasts, this may be due to sexual activity without unchaste habits. The labia majora are more or less rounded at their free edges, are firm and elastic, and approximate each other closely ; the labia minora are small and pale in colour. The posterior commissure is intact. Except in rare cases of defective development, the hymen in one of its varied forms is. always present. Its most usual appearance is that of a crescent placed transversely across the entrance of the vagina, with the crescental horns towards the urethra. Sometimes the hymen extends all round the orifice of the vagina, and is perforated by a circular or irregularly formed aperture, or by a vertical slit. There may be more than one aperture or there may be no aperture at all, constituting the condition known as imperforate hymen. The rigidity 1 Handbuch, Bd. 1. - Med. Times and Gaz., 1860. 7 98 FORENSIC MEDICINE. of the hymen varies as well as its form. In. some virgins it is patulous and yielding, so that the opening will admit of the intro- duction of the finger without injury to the hymeneal margin; in others it is firm and unyielding, in which case the passage of any object slightly larger than the opening will tear its free border. The vagina is narrow, especially in the very young, and its walls are more or less rugose. The ruga?, however, may be replaced by a smooth, non-corrugated surface, due to various conditions which arise from the state of the general health. PHYSICAL SIGNS OF THE LOSS OF VIRGINITY. The breasts undergo no alteration by a single coitus, and, in the absence of impregnation, little if any by habitual intercourse. The labia niajora et minora only afford corroborative evidence, in the form of an inflammatory condition in recent cases, when much violence has been used. The posterior commissure is not affected by complete and habitual ordinary intercourse, except in the very young, and in adults when unwonted violence has been resorted to. The hymen yields the most reliable evidence of loss of virginity, the appearance presented varying with the interval that has elapsed between defloration and the period of examination ; it also varies with the age of the indi- vidual, the original character of the membrane as to size of aperture and degree of rigidity, the dimensions of the male organ which inflicted the injuries, and the amount of violence brought to bear at the time they were inflicted. Recent injuries appear as sharped-edged tears or slits which may traverse the entire hymen, and may be con- tinued through the mucous membrane of the vulva and vagina. In the ordinary crescentic hymen there is usually one slit in a backward direction towards the commissure ; there may be others. In excep- tional cases a new aperture is made, usually below the normal opening, leaving a strip of membrane stretching across the mouth of the vagina. From the torn hymen there is usually some haemorrhage, which is occasionally excessive ; in any case if the examination is conducted soon after the infliction of the injuries, blood-clots or stains will be found on the parts. There will also be an inflammatory condition of the ostium vagina? and adjacent structures, rendering them painful to the touch; a little later, especially in young children, the inflam- matory processes will cause a muco-purulent discharge of a yellow or greenish-yellow colour. This discharge is not to be mistaken for the result of gonorrheal infection which it closely resembles, nor yet for a previously existing leucorrhcea ; the distinction is by no means easy, and many false accusations have been made solely on the strength PHYSICAL SIGNS OF TIIE LOSS OP VIRGINITY. 99 of a discharge which, though clue to pathological causes, has been attributed to criminal violence. The discharge which is due to in- flammation caused by mechanical irritation, is usually not so copious as that resulting from gonorrhceal infection; from leucorrhceal dis- charge it is distinguished by indications of an acute inflammatory condition of the mucous membrane which secretes it. Threadworms may cause a discharge from the vagina. Spitzer 1 relates the case of a girl of fourteen who was suspected to have been violated; she had a profuse discharge from the vagina, and on syringing the passage out, threadworms came away, showing the true nature of the case. The presence or the absence of gonococci have been regarded as respectively indicative of the specific or the innocent character of the discharge. holier 2 obtained cultivations of gonococci from stains on the clothing in a case of rape. Kratter 3 found gonococci in the vaginal discharge in one out of two cases of rape in which he searched for them, and he attaches much importance to bacteriological investigations in such cases. Yd nit and Bordas 4 believe that the distinction between gonorrhoea and leu- corrhcea cannot be determined with absolute certainty by bacteriological examinations even of the most complete kind, and, therefore, that an expert is not justified in affirming the nature of a discharge on this ground ; these views were accepted by the Societe de Medecine Legale de France before which body the statements were made. In the present state of bacteriology we are not in a position to say that the presence or absence of gonococci would justify a statement on oath either for or against specific infection. The rugose condition of the virginal vaginal mucous membrane is not changed by isolated acts of intercourse, and it may be absent in virgins. If an interval of four or five days intervenes between defloration and the period of examination, the appearance of the parts will differ from that above described, especially if the violence has not been excessire. At this period there will be no blood-clots found, and all inflammatory appearance may have disappeared. The sharp edges of the rents in the hymen will be rounded off and the raw surface probably healed. The result is the formation of carwrvculce myrtiformes which consist of irregularly rounded nodules formed by the remains of the hymen. If recent, the carunculse are swollen, tender, and of a deep red colour ; if more remotely formed, they are firmer, harder, and lighter in colour. It is to be observed that, unless the male organ is disproportionately large, a single intercourse does not result in the formation of a number 1 Wiener med. Wochenschr, 1S92. - Bulletin mddical du Xord de la France, 18S7. 3 Vierteljahrsschr. f. ger. Med. Supplement, 1891. 4 Annates d'Hyjivae, 1891. 100 FORENSIC MEDICINE. of nodules representing the pre-existence of correspondingly numerous rents in the hymen : if all the damage sustained by the hymen consists in a single tear, the subsequent appearance will not correspond with what is usually understood by the term carunculse myrtiformes ; complete transformation of the hymen into carunculse is, as a rule, only accomplished by repeated acts of intercourse. Tears in the hymen never unite again ; the injury to the membrane is permanent. The Physical Signs of Virginity or of Non-Virginity in relation to Kape.— For the following reasons the signs of loss of virginity do not in themselves constitute proof of rape, nor do the signs of the presence of virginity disprove its occurrence : — Absence of the physical signs of virginity may be due to lawful marital intercourse, to illicit but voluntary intercourse, to accidental rupture of the hymen, and, in very rare cases, to congenital absence or imperfect development of the hymen. The physical signs of virginity may persist in a female on whom a rape has been perpetrated : — from the presence of a patulous hymen with large aperture, especially if the penis of the assailant was of small size ; from extreme youth of the victim, the sexual organs being too small to permit of vaginal penetration (excluding tearing of the parts asunder), and lastly, it is to be borne in mind that mere vulval penetration without the infliction of any injury is sufficient to constitute rape. The hymen may be ruptured by an adequate force of any kind, apart from sexual intercourse. It is reported to have given way from the presence of blood-clots during menstruation, from ulceration following diphtheria or other diseases, from jumping, riding on horseback, or falls on a hard projection. Masturbation has been stated, but pro- bably without sufficient grounds, to be a cause of rupture of the hymen ; in the majority of cases of habitual masturbation the hymen will be found intact, the manipulations being limited to the parts anterior to it. Medical examinations or applications may cause injury to the hymen. Some of these reasons for the absence of, or injury to, the hymen are quite feasible, others are far-fetched ; each case has to be judged on its own merits. Complete intromission of the penis may take place without injury to the hymen. The conditions necessary are those previously men- tioned ; a patulous or elastic hymen, and a not too voluminous penis. Repeated acts of intercourse may take place with no other results than slightly enlarging the aperture through or above the hymen. No inference can be drawn from the presence of a large aperture, the margins of the membrane being intact, as it may be the natural condi- tion of the part. Distinction must be made between complete inter- PHYSICAL SIGNS OF THE LOSS OP VIRGINITY. 101 course through a patulous hymen, and that form of intercourse which results in impregnation through a small aperture in a tough hymen, which, though a fruitful intercourse, is an imperfect one. Excep- tionally, the hymen is hoth tough and elastic ; Maschka mentions the case of a prostitute in whom an uninjured hymen of this kind was present, although complete intercourse had repeatedly taken place. Eape, including emission, maybe perpetrated on very young children without injuring the hymen in the least. The external genitals are too small to admit the adult male organ, and the hymen is deeply seated, so that unless sufficient violence is used as to tear open the parts, the assault may be accomplished without leaving more than superficial traces of its commission. A degree of violence may be used on a young child that stops short of lacerating the parts, and is yet suffi- ciently great as to cause subsequent sloughing of the external genitals. Pathological sloughing of the vulva from noma, or from diphtheria, enterica, variola, vif taking away the power of resistance, as were made with regard to rape. Medical evidence in cases of bestiality is limited to a search for hairs (derived from the abused animal) on the clothes and person of the accused. Indecent exposure of the person is a criminal offence which dues not come under the notice of the medical jurist in the way that the above-mentioned offences do, but his opinion may be asked as to the criminal responsibility of the offender. Certain forms of cerebral degeneration dispose those who are subject to them to exhibit their persons in public. In this country the cases have been mostly those of elderly men developing senile dementia, or in younger men, the subjects of epileptic automatism, of alcoholism, or of the initial stage of general paralysis. Recently Krafft-Ebing ] has directed attention to a form of sexual psychopathy in which there is a special psychical degeneration occurring in the early years of life, mostly referable to hereditary influence, or to pathological con- ditions, such as rachitis. He gives illustrative cases in which there is an apparently uncontrollable tendency on the part of the subjects to expose their persons to others. Anion-- these is one by Freyer 2 of a man, thirty-five years of age, who was arrested for lingering about a girls' school, and when he succeeded in attracting the attention of the pupils exhibiting his person. For the same offence he had been in prison more than half-a-dozen times before, for periods of from 1 Wiener med. Blatter, 1S92. - Zeitschr. f. Mcd'rJnalbeamte, 3 Jahrg. 112 FORENSIC MEDICINE. three months to three years ; on the last occasion he was very properly sent to a lunatic asylum instead of to prison. He had been subject to epileptic seizures, and it is worthy of remark that when the impulse to expose himself developed, the epileptic attacks ceased. CHAPTER XIII. THE SIGNS OF PREGNANCY AND OE DELIVERY. Medical practitioners may be called on by legal authorities to ascertain the occurrence or non-occurrence of pregnancy under the following circumstances : — (a) When a woman sentenced to death pleads preg- nancy as a bar to execution; (b) when a woman whose husband is recently dead asserts that she is pregnant with an heir to the estate, •the heir-at-law, to protect himself from fraud by the importation of a spurious heir, may demand proof of pregnancy. In both these instances the ancient proceeding, which is only now dying out, was to empannel a jury of twelve matrons or discreet women to make the necessary investigation and to report to the court. This duty is now fulfilled by one or more medical practitioners, (c) When a woman avIio has been seduced claims increased damages on account of being with child ; (d) when an unmarried woman, or widow, or a married woman living apart from her husband, is, as she alleges, libellously accused of being pregnant ; or (e) when a woman who has lost her husband through culpable neglect of some person or persons, claims damages for his loss and for the future support of an unborn child. SIGNS OF PREGNANCY. An exhaustive description of all the various indications of the existence of pregnancy which are of value to obstetricians, is out of place in a treatise on Forensic Medicine. What the medical jurist has to depose to on oath, is not the probability or otherwise of a certain woman being pregnant, but the fact that she is or is not pregnant. Most of the signs of pregnancy are only conjectural, and although an obstetrician of great experience might probably form a fairly accurate forecast in the absence of the really diagnostic signs, he would hesitate to make a positive statement on oath, unless the infallible signs were present. The two signs of pregnancy usually depended on by married women to determine their condition are — the temporary cessation of the SIGNS OF PREGNANCY. 113 menses, and the sensation of quickening. Neither of these signs are of value to the medical jurist seeing that the woman he interrogates is an unfriendly witness. Tt is usually her object to impress the medical examiner with the idea that she is pregnant (in some cases the converse obtains), and therefore no reliance can be placed on her statements in this respect. If a truthful statement as to these Bigns is given, it is of little value, since the stoppage of menstruation maybe due to other causes than pregnancy, and the sensation of quickening is a subjective indication and is unreliable even in the case of women who have experienced it in former pregnancies. In the earliest months of pregnancy the breasts enlarge and become firmer. They are more ositive to the touch, and knotty cords can be felt in the region of the nipples; the areoke surrounding the nipples appear swollen and shiny and acquire a darker hue from increase of pigment, especially in dark- skinned women. A number of elevated nodules form round the peri- phery of the areolae indicating the presence of active sebaceous glands. When the breasts are gently squeezed a milk-like secretion exudes from the nipples. The abdomen begins to show indications of distension al >out the third month; the uterus at this period lies in the hypogastrium. During the first three months the organ retains its pear-shaped outline, afterwards it develops laterally and becomes more ovoid. If the abdominal walls permit of an accurate examination of the shape of the uterus, its form when gravid, together with its mobility and elasticity to the touch, enables the experienced practitioner to arrive at a fairly accux*ate diagnosis during the earlier months. At or soon after this period alternate contraction and relaxation of the uterine walls may be detected by palpation. The vaginal portion of the cervix becomes soft and yielding from infiltration with serum, the edges of the os being rounded ; owing to the general tumefaction of the surrounding parts the cervix seems shortened. The mucous membrane of the vagina acquires a cyanotic appearance, and the small veins of the vulva are enlarged and prominent. Bimanual examination — one hand grasping the fundus, and the first and middle fingers of the other applied within the vagina to the os — enables the operator to ascertain the size of the uterus, and probably, in the earlier months— by means of reciprocal movements of the two hands — to feel the sensation of a mobile body '// within it. The uterine souffle is a blowing sound synchronous with the maternal pulse; it chiefly arises in the arteries which run up the cervix, but extends to various parts of the uterus. It may be heard about the fourth month or even earlier. The signs so far enumerated are suggestive but not conclusive. There ai-e but two incontrovertible signs of pregnancy — the sounds of the festal heart, and the presence and movement of the foetal members 8 114 FORENSIC MEDICINE. as felt through the abdominal walls. The foetal heart beats at the rate of 120 to 160 in the minute, the sounds resemble the tick of a watch at some distance from the eai\ When the foetus is in the usual position they are best heard to the left of the umbilicus, a little below it. They become audible about the 18th or 20th week, but at times they may be heard earlier. If the child is surrounded by an unusually large amount of liquor amnii, or if there is a very thick layer of fat on the maternal abdomen, the foetal heart-sounds are heard with difficulty, if at all. By careful palpation the parts of the child's body that are accessible through the abdominal parietes of the mother may be distinguished, and in the living child movements may be felt. Here also the conditions which impede recognition of the foetal heart- sounds will probably prevent manipulation of the foetal members ; unless the contour of the child's body can be detected, the perception of movements cannot be relied on as a proof of pregnancy, since erratic contraction of the recti muscles of the maternal abdomen might be mistaken for them. If the child is dead the recognition of the foetal members is the only positive sign of pregnancy. Since the infallible signs of pregnancy are not available during the first eighteen weeks of pregnancy, no positive statement on oath can be made until this time has expired, which is equivalent to saying that the occurrence of pregnancy cannot be positively determined until quickening has taken place. A negative result yielded by an exami- nation made after a supposed pregnancy of eighteen weeks' duration affords no proof that the woman is not pregnant ; the difficulties already mentioned may prevent recognition of the signs of pregnancy, and a further difficulty may be interposed by the child being small and of feeble vitality. As in all other propositions it is easier to prove a positive than a negative ; if the foetal heart-sounds are heard, whether the body can be felt or not, the fact of pregnancy is established; if neither one nor the other are discoverable, no positive conclusion for the moment can be arrived at. It is under conditions like these that the suggestive signs of pregnancy are of value, as affording grounds for delay and subsequent re-examination or not, as the case may be. Usually a woman pleading pregnancy will state that she is several months advanced, so that some indications of the alleged condition will be present. Should she state that she has been only recently impregnated, further examination must be postponed whether there are any indications of pregnancy or not. POST-MORTEM APPEARANCES OF PREGNANCY. Little need be said under this head. In addition to many of the objective signs of pregnancy in the living, two further indications are POST-MORTEM APPEARANCES OF PREGNANCY. 11 J described, of which the firsl only is of importance. (<>) The presence of an ovum with villi, < n- of a foetus with placental attachment . (6) The presence of a so-called true corpus luteum in one of the ovaries. If an impregnated <>vuin, sufficiently developed as to be recognised ;ls such, is found in the uterus after death (or, in case of ectopic gestation, else- where) the fact of pregnancy is established. Certain abnormal products of concept ion may replace the ovum or tot us ; it is, then-fore, necessary to distinguish between such abnormal products and other pathological conditions which occur independently of impregnation. These abnormal products of conception are called mole s. They are of two kinds — the sanguineous mole and the vesicular mole. The sanguineous mole is the result of haemorrhage into the foetal membranes. The embryo perishes in consequence of pressure produced either by bulging of the chorion and amnion into the foetal cavity, or the chorion is ruptured and the foetal cavity is distended with blood; the embryo undergoes maceration and disappears, or it escapes if the ovum ruptures. If the membranes with the blood-clots remain long in the uterus, calcareous deposits may occur in them. In some cases the distended chorion and amnion form what are known as blood- cysts. The sanguineous mole rarely exceeds the size of an orange. A mole may exist along with a foetus which undergoes normal develop- ment, twin conception having taken place : one of the ova develops, the other degenerates. The vesicular mole is formed by vesicular degeneration of the villi of the chorion. The appearance is that of a vast number of vesicles varying from the size of a pin's head to that of a pigeon's egg. The vesicles are, as it were, threaded in rows, cysts forming along the length of the villi. The cysts are filled with a iluid containing mucin and albumin in varying proportions. The embryo perishes, and if the degenerative process commences at an early period of pregnancy all traces of it may have disappeared when the mole is examined; if it commences at a later period remains of the embryo or foetus may be found. It is unfortunate that the term "hydatid mole" has been applied to the results of vesicular degeneration of the chorionic villi, a condition which has no relation with the true hydatid. The distinction is not so much a matter of pathological accuracy, it concerns the important question — Can a "hydatid mole" be formed without impregnation I From the description -i\ en, it will be seen that the so-called " hydatid" or vesicular mole results from degeneration of a product of conception; therefore, it can only occur as the result of impregnation. The true hydatid (echinococcus) is very rarely found in the uterus. Gunsburg 1 reports a case in which labour was impeded by a true hydatid growing 1 Ctntralblatt fur G ' yndcologie, 1SS4. 116 FORENSIC MEDICINE. from the lower part of the uterus, and states that he found only four cases recorded of hydatid tumour in the cavity of the pelvis. Corpus Luteum. — The difference between the so-called true and false corpora lutea was formerly regarded as, in itself, constituting proof of the pregnant or non-pregnant condition having obtained during life. The false corpus luteum, or, as it is also called, the corpus luteum of menstruation, does not undergo development under the usual condi- tions. The true corpus luteum, or corpus luteum of pregnancy, develops for several months after impregnation, and attains a very much larger size. This increased development is due to greater activity of the circulation, and probably also to trophic nerve influences resulting from the presence of the ovum in the uterus. Such increased develop- ment, however, may take place in consequence of myomata and other pathological conditions of the uterus. On the other hand, pregnancy may occur without the formation of a true corpus luteum. It may be accepted for medico-legal purposes that corpora lutea, as indications of pregnancy or of non-pregnancy, are of no diagnostic value. SIGNS OP DELIVERY. The question of recent delivery most frequently comes under the notice of the medical jurist in relation to infanticide, or to concealment of birth. In civil cases feigned delivery may require investigation. In respect to imputations against the chastity of unmarried women, and under other circumstances, an opinion as to the occurrence of remote delivery may be required. Taking recent delivery first, the subject is divisible into the signs observable in the living, and those observable in the dead. SIGNS IN THE LIVING OF RECENT DELIVERY AT TERM. A woman who has been delivered at term within two or three days of the period of examination presents more or less the following appear- ances. There is usually a certain languid look, like that of a person recovering from an illness. The lower eyelid and its surroundings are pigmented to an extent which varies with the complexion of the individual. The temperature may be slightly elevated. The pulse slows immediately after labour, and then quickens, and again slows, and remains so for several days ; it is full, but there is no increase in arterial tension. The skin is moist. The breasts are full and elastic, or they may be hard and nodulated ; the superficial veins are visible. The nipples are as described in the pregnant condition. The fluid — colostrum — at first secreted is not true milk ; it is viscid, and contains yellow particles visible to the naked eye. Microscopical examination /* SIGNS IN THE DEAD OF RECENT DELIVERY AT TERM. 117 shows the presence of large corpuscles called colostrum corpuscles, which are composed of a number of fat granules hound together by a hyaline substance. According to Heidenhain, these corpuscles are cells of alveolar epithelium, which become round and faintly granular, and eventually take up fat granules from the alveoli. When treated with acetic acid they display nuclei. True milk contains very few colostrum corpuscles, and less albumin than is present in colostrum. The abdo- minal walls are flaccid and wrinkled ; beneath them the uterus is felt as a hard round ball. The cervix is soft, and open at the internal os; the external os is patulous, the lips being bruised, and they may be torn. The internal os begins to close during the first twenty-four hours ; the external os remains patulous for a long time. The vagina is dilated and relaxed, the rugae being absent. The mucous membrane at the mouth of the vagina usually exhibits some slight tears, especially in primiparse, in them also any remains of the hymen are completely destroyed, as evinced by the presence of recent tumefied nodules (ca/runculce myrtiformes). The vulva are tumid and open, especially at their perineal aspect. The posterior commissure is usually rup- tured, the perineum in some cases being lacerated. The lochia, at first almost pure blood, change about the third day to a serous fluid more or less tinged with blood, containing epithelium, mucus, exudation-corpuscles, and shreds of membrane. Subsequently, the blood diminishes, and its place is taken by fatty granules and pus, the colour changing to yellowish or greenish. The amount and the duration of the lochia are variable. The signs of recent delivery are well-m arked for the first few days ; after the lapse of a week they are more difficult of recognition, and in a fortnight will have so far dis- appeared as to render absolute diagnosis of recent delivery impossible. It is to be understood that the signs enumerated refer to those which follow delivery at term. SIGNS IN THE DEAD OP EECENT DELIVERY AT TERM. In addition to the indications available in the living, ocular in- spection of the uterus and its appendages becomes feasible when a necropsy is made of the body of a woman recently delivered. If death has taken place soon after deliver}', before the commencement of involution, the uterus will present the appearance of a flabby bag nine or ten inches long, with widely open mouth. Within, the surface is irregular and is covered with coagula of blood, with portions of decidua and with flakes of lymph. At the part where the placenta was attached the muscular structure is devoid of covering, and is darker in colour than the rest of the organ. Here may be seen as large lacunce the openings of the dilated veins (uterine sinwes). The 118 FORENSIC MEDICINE. cervix is drawn out and is much thinner than the walls of the body of the uterus ; it often presents a bruised and ecchymosed appearance. The vagina is dilated, relaxed, and devoid of rugae. A so-called true corpus luteum will probably be found in one of the ovaries. SIGNS IN THE LIVING- OF REMOTE DELIVERY AT TERM. In women who have given birth to a child at some remote period the breasts are more pendulous and flaccid, and the nipples usually more prominent, the areolae being deeper in tint than in nulliparous women. The abdominal walls also are not so firm and elastic, and the skin of the abdomen is usually marked with streaks of a silvery lustre. These marks are not invariably found after pregnancy, they are wanting in about 8 per cent, of cases that have gone on to full term. They occur from other causes than pregnancy — from peritoneal tumours, ascites, ovarian tumours, and on the legs from typhoid and typhus fevers ; in pregnant women they also occur on the breasts. Although often called cicatrices they do not result from replacement of one tissue by another, which is the characteristic of a cicatrix. They are due to partial absorption of some of the elements of the skin, and to modification of others. The fibrous tissue of the chorium, which is normally arranged in a kind of dense network, is re-arranged in parallel lines which traverse the streaks from side to side : the papillae are diminished in size by atrophy, and are spread wider apart. The labia are more open and the posterior commissure is usually represented by a cicatrix which may extend to the perineum. The hymen will not only be replaced by carunculae myrtiformes, but the continuousness of the nodules composing the carunculae will be destroyed. The formation of carunculae results from coitus, but the base of the hymen remains — where the mucous membrane of the vagina is folded over to form it — and is only completely destroyed by the passage of the child's head. The vagina is more open and smoother than before child-bearing, its anterior wall may project into the lumen of the canal. The cervix uteri is irregular, the os is puckered, fissured, and more circular and j^atent than in nulliparous women, admitting the tip of the finger. These signs are best marked in women who have born many children. When a woman has born but one child at a period remote from the time of examination, many of the signs may be wanting. The most deceptive appearance is presented by women who have given birth to a single child short of the full term. In such cases, after the lapse of a few years there may be no indication that the woman his been delivered. Even two or three deliveries of this kind may CRIMINAL ABORTION". 119 leave no trace, the woman presenting all the characteristics of ;i nullipara. SIGNS IN THE DEAD OF REMOTE DELIVERY AT TERM. The only additional evidence to that afforded by the signs of delivery in the living is obtained from inspection of the walls and cavity of the uterus. The uterus that has contained a child remains permanently larger and heavier than in the virgin state. The walls are thicker, and the cavity is not so triangular in outline, the angles where the Fallopian tubes enter being rounded off. Evidence of past rents of the external os may be seen as cicatricial irregularities. The difference between a parous and a nulliparous uterus, however, may not be suffi- ciently well marked in a given case as to enable a decision to be arrived at. 1 CHAPTER XIY. CRIMINAL ABORTION, Ix ^Medical language the term abortion refers to the expulsion of a foetus, or embyro, before the viable period — i.e., before the sixth month of gestation ; the term miscarriage is used synonymously. Delivery after the sixth month, but before full term, is called premature labour. Under the term abortion, the law includes both these periods, there- fore criminal abortion consists in unlawfully procuring the expulsion of the contents of the gravid uterus at any period of gestation s i i art of full term. It will be observed that this definition does not provide for the induction of premature labour by medical men. The law does not recognise this proceeding by making any exception in its favour, hence the necessity for medical men to protect themselves when about to induce labour prematurely, for the purpose of saving the mother's life, or from other proper motives, by explaining the object and necessity of the operation to all concerned, and, if possible, obtain- ing the moral support of a colleague. Under certain conditions the necessity for the operation is universally admitted, and if the practi- tioner under such conditions acts openly, he is held to be exonerated from the penalties imposed by the law. This does not mean that legal proceedings cannot be instituted, but that no conviction would ensue. 1 See Trans, of the Obstetrical Society, vols. xvii. and xviii. 120 FORENSIC MEDICINE. The law is thus expressed — " Every woman being with child, who, with intent to procure her own mis- carriage, shall unlawfully administer to herself any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever, with like intent, and whosoever with intent to procure the miscarriage of any woman, whether she be or be not with child, shall unlawfully administer, &c, shall be guilty of felony." " Whosoever shall unlawfully supply or procure any poison or other noxious thing, or any instrument or thing whatsoever, knowing that the same is intended to be unlawfully used or employed with the intent to procure the miscarriage of any woman, whether she be or be not with child, shall be guilty of a misdemeanour." (24 and 25 Vict., ch. 100, ss. 58 and 59.) Attention is first directed to the statement that the intention of the act constitutes the crime. I f mea ns are taken to produce abortion it matters not whether the woman is or is not pregnant ; and further, if the woman is pregnant, it is not necessary that abortion should follow the attempt to procure it, in order to constitute the crime. If a woman places herself in the hands of any one with the object of having abortion criminally induced, and she dies in consequence, the operator or administrator is guilty of murde r, although he or she had no intention of causing the woman's death. If the means employed were of such a nature as not to be dangerous to life, the crime may be reduced to manslaughter. This throws great responsibility on medical witnesses. In the first of the two sections of the act quoted, it is stated that the administration of "any poison or other noxious thing " with intent to procure abortion is felony. The question becomes what is a noxious thing 1 Any substance, however harmless, under certain conditions or in certain amount may be injurious. Much depends also on the intent with which it is administered. For ex- ample, if a large dose of jalap is secretly administered as a practical joke, or in some alcoholic beverage, with the object of punishing a surreptitious drinker of the same, the law regards such a proceeding as a venial offence. If the same drug is administered to a pregnant woman, or to a woman whom the administrator believes to be pregnant, with the object of procuring abortion, it would j)robably be regarded as a " noxious thing ; " not because the administration is of necessity likely to be followed by abortion, but on account of the criminal in- tention it displays (see Section 58 above quoted). It might be supposed that the word "noxious" was redundant in relation to the phrase "other means whatsoever," inasmuch as the latter covers all the ground ; it is not improbable, however, that the framer of the Act had in his mind a reference to mechanical or local means of procuring abortion. The first clause specifies poison, and then strengthens or enlarges the term by adding " or other noxious thing." The second clause specifies L MODES OF PROCURING CRIMINAL ABORTION. 121 "any instrument," and to prevent quibbling adds "or other means whatsoever." One judge, however (Brett), ruled in a case of criminal abortion, that the word " noxious " should be omitted in the in- dictment, as the comprehensive phrase "other means whatsoever" included any substance administered whether noxious or not. {Reg. v. Willis, 1871.) As this ruling docs not, universally obtain, it is necessary for the medical witness to Ik: prepared to express an opinion in the witness-box as to the properties, noxious or otherwise, of some of the drills most commonly used with the object of procuring criminal abortion. MODES OF PROCURING CRIMINAL ABORTION. Criminal abortion is attempted in one or more of three ways : — By the administrations of drugs by the mouth, by acts of gem wn mis- carriage by direct mechanical means. Various implements have been used with this object. Partridge 1 relates the case of a woman in the seventh month of pregnancy who introduced a hair-pin, points downward, into the uterus and allowed it to remain. No abortion took place for three weeks. The woman then became ill and sought medical advice when the hair-pin was found to have penetrated the walls of the uterus. The os was dilated and the hair-pin and ovum were extracted twenty-three days after the introduction of the former. The woman died of peritonitis. The a ttempt to procure criminal abortion is usually made in the earlier months of pregnan cy before the enlargement of the abdomen becomes obvious. Young, inexperienced girls as a rule resort to drugs first, and, after proving their inefficacy, apply to the pro- fessional abortionist ; in this way the actual abortion may be delayed until the third or fourth month or later. Women of more experience seek mechanical aid as soon as they suspect their condition — after the omission of one menstrual period. It is to be remembered that married women, as well as those who are single, have recourse to forced mis- carriage. In the earliest months the attachment of the ovum to the uterus is but feeble, and consequently direct mechanical disturbance is almost certain to cause miscarriage ; if effective, the uterus expels its contents in from a few hours to three or four days after the operation. It is quite possible, however, for a uterine sound (or other similar instrument) to he introduced into the cavity of the gravid uterus without causing miscarriage. In such cases the mem- branes are not ruptured; the blunt sound passes between them and the uterine wall, and produces but slight separation. Many gyne- cologists have unwittingly passed a sound into a gravid womb without ill effects. Saxinger 2 relates a case in which a medical man (under the impression that he had to deal with a pathological condition of the organ) on two separate occasions passed a sound into the uterus of a pregnant woman in the early months without interfering with the normal course of gestation. The induction of criminal abortion imperils the patient's life in two ways — by causing pro/use haemorrhage, the result of retention of the placenta ou some other product of conception, or by septic inflammatory 2>rocesses. Lesser 3 states that in instrumentally induced abortion the extent of injury to the uterus does not materially influence the length of time the woman survives, the cause of death being always puerperal fever. Septicaemia following abortion is a suspicious symptom, pointing 1 New York Med. Journ., 1SS4. - Maschka's Handbuch, Bd. 3. 3 Atlas der ger. Med. (zweite Abtheilung), 1891. SIGNS OF ABORTION IN THE DEAD. 127 to' mechanical interference as the cause. Little surprise can be fell at the frequency with which septic inflammation follows criminal abor- tion when the absence of all attempts to render the instruments used aseptic is taken into account. It is not to be forgotten, however, that death of the ovum from pathological causes may determine septic inflammation from absorption of the products of putrefaction. The retention of the placenta, or pari of it, after spontaneous abortion also frequently gives rise to septicaemia. SIGNS OF ABORTION IN THE LIVING. The indications that abortion has taken place vary with the period of gestation at which it occurred, and the interval that elapses between the event and the examination. If pregn ancy is cut short in the first or the second month, even on early examination, very little will he found different from that which accompanies an ordinary menstrual period; when a few days have elapsed the parts will have entirely recovered their usual condition. Abortion at three or fou r months le aves immediate traces behind in the form of a more or less patulous condition of the vagina, and possibly the vulva may be | swollen. Spiegelberg 1 describes a funnel-shaped condition of the cervix uteri, which grows narrower from below upwards, as being very characteristic of the recent occurrence of abortion. The condition of the breasts should be investigated. The further pregnancy is ad- vanced, so much the more will the signs of abortion resemble those already described as attending delivery at term. As the signs of abortion are less pronounced than those of delivery at term, so do they disappear sooner. The examination of a woman after the alleged occurrence of abortion should be conducted within twenty-four hours, otherwise little information will be yielded by it. Pathological in- dications in the form of metritis or peritonitis may be present SIGNS OF ABORTION IN THE DEAD. In making the preliminary incisions and in removing the uterus with the vagina attached, great care must be taken not to injure it in any way. If the vagina is slit open some indications may be afforded as to the best direction in which to dissect the uterus, in order to trace out any punctures in its walls. Any such puncture, or laceration. should be carefully measured, and its position and direction ascertained. The length and the breadth of the cavity and the thickness of the uterine walls should be measured. The presence in the substance of the uterus of products of inflammation, the position of any perimetric 1 Lehrbuch der Qelurtsltiilje. 123 FORENSIC MEDICINE. inflammation, the presence or absence of mucous membrane in the cavity, and the appearance of its walls are respectively to be noted. If the third month of gestation has been accomplished the site of the placenta will probably be distinguishable. Those who have not pre- viously examined the cavity of a uterus recently delivered in the natural May are liable to draw erroneous conclusions from the appearances pre- sented, more especially when the later months of gestation have been reached. The walls of the cavity are black and irregular — as though bruised — and convey the idea that violence has been resorted to; care must be taken to distinguish between the physiological condition and one that results from mechanical ill-usage. The ovaries should be examined for corpora lutea, not that the information thus obtained is of importance, but because questions on the subject may be asked by counsel. In addition to ascertaining the condition of the generative organs, the state of the stomach and the intestines must be investigated for possible indications of irritant poisoning resulting from the adminis- tration of one or more of the so-called ecbolics. For the same reason the kidneys should also be examined. In exceptional cases a caustic fluid has been injected into the vagina for the purpose of inducing abortion ; the condition of its mucous membrane is, therefore, to be observed. Lastly, if an embryo is found in the generative tract its probable age is to be ascertained. The following is an epitome of the stages of development of the foetus during the first five months of intra-uterine life : — One Month. — The embryo measures about one-third of an inch in a .straight line from cephalic to caudal curve, and three-quarters along the curve; the ovum is about three-quarters of an inch long. The p resence of the limbs is in dicated. The nasal pits, a c left indicating the position of the mouth, and t wo black clots represe nting the eyes, with the umbilica l vesicle and the blood-vessels are present. The amnion is close t o the embryo , and is separated from the villous chorion by a clear cavity. Two Months. — The embryo measures half an inch in a straight line From highest point of cephalic curve to caudal curve; along the curve about an inch. It weighs 60 grains. The nasal and oral openings are separated. The head is becoming distinct from the body. The Sylvian fossa is distinguishable. The primitive kidneys (Wolffian bodies) have almost disappeared, and have become divided into urinary and gener- ative organs. The first centres of ossification have appeared in the lower jaw, the clavicle, ribs, and bodies of the vertebra?. The amnion is in contact with the chorion, the amniotic cavity contains more fluid. The villi of the chorion are especially well developed at one spot. The umbilical vessels passing to the chorion are the only visible remains of the allantois. SIGNS OF ABORTION IN THE DEAD. 129 Three Months. — The embryo is 2| to 3£ Inches long, and weighs from 300 to 450 grains. The head is separated from the trunk by the neck. The ribs are sufficiently developed as to differentiate the chest and abdomen. The pupillary membrane is present. The eyelids and the lips are closed. The teeth begin to form. The fingers and toes can be distinguished, also the rudiments <>f the nails. The penis and clitoris are of equal length ; sexual differentiation is commencing. The chorion has lost most of its villi. The placenta is distinct. Tin; umbilical cord is spiral, about 2| inches Ion-', and is inserted into the lower fourth of the linea alba. The decidua vera and reflexa are in conl Four Months. — The fetus is 4 to <>.', inches long, and weighs from 2 to 4 ounces. The head equals one-fourth of the body length. The mouth is open; the nose, eyes, and ears are distinct. The length of the external ear is from 5-5 to 7'5 mm. The skin is firmer. Hairs (lanugo) are beginning to form. The pupillary membrane is quite distinct. The eyelids are closed. The occipital lobe is mapped-out. Points of ossification are present in lower segments of sacrum. The placenta is larger, and weighs about 2-| ounces. The umbilical cord measures 7.1 inches, is more spiral, and is thicker from the formation of Wharton's jelly; it is inserted above the lower fourth of the linea alba. The sex is distinguishable. The chorion and amnion are in contact. Movements of the limbs have been observed. Five Months. — The ff the opening through the thoracic wall are stretched wide apart, the lungs may be seen lying near the vertebral column, their sharp borders reaching forwards to about one-third of the length of the ribs. The diaphragm is only covered by them at its posterior part. If the child has fully breathed the lungs more or less till the thorax and partly cover the pericardium. The right lung is usually more pro- minent than the left. The thin sharp margins of the lungs have become rounded, and their under surface covers most of the arch of the dia- phragm. If the difference in volume between the lungs of an infant that had breathed and one that had not was invariably as pronounced as above described there would be little need for further evidence. The descriptions given, however, represent the two extremes — absolutely no respiration in contrast with fully established respiration ; in such cases there is little probability of error. When the infant has but feebly or imperfectly breathed, the volume of the lungs may be only slightly different — and possibly not at all — from that which obtains in the foetal condition ; in these cases nothing is learnt from an inspection of the size of the lungs. The Position of the Diaphragm. — The increase in the volume of the lungs causes them not only to spread forward but also downward, the result being that the arch of the diaphragm is depressed. Usually in infants that have not breathed the highest part of the arch is on a level with the fourth or fifth ribs ; after respiration it sinks to the level of the sixth or seventh ribs. It is obvious from whal has already been said in reference to imperfect respiration that the height of the diaphragm can only be distinctive in well marked cases; it is, therefore, of little use as a means of determining doubtful cases. Even in cases in which infants have fully respired, the diaphragm has been found nearly as high as before the occurrence of respiration. The presence of gases or of fluids from putrefactive processes in the abdomen or thorax alters the curvature of the diaphragm. (b) The Colour of the Lungs before and after Respiration. — Before respiration the colour of the lungs is pale brown, resembling that of 132 FORENSIC MEDICINE. the liver, but paler. It has been likened by Casper and Linian to strong chocolate and water, sometimes being lighter, more like chocolate with milk ; at the borders the colour is a little brighter. The tint varies with the amount of blood present in the lung. The lobes are indicated by lines of a lighter colour. A marked characteristic of lungs that Lave not respired is that, with insignificant exceptions, the colour is uniform over the entire surface ; the posterior portion may be a little Inker than the anterior, but there is no mottling. After full respiration the lungs assume a lighter colour, which par- takes of many shades from light red to dark bluish-red. When there is much blood in the lungs, dark bluish-red forms the ground-tone on which spots and patches of bright red are seen ; when there is less blood the ground-tone is light red, the patches then taking the darker hue. This marbled or mottled appearance is very characteristic of the occurrence of respiration ; it is never found in the foetal lung. The shaded patches and spots project slightly above the rest of the lung surface, being formed by distension of the alveoli with air. The pleura of the lung that has breathed is very transparent, and imparts brilliancy to the underlying tints; the feetal lung, on the contrary, has a dull non-transparent surface. It is absolutely necessary to observe the colour of the lungs, both feetal and respired, soon after the thorax is opened, as exposure to air quickly altei\s the tints, making them lighter. "When the infant has feebly respired for a short time only, indications in the form of spots or patches of a different colour to the rest of the lung may or may not be present on its surface. They usually appear first on the border of the upper lobe of the right lung, and may be found there when absent from the rest of the surface of both lungs. They appear as red, or bluish- red spots on the otherwise uniform brownish tint of the unrespirecl part of the lung. The spots are irre- gularly coloured, having a mottled look. The presence of these spots — inflated alveoli — is a sure indication that air has entered the lungs. They may be absent, however, in exceptional cases, even when the child has for a short time survived birth, respiration having been imperfectly carried on. Artificial inflation may cause the surface of the lungs to assume a bright red colour, which, according to Casper, is uniformly distributed over the surface without any trace of mottling. Taylor and Stevenson mention a case in which Braxton Hicks performed artificial infla- tion in a still-born infant, the attempt at resuscitation being unsuccessful. On opening the thorax it w r as found that the air cells in about three- fourths of the lungs had received air; but the colour of the lungs was different from that which obtains after natural respiration, being of a Hfe HAS THE CHILD BREATHED? 133 pale fawn tint. On the other hand, Runge 1 and Oblonsky 2 assert ili.it a mottled appearance may be produced by the method of artificial inflation called Schultze's-swinging. When death results from haemorrhage in the newly-born infant, the lungs are pale and reddish-grey; if respiration 1ms taken place,. bluish- black marbling is to be seen on the light-coloured ground. To epitomise: a uniform brownish colour of the lungs is indicative of the foetal state; a mottled or marbled appearance, of various tints as described, is peculiar to lungs thai have breathed. The possibility of artificial inflation must be taken into account. (c) The Consistence of the Lungs before and after Respiration. — Before respiration the ftetal lung resembles liver, not only in colour but also in texture; it is compact and firm, and on pressure offers resistance to- the finger. After respiration the lung is elastic and yielding, and when compressed between the finger and thumb produces a feeling of crepitation. The difference in consistence between foetal lungs and those which have respired is respectively due to the absence and to the presence of air in the alveoli; therefore, when respiration ha3 been imperfectly performed, the characteristic feel of a lung that has breathed will be only partially present, or, it may be, entirely absent ; if partially present, some portions of the lung will crepitate, others will not. Coincident with the establishment of respiration is the commence- ment of the pulmonary circulation. During foetal life the blood that reaches the lungs is limited to the amount required for their nutrition. When respiration is established, the whole of the blood in the body passes through the lungs which, consequently, at any given moemnt, contain an amount greatly in excess of that which was present in the foetal state. If an incision is made into the foetal lung it cuts like liver, and from the cut surfaces — the colour of which is uniform — only here and there a little blood appears when slight pressure is made. Lungs that have breathed are less easily cut, as the tissues, on account of their elasticity, recede before the knife, the stroke of which produces a crepitant sound ; the cut surface is irregularly coloured, and if scraped with the blade of the knife, blood-stained froth is obtained. The increased amount of blood that passes through the lungs after respiration is established adds to their weight. On this fact is founded the so-called static test. The average weight of lungs before respira- tion is stated to be from -150 to GOO grains, after respiration 9G0 grains; numerous observations have proved that these figures are far from representing the actual lung-weights respectively. As the lungs of the infant under inspection cannot be weighed both before and after 1 Berliner Tclin. Wochenschr., 1SS2. - Vierteljahrsschr, f. ger. Med., 1S8S. 134 FORENSIC MEDICINE. respiration, a reliable average weight would be necessary for the utilisa- tion of the static test. This, however, is unattainable, the lung-weights, both before and after respiration respectively, being so extremely vari- able. Ploucquet proposed to obviate the difficulty introduced by the varying weight of the lungs in newly-born infants, by assuming a certain proportion between the lung-weight and the total body-weight. The assumption is fallacious, as no such ratio exists. The static test in any form is useless as a means of determining the occurrence or not of respiration. (d) The Specific Gravity of the Lungs before and after Respiration.— Although the lungs as a whole are heavier after the child has breathed, they are specifically lighter; the increase in weight caused by the influx of blood is more than counterbalanced by the air that is present in the alveoli. On the difference in specific gravity of lungs which have and which have not respired, is founded the hydrostatic test. Advantage is taken of the fact that the specific gravity of unrespired lung-tissue is greater than that of water, whilst the specific gravity of respired lung-tissue is less than that of water. If, therefore, unrespired lungs are placed in water they sink : if respired lungs are placed in water they float. The Hydrostatic Test is thus Performed :— The lungs with the bronchi, as far as their junction at the trachea, are placed in some water con- tained in a suitable vessel. They either float or sink. If they float, observe whether the bulk of them remains above the water-level, or whether they float almost or quite submerged. The bronchi should then be divided, and each lung tied separately, the respective degree of buoyancy being observed as before. Each lung is now cut into about a dozen pieces, and each piece tested separately. If they float, they are to be taken out of the water and subjected to firm compression, in order, if possible, to drive out the air or gas that causes them to float. If the air has entered the lungs in the act of natural respiration, no degree of force, unless sufficient to cause disintegration of the lung- tissue, will expel it, and, consequently, on again placing the fragments in water they still float. If the lungs sink, it should be noticed whether one or both sink, and whether slowly or rapidly. They are then divided into a dozen or twenty pieces, each of which is tested separately. If the lungs, when whole and when cut in pieces, sink, presumptive evidence is thereby afforded that the child has not breathed. The possible fallacies of the hydrostatic test are— that the lungs may float (a) from artificial inflation, (/3) from the presence of the gases of putrefaction. That they may sink (-/) from the effects of disease, (5) from imperfect respiration (atelectasis), or from absolute HAS THE CHILD BREATHED? 135 persistence of the foetal condition, although the child has breathed and lived for sonic time. (a) Artificial Inflation. — This may he performed in several ways — by the direct application of the operator's mouth to that of the child; by forcing air into the lungs through a silver catheter, or other similar instrument passed by the mouth into the trachea; or by the method known as Schultze's -swinging. Inflation of the lungs in a new-born infant is no easy matter, the air being apt to find its way into the stomach rather than into the lungs. When the attempt at resuscita- tion is not successful, post-mortem examination shows that the lungs are rarely more than partially inflated. As already described, the appearance of lungs artificially inflated is stated by some to be very different from that displayed by lungs in which complete natural respiration has taken place. It has also been asserted that a further difference exists — that the air contained by lungs artificially inflated can be expelled by pi*essure. This is contradicted by experience, and is opposed to physiological experiment. In Braxton Hicks' case of artificial inflation, previously mentioned, no amount of pressure short of destruction of tissue caused the divided pieces to sink. An explana- tion of these contradictory statements may probably be found in the position occupied by the air artificially introduced. If it arrives in the alveoli without rupturing their walls, there is no reason to suppose that it can be more easily expelled by pressure than air which has been naturally inspired. If, however, the air has not penetrated beyond the lobular bronchi, or (as readily occurs in artificial inflation) it has been propelled with sufficient pressure to rupture the septa between the alveoli, and to obtain access to the sub- pleural connective tissue, there is nothing to prevent its expulsion on compression of the lung fragments. When artificial inflation is only partially successful in distending the lungs, it has been stated that no additional blood enters them, so that, although they may be more voluminous than in the foetal state, they are not heavier, and that an incision into the lung-substance does not yield blood, as in the case of a lung that has naturally respired. This view, supported by Casper and other leading experts, has of late years been proved to ' be incorrect. Eunge, 1 Sommer, 2 and Oblonsky 3 have all recorded cases in which the lungs of still-born children, by means of Schultze's-swinging, have acquired all the properties of lungs that have partially respired in the natural way. Oblonsky removed, by Caesarean section, a nine months' foetus from the body of a woman who 1 Berliner hlin. Wochenschr., 1SS2. ,;: Yicrteljahrsschr.f. ger. Med., Bd. 43. :i Vierteljahrsschr. f. ger. Med., Bd. 43. 136 FORENSIC MEDICINE. died suddenly, the operation being performed about ten minutes after death. The child was dead, and attempts at resuscitation were made by Schultze's- swinging. The attempts were unsuccessful, and on examining the body the thoracic cavity was found almost entirely filled with the lungs. The apices of both lungs, and the edges of the lobes were rosy-red in colour, and the rest of the lung surface was purple-red with rose-coloured spots, presenting a mottled or marbled appearance. The lungs floated on the surface of water, and when divided all the pieces floated except those derived from the posterior aspect. From the edges of an incision in the apices blood-stained froth exuded. Other cases are also recorded by the same writer in which blood-stained froth was obtained by the incision of lungs artificially inflated. The distinction formerly made between the effects of natural respira- tion and artificial inflation is no longer to be received in an absolute sense. In many cases it doubtless holds good ; but since exceptions have been proved it is to be admitted that no known test will enable an infallible opinion to be expressed as to whether lungs have respired incompletely, or have been artificially inflated. Apart from physical evidence, the occurrence of artificial inflation in cases of suspected infanticide is opposed to reason. In the newly- born infant the performance of artificial respiration is a difficult task for the expert, and without special knowledge it would be barely possible for an ordinary woman to put it into practice. Schultze's method, by which lungs have been inflated to a degree comparable with the effects of imperfect respiration, is little used in this country, and demands expert knowledge and practice for its performance. If the inflation is done by a second person who was in attendance at the labour, evidence of the fact would be forthcoming. (/3) The Gases of Decomposition. — The lungs belong to the class of organs which putrefy slowly. The thorax being intact, if there are no external signs of putrefaction, or only those of the early stage, it may be accepted that the lungs will not be influenced by the gases of decomposition so far as the hydrostatic test goes. The earliest indica- tion of putrefaction in the lungs consists in the appearance of small vesicles filled with gas between the lung-substance and the pleura, the pressure of the gas lifting the pleura in detached spots. They first appear at the free borders of the lobes, and at the base of the lungs ; subsequently, the deeper seated tissues of the lungs are infiltrated with gas. The vesicles under the pleura vary in size from that of a pin's head to that of a bean, in the early stage they are small and are often found clustered together, or in rows. By pressure of the finger the gas can be displaced, and if small the vesicle disappears as the HAS THE CHILD BREATHED? 137 gas travels under the pleura; if such a vesicle is pricked with a needle so as to allow the gas to escape, the pleura falls flat. Air within the alveoli is not expelled, neither by pressure nor by simple pricking with a needle. It is to be noted that an appearance similar to tin- small vesicles of putrefaction might he caused by rupture of the alveoli from too vigorous attempts at artificial inflation. In the early stag- of putrefaction of the lungs the organs retain their appearance sufficiently to enable distinct ion to be made bet ween the colour of the foetal lung and of that which has breathed. When a more advanced stage is reached the colour is dark green, sometimes almost black, or dirty-brown. The lung substance is softened, and on section a dirty-red fluid escapes — the odour is then highly offensive. Foetal lungs do not decompose so rapidly as those which have breathed. When foetal lung-tissue is infiltrated with the gases of decomposition its specific gravity is lessened, therefore in this state it will float. A piece of lung in this condition compressed by the finger and thumb under water gives off a number of relatively large and irregularly formed air bubbles which ascend through the water. A piece of fresh lung that has breathed when similarly treated yields a stream of fine, equal sized bubbles. Pressure drives out the gas from decomp osed lungs, s o that pieces which float in their original condition sink after compression; this result, however, may ensue in the case of lungs which have breathed when the lung-substance is softened by putrefaction. Fcetal lungs which have been rendered buoyant by putrefaction spon- taneously lose that propex^ty in a still more advanced stage of decom- position, and sink as they would before being attacked by putrefaction. It may be accepted that when the lungs are in an advanced stage of putrefaction, no trustworthy evidence can be yielded by the hydro- static test. The fact mentioned at the beginning of this section. however, is to be remembered — that the lungs putrefy slowly, therefore an advanced stage of external putrefaction does not preclude the necessity of testing the lungs. Ogston 1 found no putrefactive buoyancy of the lungs from the body of an infant which had been dead five months. Casper examined two new-born infants whose bodies were in an advanced stage of decomposition ; the heart and the liver floated from the presence of gas, whilst the lungs sank. If a distinction is to be made, the evidence afforded by tin; lungs floating is quite unreliable when the organs are undergoing putrefaction; that afforded by the lungs sinking, if an advanced stage of putrefaction is not reached, may be taken into account. (7) The Effects of Disease.— Pulmonary disease in the first days of life is rare; certain forms — as pneumonia, pleurisy with effusion, and 1 Lectures on Medical Jurisprudence. 138 FORENSIC MEDICINE. so-called pulmonary apoplexy — are capable of depriving the lung of its buoyancy after the occurrence of respiration. If the disease began during intra-uterine life, it might either completely or partially pre- vent the entry of air into the lungs. Death from suffocation may produce such a degree of hyperemia of the lungs as to cause them bo sink in water. In none of these conditions would there be any real difficulty, as the pathological appearances caused by the diseases would be apparent either to the naked eye or with the aid of the microscope. With the exception of excessive hyperemia produced by suffocation, it is unlikely, but not impossible, that the whole of both lungs would be so affected by disease as to sink when subdivided. If sinking of the lungs is due to consolidation after the occurrence of respiration, any attempt to inflate them by blowing down the trachea will be unsuccessful ; but if due to persistence of the foetal condition, inilation can be thus accomplished. (6) Imperfect Respiration. — It is a remarkable fact that very excep- tionally an infant may survive its birth for many hours, during which period the chest may rise and fall as in ordinary respiration, and what is even more remarkable, the child may cry, and yet after death the lungs are found to have completely retained their fetal condition — the colour, volume, consistence, and specific gravity being respectively the same as in the unrespired lung. From this total absence of aeration, all degrees of alveolar distention may occur up to that which accompanies fully developed respiration. The term atelectasis has been applied to such conditions, the meaning of the word being imperfect expansion ; medical jurists use the word in order to indicate defective performance of a physiological function ; it is used by others to indicate an acquired pathological condition — partial consolidation of the lungs. The word is unnecessary and inconvenient. The expression " imperfect ex- pansion" is sufficiently distinctive, and admits of change to "non- expansion " to signify absolute persistence of the fetal condition, whereas atelectasis being itself a comparative expression cannot ■correctly be thus used. There are three ways in which it is sought to explain the anomaly of a child living and breathing for many hours without a trace of the occurrence of respiration being present in the lungs after death. Maschka and others deny that air enters the lungs at all in such cases, the passage of air along the trachea and bronchi is regarded as sufficient to account for the signs manifested during life. Others accept the theory first propounded by Simon Thomas 1 — that in feeble infants the respiratory movements may gradually subside in such a way that the passive elasticity of the lung-tissue, at every expiration, 1 Nederl. Tijdschr. v. Geneesl:, 1854. -> M HAS THE CHILD BREATHED? 139 drives out more air than is drawn in at the inspirations, in this way the lungs after having breathed gradually return to the foetal con- dition. As the result of experimental investigation Ungar 1 states that the air which has entered the lungs may be entirely absorbed after respiration has ceased by the blood circulating through them. When from immaturity or from extreme feebleness a newly-born infant barely exists, its demand for oxygen will be very slight, and it is conceivable that the necessary interchange might take place in the air tubes without the help of the alveoli. The rising and falling of the chest, as in ordinary respiration, is not inconsistent with retention of the foetal condition of the lungs. Hermann 2 showed ex- perimentally that the lungs in the foetal condition require more pressure to expand them than those which contain air on account of the adhesion of the bronchial and alveolar epithelium. If the lungs are once expanded, however feeble the infant may be, there will be some movement of air in them ; but, if the initial unfolding of the lung-tissue has not already taken place, the movements of the chest wall may be inadequate to overcome the resistance. It is, however, difficult to understand how sufficient air could be inspired under these conditions as to enable the child to cry to the extent that has occurred in many cases. Vernon 3 heard a newly-delivered child cry, whilst under the bed-clothes, sufficiently loud as to be audible to him as he entered the adjoining room. The child lived five hours, and after death the lungs sank, whole and divided, and showed no trace of air-vesicles under the microscope. The second hypothesis — gradual expulsion of all the air by the elasticity of the lung-tissue is in accord, neither with physiological experiments nor with clinical ex- perience. Hermann (I.e.) proved that the elastic power of the lung that has once contained air cannot expel the air and restore the lung to the fcetal state. Children are frequently born immature and feeble, and die shortly after birth, but the occurrence of lungs in a fcetal condition under such circumstances is exceptionally rare. Ungar's hypothesis is not improbable, seeing that in these cases of low vitality the heart may continue to beat some time after the cessation of respiration, in this way it is feasible that the residual air might be entirely absorbed by the blood. Causse 4 records the case of a seven months' infant which survived several days. After death the right lung was found more expanded than the left, and when cut into yielded dark coloured blood, but it was not crepitant. Both lungs, whole and divided, sank in water. In this case it seems probable that modified respiration took j:>laee in the right lung as it was 1 Yierteljahrsschr. f. schr. f. 166 FORENSIC MEDICINE. In a great many accusations of infanticide the jury reduce the crime to that of concealment of birth. Concealment of a living child that does not die before it is discovered does not constitute the misdemeanour. In cases of concealment of birth the question of live birth does not arise, therefore medical evidence is simplified in com- parison with that required in cases of infanticide. Medical evidence is limited to proof that the remains found are those of a child, and that the accused has or has not been recently delivered. The pi-esent state of the law leaves it uncertain whether a fetus before quickening would come under the definition of "a child." According to Scotch law concealment of pregnancy is a crime. It is not necessary that the dead body of the child should be found, nor need there be proof of infanticide ; all that the law requires is that the woman must be proved to have been pregnant sufficiently long as to render possible the birth of a living child. If, during her pregnancy, the woman reveals the fact to another person, even if it is with the object of arranging for concealment of the child's birth, and evidence to this effect is tendered, the law is evaded — the pregnancy is no longer "concealed." CHAPTER XYI. BIRTH IN RELATION TO THE CIVIL LAW. Live-birth, in the legal acceptation of the term, is determined by the same conditions in both criminal and civil cases. In criminal cases the character of the medical evidence differs from that which is usually tendered in civil cases, because in the majority of criminal cases the woman gives birth to the child in secrecy, so that no witness to the fact that the child was fully born at the time when signs of life were developed is forthcoming; consequently expert evidence founded en- tirely on the indications presented by the dead body of the newly-born infant has to be relied on. In civil cases witnesses are usually to hand — the accoucheur and the nurse — who were present when the child was born, and who therefore can testify to the fact of legal birth at the time the child displayed tokens of vitality ; hence proofs of live birth are available in civil cases which, by circumstances, are excluded in criminal cases. The occurrence of respiration, to which so much significance is attached in cases of infanticide, constitutes but BIRTH IN RELATION TO THE CIVIL LAW. 1G7 one indication of life ; its importance arises from the fact that it leaves after death more or less permanent and reliable traces of its occur- rence; with the exception of the stomach-bowel test, all other mani- festations of a life that ceases almost immediately after it has demonstrated its existence vanish and leave no trace behind. According to the law of England, t he most evanescent sign o f life. provided that it is observed after the child is entirely outside the body of the mother, constitutes proof of live birth. With this proviso tin- least muscular movement that may amount to a mere momentary twitching of the lips or of a limb, or a few beats of the heart, either heard with the stethoscope or felt in the cardiac region, or by pul- sation in the undivided funis, or the more obvious evidence afforded by respiration, with or without crying, are each, and severally, proofs of live birth. The duration of any of these signs is immaterial — one moment of life thus manifested avails, as proof of live birth, as much as though the child continued to live for days or months. According to the law of Scotland the commencement of respiration after expulsion must be px*oved to establish live birth. In civil law, live birth comes into consideration in respect to the inheritance of property ; in such cases much may depend on the fact that the child displayed, or did not display signs of life after birth, and in event of live birth, on proof of the exact time when it was born. If the head is born, and an interval elapses before the body is expelled during which the child is observed to breathe and cry, that is not the moment of birth. The delay may extend over some minutes, and, as the law does not recognise the fractional part of a day, if it occurs partly before and partly after midnight, a mistake in recording the exact time of birth might make a difference of twenty-four hours, and possibly alter the succession to an estate if the child continued to breathe until and after birth. It may die, however, during the delay, before the body is expelled ; in which case the child is still-born, the law taking no cognisance of signs of life manifested before complete expulsion. The question of live birth has to be considered in respect to Tenancy by Courtesy. " When a man marries a woman seized of an estate of inheritance, and has by her issue born alive, which was capable of inheriting her estate ; in this case he shall, on the death of his wife, hold the lands for his life as tenant by the courtesy of England." It will be seen that there are two obvious conditions to be ful- filled — (a) That the issue must b e born alive, (6) that it was capable d1' inheriting. A third condition, which is ny deficiency of vigorous movements and clamorous cries, with inability to suck the proffered nipple. The body-heal of immature children is subnormal, and requires conserving by means of thick layers of cotton-wool and other surroundings, which lessen the loss from the surface. Viability. — An infant may have arrived at a sufficiently advanced period of development as to be born alive, but not to be viable — that is, not to be endowed with the capacity of continuing to live. As a 172 FORENSIC MEDICINE. general statement it may be accepted that 180 days repr esent the lowest limit at which aninfant is viable, but it is by no means to be inferred that all infants at this period of iutra-uterine life are viable ; on the contrary, prolonged survival is the exception and not the rule, consequently good evidence is required to establish the occurrence of viability at this age. Bonnar 1 tabulated a number of cases of premature birth, tracing the after life of the infants ; of 22 which were born alive at 180 clays of intra-uterine life, only 4 lived one year and upwards; six more of the same group lived twenty four-hours and upwards, but none of the rest longer than four months. Bailly 2 records the case of a child born at six months and twenty days. It was very feeble, and required much care to sustain the body-heat ; as an illustration of its small size it is stated that the father's finger-ring could be passed over the child's foot nearly as far as the knee. Thir- teen days after birth the child weighed 1,250 grammes (about 2§ lbs.) ; twelve months after birth, when the case was reported, it was living and thriving. In a well authenticated case reported by Outrepout 3 the child was at about 27 weeks of intra-uterine life when born. It measured 13.V inches, and weighed 1J lbs. ; the skin was wrinkled and covered with down, the nails were like folds of skin, and the papillary membrane was entire; the limbs were small and were maintained in the fcetal attitude. The child was living at the age of 1 1 years, and had the appearance of a boy about 8 years old. Instances are recorded in which infants born before 180 days have been reared; such cases are very exceptional and provoke scepticism as to correctness of data. Bonnar's list contains the case of one child born at 150 days which lived to the age of 19 years. A case is recorded by Moore 4 of a child born at the end of the fifth month, which measured 9 inches in length, and weighed 1^ lbs.; at the age of 15 months the child was healthy and weighed 19 lbs. Illustrative of the risk encountered in estimating the stage of development from the size of the child is a case recorded by Hubbard. 5 The period of utero-gestation is stated to have been about the seventh month. The infant was 10 inches long; the circumference of the head round the ears was 8 inches, round the thighs 2i inches; the weight was 1 lb. 2 oz. ; the child was well formed, the finger-nails being perfect ; it lived eight hours. Reference to the Table on p. 26 shows that the finger-nails are not perfectly formed until utero-gestation has advanced eight months, but the length and weight of this child would indicate that it had not exceeded six months. Barker 6 relates the case of a 1 Edinburgh Med. Journ., 1865. 2 Arch, de Tocologie, 1879. 3 Henlce's Zeitschr., 1823. 4 Philadelphia Med. and Surg. Reporter, 1SS0. 6 New Tor I; Med. Journ., 1S90. 6 Med. Times, 1S50. SUPERFCETATION*. 173 child born 158 days after intercourse. It measured 11 inches in length and weighed 1 pound ; the nails were scarcely visible ; the eyelids were closed until the second day after birth ; the skin was wrinkled ; three and a-half years after it was thriving and healthy, but only weighed 29 h lbs. A number of similar cases have been recorded but none of very recent date. Culling worth 1 collected several, amongst which is included an instance of early viability (seventh month) that he met with in his own hospital practice. Children born at the intra-uterine age of five months have lived for a few hours, but not much longer ; it is needless to cite such cases as it is acknowledged that a foetus may display signs of life when born at that period of development. Without impugning the veracity of I those who have recorded such cases, it is nevertheless true that no instance, accompanied by absolutely convincing evidence of viability in a five months' fcetus, has yet been recorded. In France and Italy a child born -within .180 days after marriage can be repudiated by the husband if no intercourse has taken place between him and his wife before marriage. In Germany a husband can repudiate the parentage of a child given birth to by his wife when he can prove non-intercourse from the three hundredth to the one hundred and eightieth day before the birth of the child. In Scotland a child born six months after the marriage of the mother is considered legitimate. In England and America no limit is fixed : as with protracted gestation each case is determined on its own merits. SUPERFCETATION. The possibility of superfoatation is a disputed point amongst obste- tricians ; some allow that exceptionally it may occur, others regard it as being physiologically impossible. All allow the possibility of superfecundation— that is, the separate impregnation of two ova dis- c harged during the same period of ovu lation ; the difficulty arises with respect to the possibility of an ovum derived from a subsequent ovulation being impregnated some months after the occurrence of testation resulting from fecundation of an ovum discharged during a previous ovulation. It is now admitted on all sides that the condition of the impregnated uterus until the middle of the third month does not interpose any insurmountable obstacle to re-impreg- nation. The union of the decidua reflexa with the vera is not then complete, and therefore no absolute barrier exists between the ovum and the spermatozoa ; the plug of viscid mucus in the cervical canal also offers no insurmountable obstacle. Those who deny the possibility 1 Obstetrical Journ. of Great Britain and Ireland, 1878. 174 FORENSIC MEDICINE. of superfretation base their opposition on the non-occurrence of ovula- tion during gestation. If ovulation never takes place from the commencement of gestation until after delivery, it is clear thai superfoetation is impossible. The rule is that ovulation is in abeyance during pregnancy ; are there any grounds for assuming the occurrence of exceptions to the rule 1 Galabin l instances extra-uterine pregnancy as affording evidence that ovulation may exceptionally take place during pregnancy : a five months' foetus has been found in the abdomen and one of three months in the uterus ; the intra-uterine foetus would be better situated for obtaining nourishment, and therefore its inferior development cannot be attributed to failure in this respect. The exceptional occurrence of menstruation during the early months of pregnancy does not afford more than an inferential support to the hypothesis of ovulation occurring at the same time since menstruation and ovulation are not interdependent. Those who deny the possibility of superfoetation explain the cases in which its occurrence has been assumed as being instances of twin pregnancy in which, as is common, one fietus develops more than the other. Spiegelberg, 2 in applying this fact, regards superfoetation as a physiologically untenable and exploded hypothesis, and considers those cases in which a fully developed child has been born, followed by another, also fully developed (within the limits attributed to super- fetation) as instances of twin fetuses; one, much more developed than the other, being born first, and the one left behind making up for lost time and eventually appearing in as fully developed condition as the first, Cases of supposed superfoetation in which the births are more widely separated have been accounted for by the presence of a double uterus, with or without separate vaginas. If only the body of the uterus is duplex, the abnormality is more likely to escape detection than when a double vagina is present. Ross 3 relates a case illustrative of this abnormality. On the 6th of July a woman was delivered of two fetuses at about six months of utero-gestation ; on the 31st October she was delivered of a child at full term; subsequent examination showed the existence of a double uterus. The explanation of the interval between the births of the two immature fetuses and the child at term, is that one cavity of the uterus was prematurely delivered of twins, and that the other retained its contents up to the full period of utero-gestation. In this case there was no septum in the vagina, and unless a careful examination had been made, and the cause of the abnormal course of pregnancy 1 Manual of Midwifery, 1886. - Lehrbuch der Oeburtshul/e, 18S0. 3 The Lancet, 1871. SUPERFOETATION. 175 thus explained, another case of superfoetation would have been placed on record. The occurrence of ordinary twin gestation with a prolonged interval between the births is well illustrated by a case recorded by Pincott. 1 A woman gave birth to a weakly female infant on the 18th of October, which died the same day; after delivery the placenta came away as in ordinary confinements. On the 19th of the following November — 35 days after — she gave birth to a second and finely developed female child at full term ; foetal movements were felt before the- membi'anes ruptured, but the child was still-born. Of the cases adduced in favour of superfoetation, those in which an interval of not more than from two to three months apparently elapsed between the respective conceptions, may be explained on the supposition of ordinary twin impregnation with retention of the second foetus after expulsion of the first. Even a longer interval is not impossible if the development of the foetus which remains behind, has been greatly retarded by its more favourably placed companion. If, as supposed by some, maturity of the foetus is the initiative cause of natural labour, it is easy to see how a backward foetus, rendered so by no inherent defect, may remain in the uterus for a considerable time beyond the limit of the normal period of gestation. The cases which, from a still longer interval between the respective conceptions, are regarded as proving the occurrence of superfoetation, prove too much. Towards the end of the third month the union of the decidua reflexa and vera introduce an actual barrier to re-impregnation, and a further difficulty is interposed by the then or subsequent position of the ovaries and oviducts in relation to the uterus. These obstacles, in addition to the almost invariable cessation of ovulation during pregnancy, render cases of alleged superfoetation in which an interval of five and a-half months has occurred between the births of two viable children extremely difficult of acceptance. As with other negative propositions, the occurrence of superfoetation cannot well be disproved, but it may be regarded as being very close to the vanishing-point of probability. Death of the Foetus in Utero. — It occasionally happens that the foetus dies in utero and is retained for a more or less prolonged period ; if its surroundings remain intact the access of air and of micro-organisms is prevented, and either maceration or niunmiilica tion of the body without putrefaction takes place. If the development of the foetus has not advanced beyond the first month the recently formed tissues are disintegrated, so that when expelled no trace of structure is discernible. At a later period of utero-gestation there 1 Brit. Med. Journ., 1SS6. 17C FORENSIC MEDICINE. may be simply maceration of the skin, which is raised in blisters, or is entirely peeled off, the foetus being otherwise fairly well preserved ; in other cases, the foetus undergoes mummification, and presents a flattened dried-up appearance. Schellenberg 1 describes a case of this kind. A -woman ceased menstruating on the 20th of June, 187G; she felt the child at the beginning of November; on the 12th of May, 1877, she -was delivered of a six months' foetus, which was pressed flat and in a mummified condition ; it had remained in the uterus five months after death. Garrigues 2 describes a case occurring in a woman 37 years of .age. Nine months after the last menstruation a foetus and placenta in a perfectly fresh condition were expelled ; the foetus was at about the end of the fourth month of development; the epiderm had come off, and the soft parts were atrophied. The medico-legal bearing of twin deliveries, separated by an interval of two or more months, and of retention of a dead fcetus, is of theoretical rather than practical value. The cases in which these ■conditions might come in question are where a woman gives birth to an apparently fully developed child — born alive, but dying soon after birth — within seven or eight months after the death or absence of her husband, and two or three months after is delivered of a second infant, also of full development, which lives; the heir-at-law might dispute the legitimacy of the second infant. Again, if a woman whose husband had been absent for eight or nine months, gave birth i;o a four months' fcetus eight months after her husband left her, her chastity might be called in question. The earliest period at which a woman who has been delivered of a child can again be impregnated is usually understood to be about a month after delivery; Bonnar states that it may take place as early as the fourteenth day. Paternity and Affiliation are determined by circumstantial evidence, and by resemblance to the father in appearance, voice, manner, gait, and other characteristics. Medical evidence is directed to the minute examination of deformities, birth-marks, or other bodily peculiarities. In the newly-born the questions discussed in the section on legitimacy might have to be considered. When a child is alleged to be supposititious, it may become the duty of a medical man to examine the child with regard to the length of time it has survived birth, and the pretended mother for signs of recent delivery. If the fraud has been so successfully accomplished that suspicion is not aroused for some time after the feigned delivery (the woman having at some previous time given birth to a child at term), detection may not be easy. In recent cases the condition 1 Arch./. Gynacol., 1S77. - American Journ. of Obstetrics, 1SS4. SURVIVORSHIP. 177 of mother and child will probably be found not to agree; it is difficult for a woman to obtain a new-born infant at the right moment, and consequently indications of its having survived birth longer than the alleged date of confinement will reveal the fraud. If the woman is examined within three or four days of the pretended parturition, the usual signs of recent delivery ought to be present. It is the duty of a medical man summoned to attend a woman in labour, if he arrives after the child is born, to assure himself that the woman has been just delivered, and that the child has been recently born ; the placenta also should be examined. All this is perfectly natural from the purely obstetrical standpoint and cannot be reasonably objected to. Any attempts to hinder such investigations constitute grounds for suspicion, and are to be met by firm, though gentle persistence. This applies to both rich and poor : with the former the legitimate succession to an estate may be imperilled ; with the latter the extor- tion of money from an alleged seducer may be the motive. In event of absolute refusal to permit the desired examination as being unneces- sary, the contingencies that might arise should be explained ; further objection would constitute reasonable ground for suspicion as to the hona-fides of the transaction. SURVIVORSHIP. When two or more individuals, concerned either actually or pre- sumptively in the succession of property, lose their lives by the same accident, it may be of great importance to others concerned in the succession to determine respectively the precedence of death. In the absence of eye-witnesses the determination is necessarily founded on conjecture ; for this reason t he later decisions of the cour ts of appeal are in favour of_each_ case Joeing determined by the balance of facts that can be substantiated, rather than on presumption of survivorship on account of difference in age or sex. In the absence of positive evidence as to which of two persons lived the longest who perished under like conditions and from the same cause, they are assumed to have died at the same time so far as succession to property is con- cerned. A number of rules have been formulated as to probabilities of the survival of one person longer than another when menaced with a common death. Age, sex, physical strength, special resources (as the capacity to swim when the cause of death is drowning) have been regarded as affording presumptive evidence sufficiently strong to justify the determination of survivorship. The possible effects of these various conditions are described when dealing with the respec- tive modes of death. 12 ITS FORENSIC MEDICINE. CHAPTER XVII. LIFE ASSURANCE. Insurance companies avail themselves of the services of me dical men in two distinct capacities — as chief medical adviser, or as medical examiner. Each company has one chief adviser, and an unlimited number of medical examiners. The chief adviser, in addition to acting as examiner with regard to proposers who present themselves at the head office, reads through and criticises all reports from the medical examiners in various parts of the country. He acts as a medical assessor or referee to the Board of Directors, and advises them as to the importance of any indications of disease, or as to the significance of details of personal or of family history. When a life cannot be regarded as first-class on account of the presence of some disease, or tendency thereto, it is customary to add a certain number of years to the actual age of the applicant and to demand a correspondingly in- creased annual payment ; under such circumstances the chief medical adviser has to estimate the probable duration of life, and to fix the age at which the proposal shall be accepted. He has to satisfy himself that there are no omissions nor obvious errors in the examinei's' reports, and if he detects any discrepancy his duty is either directly or through the office to communicate with the examiner, and to request an explanation. Medical Examiners are selected by the actuary or other officer of the company in those towns in which an agency is established ; in large towns all the proposers are usually sent to one medical man, who in this way becomes an adviser of the company; in country places any medical man may be selected wdiose residence happens to be con- veniently near to that of the proposer. When the policy is for a very large sum, the office may require the proposer to be examined by two medical men. The object evidently is to secure, as far as possible, a thorough investigation of the physical condition and functional activity of the various organs of the body ; to accomplish this the two medical men should make the examinations sepai'ately, an arrange- ment however which is usuall}' not specified, and as competition between rival offices is very close, the agents favour a conjoint exami- nation by the medical men in order to avoid deterring the applicant by the prospect of having to undergo two distinct examinations. Insurance offices vary in their requirements as to reports: some provide elaborately arranged printed forms which suggest all the LIFE ASSURANCE. 179 necessary investigations, and contain a long string of questions relat- ing to personal and family history to be answered by the applicant, which are severally asked, and the answers recorded by the medical man at the time the examination takes place. Printed forms of exhaustive questions have one distinct advantage : their routine character enables questions of a more or less delicate nature to be put without causing offence ; this applies especially to syphilis, the possibility of the presence of which in a latent form is not to be lost sight of. Other offices, in the letter to the medical man requesting him to examine an applicant, direct attention to the chief subjects on which information is required, and ask him to furnish a report in the form of a letter to the actuary; when this is the case the applicant himself fills in his statement of family and personal history and sends it direct to the office. Xo one should be present at the examination except the applicant and the medical examiner. The first thing is to observe the general appearance of the applicant — the complexion, the healthy or cachectic colour of the skin, the presence of enlarged veins on the nose or cheeks, puffiness or redness about the eyes, together with the general expression, whether it affords indications of latent physical disease, or of mental anxiety. The gait of the applicant as regards spasticity, ataxia, or other deviation from the normal, and the state of the tongue, gums, teeth, and throat are to be noted. Inquiries are to be made as to the p resence of h ernia and other pathological conditions. The height and weight, the measurements of the chest at the level of the sixth rib, during full inspiration and deep expiration, should be ascertained. The expansion of the chest should also be observed with the eye and the respiration rate taken; this and the rate of the pulse, which should also be counted, is frequently influenced by nervousness of the applicant. The lungs and heart are to be ex- amined in the usual way (the skin being bared) and the result re- corded. Special attention should be devoted to the apices of the lungs, back and front, especially if the family history is indicative of phthisis. The character of the breath-sounds as regards harshness, vesicular breathing, prolongation of the expiratory sound, and less- ened audibility of the inspiratory sound, together with increased vocal resonance at the apices, are all of significance. If a heart murmur is present, the valves implicated and the character of the murmur is to be recorded ; if the murmur is mitral-regurgitant listen how far posteriorly it can be heard, as affording some clue to the amount of regurgitation and consequently of the importance of the lesion. In some nervous people a sound resembling that of a murmur of organic origin may lie heard on applying the stethoscope; such a sound disappears after the first impression produced on the nervous system 180 FORENSIC MEDICINE. by the momentous nature of the examination has passed off. It is to be borne in mind that even strong healthy men are often influenced to an extraordinary degree in this way; the very fact of not having undergone medical examination before, with the possibility presented to their minds that some deadly latent disease may be discovered, produces no little mental perturbation. If there is a gouty family or personal history the tension of the pulse and the daily amount and the colour of the urine should be ascertained. In all cases a specimen of urine voided in the presence of the examiner, or with such precautions as preclude the possibility of deception, should be examined as to naked-eye appearance, reaction, specific gravity, and presence or absence of albumen ; if albumen is present a microscopical examination should be made for casts. In the case of applicants of or above middle age, especially if the urine is pale and of low specific gravity, more than a cursory examination for albumen should be made. As is well known the urine from cases of granular kidney is light coloured, of low specific "ravitv, and often contains a mere trace of albumen, and at times none at all; such urine examined off-hand, with nitric acid, may appear free although a little may be present; after adding the acid, it should be allowed to stand for ten or fifteen minutes, and then examined. It is preferable to add two drops of acetic acid to a test- tube nearly full of the urine and to boil the upper stratum ; a slight haziness where the heat has been applied reveals the presence of a very small amount of albumen. If the specific gravity is above 1020 the urine should be examined for sugar, and in any case if there are reasons for suspecting diabetes. Discussion as to the probable duration of life when albumen is present in the urine, or when auscultation reveals the presence of a heart-murmur, would be out of place in a book of this kind ; the reader is referred to treatises on general medicine. Insurance companies not unfrequently send a separate form to the usual medical attendant of the applicant requesting answers to the questions there printed. It is optional on the part of the medical attendant whether he answers the questions or not, but if he does so and accepts the fee, he is bound to answer fully and without reserve. Some offices ask the applicant's permission to interrogate his medical attendant ; if given it is supposed to relieve the attendant from any obligation to professional secrecy in this particular instance. Formerly it was customary for insurance offices to bar death from suicide, and this restriction gave rise to medico-legal discussions in relation to insanity as a cause of the suicidal act. At the present time it is the custom to take the risk of suicide along with other risks, provided that death from this cause does not occur within LIFE ASSURANCE. 181 FORM OF MEDICAL REPORT IN LIFE ASSURANCE. Figure and general appearance ? . Weight? Height ? Measurement of abdomen ? Of the chest at full inspiration ? At deep expiration ? Number of respirations per minute? Is there anything abnormal in the character of the respirations ? Is there any indication of disease, either acute or chronic, of the respiratory organs ? . . State the rate and tension of the pulse? Is it intermittent or. irregular ? Is there any indication of disease of the heart or blood-vessels ? . Test the urine, voided at the time of examination, and state : A. Specific gravity ? C. Presence of albumen ? E. Result of examination by the microscope ? . Do you know the party examined to be the person described in the application ? . . , . How long have you known the applicant? Mention some physical mark of identification ? . . . Is the risk affected by anything in his residence or occupation? Where was this examination made, at applicant's place of business, residence, or examiner's con- | suiting-room? .... Was there present at the exam- ination any person other than the applicant and the examiner ? Are you satisfied that there is nothing in his physical condition, habits, personal or family his- tory not distinctly set forth tend- ing to shorten his life ? Do you unqualifiedly recommend the applicant for insurance ? .lbs. .B. .D. Reaction ?. Of Sugar?. a certain period, which lias been fixed by most offices at one year after the payment of the first premium— that is to say, after the first re- 182 FORENSIC MEDICINE. newal of the policy, by the payment of the premium due at the expiration of one year from the date on which the policy was granted, the risk of suicide is accepted by the office, and in event of its taking place, the sum insured for is paid. Some offices retain older customs, and simply return to the legal representatives of the holder of a policy who has committed suicide the money, without interest, paid in premiums. CHAPTER XVIII. MEDICO-LEGAL BEARINGS OP DIVORCE. ' Marriage is of the nature of a contract and is not legally landing if one of the parties to it is incapable of consenting to, or fulfilling, the contract at the time it was entered into. In relation to divorce there are two questions which come within the province of the medical jurist. The first is one of unsoundness of mind preventing consent : this constitutes a civil disability which invalidates marriage; the second is impotency or physical incapacity for sexual intercourse : this constitutes a canonical impediment to marriage. The plea of insanity can only be offered in a suit for nullity of marriage when the mental disorder existed at the time the marriage took place ; the fact that one of the contracting parties was insane at the time the contract was entered into renders the contract null and void, because insanity incapacitates the person subject to it from giving a rational assent to the terms of the contract. Insanity rarely develops without warning, but salient symptoms may suddenly show themselves after the mind has been some time diseased, the previous condition not being sufficiently marked as to give rise to suspicion of mental disorder; marriage, in such cases, not imfrequently kindles up the dormant state of mental disease into one of an acute character. In some instances the relatives and friends of the affected party conceal the disorder from the person with whom the marriage contract is to be made, with the forlorn hope that the new domestic relations will dissipate the existing trouble, the result almost invariably being disastrous to all concerned. "When insanity is pleaded as a cause for nullity the diseased mental state is usually observed shortly after the marriage takes place. In the case of Hunter v. Edney (Divorce Court, 1S82) the wife refused to allow the marriage to he consummated, MEDICO-LEGAL BEARINGS OF DIVORCE. 183 and an investigation of her mental condition showed that she was suffering from melancholia, and probably had been for some time. The judge, in granting a decree, pointed out that the woman did not appear capable of understanding actions free from the influence of delusions, and was, therefore, incapable of entering into a contract like that of marriage. The plea of insanity in relation to proceedings in the divorce court took a new departure in the case of Hanbury v. Ha/nbury (Divoxxe Court, 1892.) The wife brought an action against the husband for dissolution of marriage because of his adultery and cruelty. The defence was that the respondent was suffering from insanity when the acts complained of were committed. The President, Sir C. Butt, in summing up said that it had been argued that insanity was an answer in a suit for dissolution of marriage. He was far from asserting that it was not in any case, but he thought to make the plea a good one, the insanity must' be lasting. It might be that the plea would be a good one if the insanity of the person were such as to necessitate his being placed in an asylum, from which there was no prospect of his discharge because there was no prospect of his recovery, or of amelior- ation of his malady. A decree nisi was granted. From this it seems that insanity might be admitted as a plea for irresponsibility. The case in point did not decide the question, because the respondent had given way to great excess in alcohol, a fact that weighed with the jury and confused the issue so far as precedent in relation to insanity itself is concerned. In order that incapacity to take part in the performance of sexual intercourse can be regarded by the Court as a ground for a decree of nullity, it must be proved that the defect existed at the time of marriage and that it is of a permanent nature. It is not essential that the malformation should be of such a nature as absolutely to prevent coitus; if it interposes only a partial obstacle it con- stitutes a ground for a suit for nullity. The incapacity must be permanent; if a cure is at all possible, though it may be extremely improbable, it is sufficient reason for refusal of a decree; if, however, an operation to effect a cure would be attended with great danger to life, the malformation is regarded as incurable. If the impediment did not exist at the time of marriage but has occurred since, it does not constitute a ground for nullity. In cases where there is no apparent physical defect a cohabitation of three years' duration is required to ascertain with whom the fault lies. This rule is not invariable. If the Court deems that a sufficient time has elapsed for the difficulty to be overcome were it not of a permanent nature, a decree may be gi'anted sooner. In one. case, 184 FORENSIC MEDICINE. upon an apparently conclusive medical certificate that the impotence would be permanent, nullity was pronounced after a cohabitation of three months only. Triennial cohabitation is not required when the incapacity of husband or wife is of a visible and incurable nature which can be ascertained at once. Wilful refusal of marital intercourse is not sufficient to obtain a decree, although persistent resistance on the part of the wife has been so regarded. Repeated attacks of hysteria in the wife brought on by the husband's attempts at intercourse has, after a cohabitation of three years without consummation, been deemed ground for a decree nisi. Impotence does not render a marriage void, but only voidable — that is, the injui'ed person must take active proceedings and sue for a decree. If sufficient grounds have existed, such as an absolute physical impediment to intercourse so that the marriage has not been consum- mated, and no proceedings are taken during the life-time of husband and wife, the marriage cannot be declared void after the death of one of them. This has been attempted in order to deprive the husband of benefits from a Avife who died intestate, the next of kin claiming the estate. It is incumbent on the petitioner for a decree of nullity of marriage on the ground of impotence to prove that marriage has not been con- summated. The necessary evidence is obtained by medical examina- tion of the generative organs of the respondent, which is made by two medical inspectors appointed by the Court. The husband and wife may conjointly select two medical men, or if they cannot agree each may nominate one ; the petitioner then moves the Court for the appointment of the medical men chosen as inspectors, and at the same time moves for an order that the respondent submit to the inspection. The two medical inspectors after appointment have the following oath administered to them which sufficiently explains the duties they are called upon to fulfil. "la the High Court of Justice. Probate, Divorce, and Admiralty Division (Divorce). " A.B. and CD., doctors of medicine. " You are produced as inspectors in a cause depending in the Probate, Divorce, and Admiralty Division of the High Court of Justice (Divorce), entitled , falsely called v , to examine the parts and organs of generation of , the petitioner in this cause, and also of , falsely called , the respondent in this cause. " You respectively swear that you will faithfully, and to the best of your skill, inspect the parts and organs of generation of each of them, the said and and make a just and true report in writing, to the Right Honourable the President of the above Division, whether the said [the petitione?-] is MODES OF DEATH RESULTING CHIEFLY FROM ASPHYXIA. 185 capable of performing the act of generation, and, if incapable, whether such, his incapacity, can be cured by art or skill; and also, whether the said is or is not a virgin, and whether she hath or hath not any impediment on her part to prevent the consummation of marriage, and that one of you will deliver such report under your hands and seals, closely sealed up, to one of the registrars of the above Division. " Sworn at the Principal Registry of the Probate, "V I "ivorce, and Admiralty Division of the High I [Signatures of the Court of Justice, this day of ,18..., j medical inspectors.] Before me, I , Registrar. " Medical evidence will be received upon the question of incapacity, although no application has been made for an order for personal inspection of either of the parties. MODES OP DEATH RESULTING CHIEFLY FROM ASPHYXIA. CHAPTER XIX. Death from hanging, strangulation, suffocation, and drowning, i s chiefly due to asphyxia. HANGING. Death from hanging is produced when the body is wholly or partially suspended by means of a cord or other ligature round the neck, until life is extinct. It is not necessary that the body should be in the upright posture, nor that it should cease to rest on the ground or other means of support; as will be presently shown, a very slight degree of tension on the ligature, such as that caused by partial suspension, is sufficient to produce death. Apart from judicial hanging the post-mortem appearances are those of death from asphyxia, together with indications of the manner in which asphyxia was produced. In by far the greatest number of cases of death from hanging the ligature surrounds the neck above the thyroid cartilage. Even if the noose is originally placed lower down, it is not in the first instance drawn tight enough to prevent the weight of the body dragging the neck as far through it as it can come. In 153 cases ob- 1S6 FORENSIC MEDICINE. served bv Maschka (I.e.) the ligature was abovre the thyroid cartilage in 149, on it in 1, and below it in 3. When the ligature is above the thyroid cartilage slight constrictive force suffices to occlude the air- passages. Langreuter 1 investigated the mechanism of the closure of the air passage on the dead body by removing the skull cap and brain in the ordinary manner, and cutting away the base of the skull so that the laryngopharyngeal region came into view. The subjects of the experiments had died from natural causes — they were not cases of death from strangulation. A cord was placed round the throat, between the thyroid cartilage and the hyoid bone, and carried up under the angle of the lower jaw. By moderate traction in the long axis of the body, as in hanging, the epiglottis was pushed against the back of the pharynx: by stronger traction the base of the tongue followed, and the free end of the epiglottis was pressed between the base of the tongue and the posterior pharyngeal wall; only moderate force was necessary to entirely close the air-passage. If the cord was placed below the thyroid cartilage, or horizontally upon it, and traction made as before, it slipped up above the cartilage ; if retained on the cartilage with the hand, the vocal cords could not be completely approximated even when great force was used in pulling the con- stricting medium upwards and backwards. On suspending the bodv, the cord at once slipped up immediately under the lower jaw, and on looking from above, the tongue was seen to be dis- placed, upwards and backwards, and pressed into the opening in the base of the skull. Most of the experiments were repeated with a rolled-up handkerchief, the results were the same, but more force was recpuired. Ecker 2 demonstrated like results with the body of a man which was found hanging from a tree in winter, frozen so hard as to be easily sawn into vertical sections. The soft structures at the posterior part of the floor of the mouth were doubled up into the cavity of the pharynx so as completely to fill and obliterate the naso-pharyngeal passage. Fig. 15 is an exact represent- ation of what was found. AVhen hanging causes complete occlusion of the air-passages, death results for the most part from asphyxia. Another factor, however, has to be considered, which may produce effects equal to or even exceed- ing those of asphyxia in prominence — compression of the large blood- vessels of the neck. These vessels, in any case, will undergo some compression, and, if the air-way escapes complete occlusion, arrest of the intra-cranial circulation may be the principal cause of death. When death begins in the brain, as the result of compression of the large vessels of the neck, it is not so much from excess of intra-cranial 1 Ykrtdjalirssc.hr. f. get: Med., 1SS6. - Virchow's Arch., 1S70. HANGING. is; blood pressure, as from arrest of the cerebral circulation; it is very exceptional for cerebral haemorrhage to take place. If the air-way escapes occlusion, or is only partially occluded, a much longer time elapses before death takes place than if respiration is completely arrested. This has been shown experimentally with a dog — an open- ing was made in the lower part of the trachea, and the animal was hung by the neck with a cord, the noose being above the opening; a much longer time was required to cause death than is the case in ordinary hanging, and the post-mortem signs are different. Fig. 15. — A, soft palate ; B, wall of the pharynx ; C, tongue ; D, tip of the tongue pressed between the teeth ; E, body of the hyoid bone ; F, groove made by the rope ; G, anterior portion of the atlas ; H, odontoid process of the axis. Great importance was formerly attributed to the respective in- fluence of pure asphyxia and of what was called apoplexy as proxi- mate causes of death from hanging. This resulted from the inconstant post-mortem appearances presented by the brain and by the lungs : sometimes the brain, sometimes the lungs, and sometimes both are found gorged with blood. It was inferred that if death took place from asphyxia the post-mortem signs ought to be invariable ; as they 188 FORENSIC MEDICINE. were found not to be invariable, hypotheses were formulated to ex- plain the discrepancy. It was assumed that death from hanging might be brought about in two distinct ways : by pure asphyxia and by apoplexy without asphyxia; seeing, however, that in a large number of deaths from hanging both lungs and brain are hypersemic, a mixture of the two causes of death was described to suit this post- mortem condition. In consequence of these views the post-mortem appearances respectively produced by two closely allied modes of death were frequently treated as though they resulted from separate and distinct causes, and variable external conditions were regarded as necessary factors in the production of these dissimilar results. Experiments, however, show that the preponderance of the signs of death from asphyxia over those indicating disturbance of the intra- cranial circulation, or the converse, are not solely dependent on the varying degrees of compression produced by the ligature on the air- and blood -channels respectively. Precisely similar external condi- tions may cause, in one case excess of blood in the lungs but not in the brain, and in another excess of blood in the brain but not in the lungs. It is probable that the state of the lungs, as regards inflation at the moment the air-passage is occluded, has a good deal to do with the relative hyperemia of brain and lungs; some experi- ments made by Patenko 1 tend to prove this. A number of dogs were hung, some at the end of full inspiration, others at the end of full expiration, and the distribution of the blood in the various internal organs was observed after death. I n those hung at th e end of full inspiration the lungs contained little blood, but the sinuses of the skull, the membranes of the brain, and also the vessels of the abdominal organs, contained a great deal. In the animals hung at the end of full expiration the lungs contained much blood, and the cephalic and abdomen vessels little. When the air-passages are occluded at the end of full expiration, the blood flows from the periphery into the heart and — on account of the negative pressure developed in the thoracic cavity — from thence to the lungs ; it cannot leave the lungs on account of the damming up that occurs in the dilated pulmonary vessels and from the want of intra- pulmonary pressure. On the other hand, when occlusion takes place at the end of full inspiration, the pressure on the lungs causes expulsion of the blood they contain and consequent excess in the cranium and in the abdominal vessels. Hofmann (I.e.) considers that retraction of the abdominal walls, especially at the pit of the stomach — which occurs simultaneously with the efforts at respiration — compi'esses the lungs, and thus drives out the blood from them. Strong corroborative evidence that the want of uniformity in post- 1 Annates (V Hygiene, 1SS5. HANGING. 189 mortem appearances of death from hanging is not dependent (or is so only under exceptional circumstances), upon external condi- tions, is afforded by an appeal to the statistics of deaths resulting from asphyxia in general. Out of 231 cases of death from asphyxia produced in various ways, Maschka found in 48, hyperemia of the brain, membranes, and sinuses; in 30, a condition rather resembling anaemia; in 15G, an ordinary moderate amount of blood. It is thus evident that a clearly defined condition of the brain and lungs is not to be expected when making post-mortem examinations on cases of death from hanging, nor is it possible from inspection of these organs to determine the relative importance of stoppage of the air- and of the blood-channels, as the cause of death in any given case. Another mode of death from hanging has been described, said to be due to compression of the vagi in the neck by the suspending cord or ligature. Hofmann 1 attributes the immediate loss of consciousness, and cessation of the action of the heart, to pressure on the vagi and the large vessels in the neck. If pressure on the vagi produced any effect on the heart it would be suddenly to arrest it in diastole ; there is abundant evidence, however, apart from physiological experiment, to prove that the heart continues to beat for a considerable time after stoppage of respiration by hanging. M'Causland 2 made some observations on a man executed by hanging, the rate of the pulse being taken every quarter of a minute after suspension. At the third quarter of the first minute it equalled 40 heart-beats per minute ; at the last quarter of the fifth minute 152. The radial pulsation became less distinct until the end of the seventh minute, when it could no longer be felt. With the stethoscope the heart-beats could be heard during the eleventh minute at a rate of 120 per minute; at the end of the fourteenth minute it was still heard, but weak and fluttering; at the filteenth minute it had ceased to beat. Schwab in a similar case found that the heart did not cease to beat until eight minutes after suspension. Maschka (I.e.) observed two similar cases; in one the heart-beats continued for four and in the other for five minutes after suspension. Balfour 3 gives three sphygmographic tracings taken from the radial artery of a criminal at intervals of oh, 5|, and i h minutes after suspension; the heart continued to beat for twenty minutes. Misuraca 4 tied both vagi in dogs. Death did not take place : Journal de Medec'ine, 1S78. 2 Philadelphia Med. and Surg. Reporter, 1SSM. * Clinical Lecture* on Diseases of the Heart, 1SS2. 4 Revista Sjierimentale, 1889. 190 FORENSIC MEDICINE. until from fourteen hours to seven days afterwards. It is not pro- bable, therefore, that pressure on the vagus has to do with the cause of death by hanging. Compression of the large vessels of the neck by arresting the cerebral circulation induces very rapid loss of consciousness. The accounts given by those who have been rescued after a sufficiently lon<* suspension to produce complete unconsciousness are mostly to the effect, that after a preliminary feeling of loss of power and ability to make any attempts to move the limbs, which is often preceded by subjective ocular and aural sensations (such as the appearance of sparks and a rushing sound), all becomes dark, and consciousness is abolished. The sudden onset of insensibility explains why in accidental and in suicidal hanging no attempts are made by the victim to save himself; in many instances the least movement would be enough to avert death. In other modes of committing suicide, voluntary or involuntary endeavours to escape the con- sequences of the act are not uncommon. Post-mortem Appearances— External— Cadaveric rigidity varies as to the time of its appearance. In one case subsequently mentioned it commenced within half an hour after death ; in other cases it is delayed. If the body has been long suspended the post-mortem stains are most marked at the lower parts and there may be punctiform superficial ecchymoses. The f ace is usua lly pale and the expression tranquil ; in some cases it is swollen and livid. The eyes are half open and not usually prominent, although in some cases they may be ; the pupils vary as to dilatation. The tongue may be protruded be- tween the teeth, but this is by no means invariable; it occurs in rather under 50 per cent, of cases. Maschka directs attention to a bluish colour of the free border of the lips (which has been noticed by previous observers) as of frequent occurrence — in 98 cases out of 153. According to Adamkiewicz 1 cyanosis and swelling of face, ears, and lips only occur when the death agony is prolonged; this condition is more likely to be present in plethoric individuals. If the body is cut down at an early period the tumefaction and cyanosis disappear. Punctiform ecchymoses may be present on the face and neck ; they are more likely to occur under the conjunctivae — ocular and palpebral — and also on the outer surface of the lower eyelids ; they are only present in 8 or 10 per cent, of cases, therefore their absence is less significant than their presence. Turgescence of the genital organs of both sexes may or may not be present ; it is due to hypostatic hyperemia and is of no value as a sign of death from hanging. Escape of semen, urine, or fieces is of no diagnostic value, as it results from muscular 1 Yierteljahrsschr. f. ger. Med., Bel. IS. HANGING. 191 relaxation, and is met with in many kinds of death both violent and natural. Sometimes saliva flows from the corner of the mouth and may be traced after death ; this is not invariably the case, but when observed indicates suspension during life. The hands may be clenched, but this is at the most an indication of violent death; in suicidal hanging the hands, as a rule, are not clenched unless the act has been associated with more effort than is usually the case, or when the suicide has given himself a long drop. The most important external appearance is the mark round the neck produced by the suspensory medium. Generally speaking, the breadth and depth of the mark depends upon the nature of the ligature need. If it is broad, soft, and yielding, only a superficial mark will be produced, and exceptionally there may be none at all ; if it is thin. hard, and firm the mark will be deep and narrow. In cither case any pattern or irregularity on the surface of the suspensory medium may be reproduced on the skin with which it has been in contact — the strands of a rope, or the texture of a handkerchief, for example. The mark may entirely surround the neck, but is more frequently limited to the anterior half, and runs between the thyroid cartilage and the hyoid bone, taking an upward direction at the sides immediately behind the ears, where it usually ceases. If a cord with a running noose has been used, and sometimes even with a medium like a pocket-handkerchief, the mark may be continuous round the neck; in the latter case, probably on account of excessive weight of the body or the length of drop. From irregularity of pressure, or from some peculiarity in the nature of the suspensory ligament, the mark may be interrupted in a part where it is usually continuous. Exceptionally the mark may only exist at one side of the neck, the opposite side Vicing free; this arises from the position of the noose which causes the head to fall sidewise instead of forwards as is usual. Occasionally the mark runs horizontally round the neck under the thyroid cartilage, the original position of the cord being maintained owing to the use of a noose that tightens easily and so keeps its hold, and also po to unusual prominence of the cartilage preventing the cord from slipping up. . The colour and consistence of the mark varies with the nature of the ligature. It may be pale and soft, with slightly reddened or livid borders; or it may be dusky red, or bluish-grey in colour, with margins of a slightly deeper hue; or, finally, it may be yellowish-brown, with darker margins, and of a horny or parchment-like consistence. The first two varieties are the result of soft or yielding ligatiu-es ; the last is produced by hard, rough ligatures which injure and partially rub off the epiderm, so that the underlying cutis becomes dry. More 192 FORENSIC MEDICINE. than one of these forms may be met with in a single mark : it may be %vhite and soft at one part, brown and hard at another. Internal Appearances. — Haemorrhage into the subcutaneous tissue in the neighbourhood of the mark produced by the ligature is compar- atively rare; Maschka found it only in 10 cases out of 153. The adjacent muscles are not often injured, although Lesser 1 states that in 50 cases of hanging he found injuries to the muscles in 11, mostly in the sternomastoid. Fractures of the hyoid bone and thyroid cartilage are of exceptional occurrence; when present, they are mostly due to degenerative changes producing abnormal fragility. Fracture or separ- ation of the vertebra? has only been seen in one or two cases, of which Lesser records one. Rupture of the inner or middle coats of the carotids sometimes happens; Lesser found it in 7 cases out of 50. It mostly occurs in individuals at or past middle life; the 7 cases just mentioned were all above forty years of age, although in none of them was endarteritis deformans present. The remaining internal appear- ances are common to all modes of death from asphyxia. The appearance of the brain and lungs has already been described when discussing the modes of death from hanging. In rather over 50 per cent, of cases the amount of blood present in the brain and cerebral vessels does not differ from the normal ; in the remainder there is sometimes more and sometimes less than normal. Very rarely is there extravasation of blood, although in odd cases small ecchymoses may be present in the dura mater ; their presence is significant of the mode of death. The mucous membrane of the trachea and epiglottis is generally injected. Maschka directs attention to a cyanotic or dark blue colour of the mucous membrane of the pharynx sharply limited below, which is rarely absent in death from asphyxia and seldom present in other modes of death. The lungs may exceptionally contain lnemorrhagic foci in their substance; sometimes they are (edematous, probably in conserpaence of slow death. The presence of email sub-pleural extravasations of blood is very suggestive of death from asphyxia ; they are due to rupture of capillary vessels, occa- sioned by attempts at respiration after the air-passages are occluded. They are more likely to be formed when the occlusion takes place at the end of full expiration; increased blood pressure caused by stimulation of the vaso-motor centre has probably also to do with their formation. It is to be remembered, however, that they occur in other modes of death from violence — as from falling from a height, from burns, from CO and some other forms of poisoning, and in the course of certain diseases, such as scurvy. Their absence does not contra-indicate death from asphyxia. Ecchymoses sometimes 1 Vierte{jaJtrsschr. f. r/er. Med., 1SS1. HANGING. 193 occur in the heart, the right half of which is usually filled with dark fluid blood ; but this appearance is by no means constant. The mucous membrane of the stomach is not unfrequently intensely injected, a condition which may be shared by that of the intestines; ecchymoses are occasionally found in both. The kidneys are often hypersemic, sometimes ecchymoses are present. The liver may contain more blood than usual. The blood is usually dark-coloured and fluid. From the medico-legal standpoint three contingencies have to be considered in all cases of death from violence — Was death the result of Accident, Homicide, or Suicide ? Accidental hanging is of exceedingly rare occurrence. With one or two exceptions, the few instances recorded resulted either from playful attempts made by boys to imitate judicial hanging, or, in the case of still younger children, from swinging in the vicinity of a dependent rope, by which the child's neck was surrounded and its body sus- pended until death took place. Maschka records a case of fatal accidental hanging in which a man, slightly under the influence of alcohol, slipped off a ladder and was caught in the noose of a rope hano-ino- from the ceiling. Kirkhead 1 relates a case which he regards as accidental rather than suicidal, in which the mode of suspension was peculiar. A young man eighteen years of age, who was a prisoner, was found dead in his cell, suspended by one of his braces round the neck, his feet touching the floor; the braces were made of frieze and lined with coarse calico. The deceased, with his back to the wall, had evidently stood on some hot-water pipes about 6 inches from the floor ; placing the brace under the lower jaw he had passed the ends, without tying them, through a chain-loop which depended from the window of the cell ; he had then either stepped or slipped off the pipe, when the sides of the chain-loop came together sufficiently close as to grip the brace and hold it fast, with the body suspended by it. The brace was not knotted nor fastened to the chain in any way, and it appeared highly impi-obable that it could in this manner sustain the weight of the body ; subse- quent trial showed that the grip of the chain was sufficient to prevent the rough surfaced material from slipping under the strain placed upon it. The incompleteness of the preparations, with other circum- stances, made it probable that the prisoner contemplated only a feigned attempt at suicide in order that he might be placed in a ward with company. Quick onset of cadaveric rigidity was observed in this case; the boy was seen alive at 2.20, the body was found at 2.30, and at 3 o'clock cadaveric rigidity had commenced in the neck. A most exceptional case of accidental hanging was the occasion of a 1 The Lancet, 18S5. 13 194 FORENSIC MEDICINE. trial for manslaughter, Reg. v. Montague (Com. Oyer and Term. Dub., 1892). The prisoner was accused of having caused the death of her daughter, a child three years old. As a punishment, she tied the child's arms above the elbows with a stocking, which was then passed round the body so as to pinion them to the sides. At the back one end of a cord was attached to the stocking, the other end being fastened 5 feet 8 inches from the ground, and, consequently, about 2| feet above the child's head— to a ring in the wall of a dark closet. The child was left three hours, and when the mother went to liberate her, she found her dead and suspended by the cord in such a way that when it was loosened from the ring the body fell forward. There was a mark produced by pressure on the neck at the lower part of the wind- pipe. Either the stocking slipped up to the throat, or the cord got partially round the front of the neck, the result being death from hano-in^. The prisoner was found guilty, and was sentenced to twelve month's imprisonment. Homicidal hanging is also infrequent. It would be exceedingly difficult to murder a man of average strength by hanging unless he was deprived of the power of resistance. In the case of the very old or very young it might be accomplished single handed, or even with a robust man if he was taken unawares. In the greatest number of 1 cases, however — not the result of accident nor suicide — in which bodies are found hanging, death has been caused in some other way, and the body hung in order to simulate suicide. This leads to a consideration of the signs of death from hanging, with regard to the possibility of distinguishing between suspension during life and after death. First, as to the punctiform ecchymoses that may be found on the lower parts of the body. Two antagonistic views are held as to their causation; one is that they are produced after death by the weight of the blood in the body rupturing the coats of some of the smaller vessels ; the other is that they are formed during life from the increased blood-tension occasioned by the asphyxia. Observations are forthcoming which serve to support both views. Lesser 1 hung recently-dead bodies for twenty-four hours, and although the lower parts were as hypersemic as they well could be, not a trace of extrava- sation was found ; he also found extravasations in the non-dependent parts of bodies in which death had resulted from asphyxia. Strassmann' 2 relates a case of suicidal hanging in which the body was found in a kneeling posture ; the post-mortem stains were limited to the thighs where ecchymoses were found in abundance ; the legs below the knees were pale and free from ecchymoses. Hofmann (I.e.) believes that the 1 Viertdjahrssclir. f. rjer. Med., 1S84. - Vierleljahrsschr. f. rjer. Med., 188S. HANGING. 195 extravasations are formed intra-vitam, but developed after death when the body is left suspended. Liman regards the ecchymoses solely as indicative of prolonged suspension after death. It may be accepted that ecchymoses on the Lower parts of the body are of no value as indical ions of suspension during life. A mark round the neck affords no proof th at death was caused by hanging. Casper regarded the mark as purely a post-mortem pheno- menon — probably a too sweeping assertion ; still, it is perfectly true that a cord-mark may be produced after death that cannot be dis- tinguished from one produced during life ; this applies not only to a period immediately after death, but also to an interval of several hours after. Punctifbrm extravasations of blood are occasionally found when the cord-mark is cut into, but they cannot be relied on to indicate suspension during life, as they have been found in the bodies of those suspended after death ; for the same reason the injected vessels along the borders of the mark are of no diagnostic value. Deeper seated injuries in the neck, such as fracture of the cartilages or hyoid bone, or rupture of the muscles, have also been found after post-mortem hanging. Bents in the inner coats of the carotids, when accompanied by extravasation of blood within the walls of the arteries, are indicative of suspension during life ; they occur very rarely, however, and are easily caused accidentally when making the post- mortem examination. It is to be remembered, on the other hand, that death may result from hanging, and yet, for the reasons previously given, no trace of a mark round the neck ma} 7- be visible. The presence on the chin of saliva which has flowed from the mouth points to sus- pension during lif e ; but it is not a constant sign, nor one on which alone a decided opinion could be expressed. The remaining internal signs are at the most indications of death from asphyxia — they cannot be utilised as evidence of death from hanging. The result of this inquiry as to the value of the signs of death by hanging in determining whether a body was suspended before or after death is, that they are not sufficiently conclusive as to justify the | expression of an absolute opinion. Other circumstances should be taken into consideration in attempting to solve the question. The body should be carefully examined for si_ms of struggling or of injuries other than those due to the assumed mode of death ; the possibility of poisoning must not be overlooked. The absence of any such signs is more significant than their presence. It is not an unfrequent occurrence for a person who has determined to commit suicide to make the attempt in more than one way : such a person may ineffectually cut his throat, or take poison, or in some other way injure himself, and, finding that death is long in coming, 106 FORENSIC MEDICINE. may subsequently eft'ect his purpose by hanging. If the injuries are of such a nature that they could not be self-inflicted, the fact of the body being suspended affords presumptive proof of homicide. The possibility of accidental post-mortem injuries caused by the body falling to the ground when cut down, or if examined at a distance from the place where it was found by rough handling during transport, should not be lost sight of. Illustrations of self-inflicted wounds found on bodies in cases of suicidal hanging which might, at first sight, give rise to suspicion of homicide are given by Maschka. In one case, several incised wounds were found on the inner side of the left fore-arm, one of which divided the radial artery. In another case, a suicide discharged a fire-arm into his mouth, fracturing the hard palate, and lacerating the soft parts, and then hung himself. In a third, an old woman, sixty years of age, hung herself, and was cut down by her husband ; on return to consciousness she seized a knife and cut her throat ; at the necropsy an ordinary cut-throat wound was found above the thyroid cartilage and a cord-mark as well. In some cases the balance of probability would be against that which actually occurred. Liman * records the case^ of a woman who inflicted on herself two wounds which penetrated the pericardium and afterwards hung herself; also that of a man who, in consequence of being shot in the back by another person, hung himself. In such cases it would be impossible to determine the question of suicide or homicide from the post-mortem appearances alone. Compare them with some cases of homicide, in which the dead body was subsequently hung, and the necessity for great caution is apparent. Deveaux relates the case of a woman who was found hung in a barn; on careful ex- amination a small round wound was found under the left breast which transfixed the heart, the case being one of homicide. In another case, (reported by Vrolik, a sailor was stabbed through the heart by a woman in a brothel; the body was afterwards washed, clad in a clean shirt and hung to make it appear that the death was suicidal. Homicidal hanging is almost exclusively confined to young children; in adults, strangulation and suffocation — the analogous modes of death — are much more easy of accomplishment. One case is recorded by Ogston in which a woman tied a ligature round the neck of her hus- band while he was asleep and then pulled him up with it. Hofmann 2 relates the case of a man who, by hanging, killed five of his children, aged 8 months, 2, 6, S, and 9 years respectively ; and, finally, hanged himself. In another case a man hung his two children (girls), aged 6 and 13 years, probably whilst they were asleep. 1 Handbuch d. ger. Med. * Lehrbuch d. rjer. Med. HANGING. 197 In 188S an exceptional and dramatic mode of homicidal hanging was put into execution in Paris by a man named Eyraud with the aid of a female accomplice named Bompard. The girl formed an illicit connection with one Gouffe, who was the selected victim. In the alcove of a room where an interview was to take place between Gouffe and Bompard, Eyraud fixed a compound-pulley over which a rope fur- nished with a strong hook was passed ; the apparatus and the alcove were concealed by a curtain behind which Eyraud was placed ; in front of the alcove was a sofa. "Whilst Gouffe was sitting on the sofa the girl placed herself on his knee and in a playful manner adjusted the noose of a silk cord round his neck, and then passed the free end of the cord (which was furnished with an eye or small loop) to her accomplice who slipped the eye over the hook depending from the pulley, and pulled the rope to which it was attached until Gouffe was drawn up from the sitting posture and suspended by the neck ; the rope was then made fast to the sofa so as to keep the body suspended. After robbing the corpse — which was the object of the murder — it was put into a box and taken to a distance and there left. The body was discovered fourteen days after, and on examination it was found that both corniue of the hyoid bone were fractured. The culprits were ultimately arrested, and from the confession of Bompard the actual mode in which the deed was perpetrated became known. The case is remarkable in itself, and, further, has an adventitious interest, because the question of hypnotic suggestion was raised in favour of the female prisoner; it was urged that she was subject to the will of her accomplice, and was not personally responsible for the part she took in the transaction. A full account of this case by A. Lacassagne is contained in the Arch, de VAnthropologie, 1890. Suicidal Hanging. — Hanging is t he commonest of all modes of com. mining suicide ; about twice as many people put, an end to their lives in this way as by any other single means of self-destruction. Judicial hanging apart, suicide is accountable for about 95 per cent, of the total deaths by hanging. The proportion of men to women who commit suicide by hanging is about as 3-5 is to 1. The reason why this mode of self-destruction is relatively so frequently adopted is that the means for carrying it out are to be found in every house and but little skill or effort is required in its execution, and further the act of placing the head through a noose and allowing the body to depend from it partakes of a more passive chai'acter than using a knife to cut the throat, or a revolver to blow out the brains. If the body of an adult of ordinary physical development is found hanging without any sign of injury or of struggling, and the general appearances are consistent with death from hanging, the probability 198 FORENSIC MEDICINE. of its being a case of suicide is very great. From what has been previously said the presence of wounds or of poison does not preclude suicide, but in such cases the contingency of homicide would be greater. In addition to making a thorough examination of the surface of the body for marks due to scratches, bruises, or blows, the clothing and immediate sm-roundings should be investigated. A few scratches on the neck are not necessarily indicative of homicide; occasionally they are inflicted by the victim himself involuntarily clutching at the noose. Care must be taken not to mistake signs of antecedent injui'ies for those caused at the time of death. No conclusion can be arrived at as to the relative probability of suicide or homicide from the position in which the body is found. It is not necessary thai the feet should cease to rest on the ground, sufficient pressure on the neck to cause death may be produced even in the sitting posture. Grant 1 relates how a man, aged 48 years, hung .himself by tying the ends of a common cotton pocket-handker- chief together and suspending it from the handle of his bedroom door, which was only 2 feet 9 inches from the_floor; he then sat down on the floor with his back to the door, put his head through the loop and bent forwards. This was proved by flattening of the nates — cadaveric rigidity having set in before the body was discovered — and by the post-mortem staining on the lower part of the back and lees. The mark on the neck was 1| inches broad and extended from below the chin obliquely upwards and backwards over the occiput, the texture of the cloth being plainly impressed on the skin. Many cases of a more or less similar nature are recorded. Nobiling 2 reports the case of a man, aged 24, who also hung himself with a pocket-handkerchief attached to the latch of a door, which was 3 feet 7 inches from the floor. He adopted the kneeling posture and was found dead with the knees bent and the toes touching the floor; The handkerchief was folded broadly and left no mark behind. In some cases the attitude is such that death can scarcely be said to be due to hanging, inasmuch as there is little or no suspension; such cases more nearly approach strangulation. Hurpy 3 records a case of this kind, of which the accompanying figure is an illustration. A woman, 77 years of age, was found dead in the posture depicted. The arms were extended alongside the trunk, and the pronated hands touched the floor on their dorsal aspect ; the legs and feet were also extended ; the night-dress and chemise covered the body and showed no signs of disorder. The cord by which she hung herself was nearly 40 inches long, and was attached about 17 inches from the floor to the 1 The Lancet, 1889. - Aerztliches Intelligemblattf. Baiern, 18S4. 3 Annates d* Hygiene, 1SS1. HANGING. 199 leg of a heavy table. The head half-rotated to the left vested with the right malar prominence on the floor, about 12 inches from the table foot. The woman was subject to delusions, and had committed suicide in this exceptional manner. In Tardieu's Etude sur la Pendaison a number of somewhat similar iustances of hanging by incomplete suspension are illustrated. The d iagnosis between suicide and hom icidejs occasionally einbar- r assed bTThe hands or the legs of the decease d being found tied together ; in such cases the way in which tin' limbs are secured, the position and the kind of knot, and the firmness with which it is tied are to be carefully noted. In some instances there is little difficulty in determining that the ligature round the limbs was tied by the victim himself; in other undoubted cases of suicide the position or the character of the knot is such as to make it appear almost impos- sible that it was self-tied. A striking illustration of the latter kind Fig. 16. is given by Filippi, Severi, and Montalti. 1 The nude dead body of a man hanging by the neck was found in his office; the right foot touched the floor, the left was slightly lifted from it by flexion of the knee. The wrists were tied together behind the back in such a way that the knot of the cord was in front of them and rested on the back of the body. It was exceedingly improbable that the knot could have' been tied as found, behind the back of the individual himself, and as every other indication pointed to suicide, the ques- tion arose— could he have tied them in front, and then passed his legs between the arms? Professor Filippi, to whom I am indebted for a copy of a photograph taken at the time, with permission to reproduce it, informs me that this was subsequently tested by enlist- ing the services of a young acrobat, who, with considerable difficulty, 1 Manualc di Med. Legale, 1SS9. 200 FORENSIC MEDICINE. succeeded in passing his legs between his arms, with the wrists tied together in front. The after effects of Threatened Death from Hanging.— When the body is cut down before life is extinct, efforts at resuscitation may be so far successful as to re-establish respiration; it is to be noted, however, that in some cases return of automatic respiration is not followed by ultimate recovery ; the surface of the body remains cold, the circulation feeble, and insensibility persists, death taking place some hours subsequently. When recovery takes place, certain neuroses or psychoses occasionally manifest themselves. Terrien 1 met with one case, in which epileptiform convulsions with tetanic spasm drawing the head to one side occurred ; the patient remained uncon- scious for several days, and on regaining consciousness was found to be amnesic. In a second case, there were epileptiform convulsions with opisthotonos, and on return to consciousness the patient made movements for some time as though walking. Petrina 2 records the case of a man who remained unconscious for twenty-four hours after attempted suicide by strangulation, during which time he had violent clonic convulsions of the whole body, but especially of the right side of the face and of the left arm, followed by a general condition of muscular rigidity. When he became conscious the speech was stammering, but deglutition was not difficult ; there was paralysis of the right facial nerve and of the left side of the body, with diminished sensibility on the right side of the face and on the left side of the body, except on the front of the thorax, where there was some hyperesthesia. The paralysis gradually improved. Ataxia subse- quently occurred on the non-paralysed side, the inco-ordination spreading from the upper to the lower extremities, and then passing over to the paralysed arm. This was probably a case of haemorrhage into the pons. Wagner 3 records the occurrence of acute dementia as a result of threatened death from hanging. STRANGULATION. When death results from asphyxia caused by constriction of the neck by means of some form of ligature ^vithout suspension of the body, it is said to be due to strangulation. The mode of death is the same as that which occurs in hanging. Post-mortem Appearances— External. — The only appearance that needs special consideration is the mark produced by the ligature round the neck. As a rule, the mark produced by strangulation differs from that produced by hanging in taking a more horizontal 1 Proyres Mtdical, 1887. "Prag. med. Wochenschr. , 1SS0. 3 Jahrbiicherf. Psychiat., 1SS9. STRANGULATION". 201 direction, and in more completely encircling the neck; since the direction of the constrictive force does not necessarily tend to draw the ligature above the thyroid cartilage as in hanging, the mark is not unfrequently on the level of or below the cartilage. Exceptions occur when the victim is thrown to the ground and the- ligature is pulled upwards and backwards ; the direction taken by the mark then resembles that due to hanging. On the other hand, Fig. 17. a horizontal mark may be produced by hanging when the position of the noose is different from that which is usual— e. Ablfo ilung), 1890. 204 FORENSIC MEDICINE. strangulation ; in such cases it is probable that the violence of the act is not the sole cause, but that extreme efforts at self-defence on the part of the victim unduly distend the blood-vessels of the head before the ligature is sufficiently tightened as to completely arrest the blood- current. In suicidal strangulation, bleeding from the nostrils has occurred from the violence of the efforts made by the suicide to tighten the ligature to the uttermost. Signs of general violence are to be sought for as indicative of homicide. As previously stated, scratches or excoriations in the neighbourhood of the strangulation mark are suspicious, but do not constitute proofs of homicidal violence; they may have been pro- duced by the ligature before it arrived at its final position, or by the suicide involuntarily plucking at it, especially if the finger nails are long. The rest of the body should be carefully examined for wounds and bruises; the back of the shoulders, for example, may show traces of counter pressure employed to steady the victim whilst the ligature was being tightened. When discussing the subject of supposed homicidal hanging, it was mentioned that death was not unfrequently caused by strangulation, and the body subsequently suspended by the neck to simulate suicide by hanging. In such cases there would probably be two marks on the neck; this, however, has occurred in suicidal hanging, from the neck slipping further through the noose after a period of suspension. Homicidal strangulation occupies a prominent position among the modes of violent death that from time to time are feigned by an indi- vidual who wishes either to excite compassion ; to account for the loss of a sum of money entrusted to his charge which he has embezzled, but which he alleges was stolen from him after he was rendered un- conscious; to revenge himself on some one against whom he has a grudge, by accusing him of an homicidal act; or, in the case of hyster- ical women, without any obvious reason whatever. All cases of alleged attempted homicidal strangulation, in which the victim has sustained little external injury, should be approached with a certain amount of scepticism on the part of the medical man. This need not be displayed in the first instance; the mental attitude should be that of a man open to conviction, but who requires convincing. Many of these cases of imputed homicidal violence would scarcely be heard of were it not that the medical man who first sees the case does not approach it in a sufficiently judicial frame of mind; he accepts the statements of others who first discovered the supposed victim without sufficiently weighing their probability. Tardieu relates more than one instance of this description. In one, a man, stated to be in an almost lifeless condition, was found in a cellar with the hands and feet tied, STRANGULATION. 205 and a cord three or four times round the neck, but not tied ; in three hours he was himself again, except that he could not speak. According to the man's own statement subsequently made, he had been eleven hours in the condition as found. The whole affair was a palpable fraud, but there was not wanting medical evidence in favour of the account given, which was that the man's master had attempted to strangle him. Another case was that of a girl who asserted that she was the victim of a political conspiracy, and that a man had attempted to strangle her and at the same time had stabbed her with a dagger. Her dress was cut, but not her body. She was dumb when discover' id after the alleged assault, but when Tardieu told her she would speak in a minute, she did so and confessed the imposture. Suicidal Strangulation. — Although strangulation is an exceptional mode of committing suicide instances are not so rare as formerly was assumed. Self-strangulation was regarded as next to impossible, except some contrivance of the nature of a tourniquet was adopted, such as passing a short stick between the cord and the neck, and twisting it round until asphyxia was produced. Numerous cases have proved, however, that the necessary constrictive force can be brought to bear by simply encircling the neck once or twice with a ligature and then tying it, or even without tying. The way in which the ligature is applied, together with the position and the formation of the knot, is of great importance in differentiating between suicidal and homicidal strangulation. Maschka considers that when the ligature goes several times round the neck, suicide is indicated rather than homicide; because quick and powerful tightening of it by a murderer would be more easily accomplished with a single turn than if there were several. On the other hand, there is nothing to prevent a murderer from using a single turn first, and, when unconsciousness has been produced, twisting the cord once or twice more round the neck, and tying it to make sure that the victim shall not recover. In Lesser's case of homi- cidal strangulation, previously mentioned, the cord went several times round. The position of the knot varies : it is most commonly found in front or to one side, usually the left; exceptionally it has been found on the back of the neck ; the right- or left-handedness of the suicide may affect the position of the knot. More than one knot, espe- cially if one is separated from the other by an extra turn of the cord round the neck, points to homicide. The more perfect the formation of the knot, the less likely is the case to be one of suicide. Anything peculiar about the construction of the knot must be noted; sometimes an indication is thus obtained as to the trade of the person who made it — sailors, for example, use knots of a different kind to those used by landsmen. The material of which the ligature consists may afford a clue. 206 FORENSIC MEDICINE. The degree of violence inflicted by the ligature is a valuable indica- tion. Fractures of the thyroid or cricoid cartilages or of the hyoid bone may almost be taken to exclude suicide; the like may be said of rupture of the muscles and of the inner coats of the carotids. Slight extravasations into the substance of the muscles underlying or near the cord-mark may occur in suicidal strangulation ; but they are then limited in extent, being for the most part of the punctiform type. When the subject of homicidal strangulation was discussed, attention was drawn to the possibility of after-suspension of the body, in order to simulate suicide, and the consequent formation of a double mark round the neck ; a like occurrence may be met with when a primary and unsuccessful attempt at suicide by strangulation has been followed by self-suspension. A careful comparison of the two marks would probably enable an opinion to be formed as to the real mode of death: if by strangulation, the lower and more horizontal mark would be characterised by signs of greater violence than the mark due to sus- pension; if by hanging, the converse would hold good. Signs of general violence would be absent, except such as might be produced in applying the ligature — scratches and slight abrasions about the neck. The possibility of unsuccessful attempts to put an end to life in other ways before adopting strangulation must not be lost sight of. When the body is examined before it has been dis- turbed, the state of the clothing and of the surrounding objects would show whether there had been any struggling or not. It is to be remembered, however, that a murderer might obliterate such indica- tions, and also that suicides have been known to be affected with a kind of fury before putting an end to themselves, and have thrown all the surroundings into disorder. The following cases are illustrative of the manner in which suicidal strangulation has been effected : — In a case reported by Filippi, 1 an insane man strangled himself by simply surrounding his neck twice with a strip of woollen material and tying it in front. Francis 2 records the case of a man, also a lunatic, who strangled himself by twisting some string round his neck, tying the ends to his wrists, and then extending his arms to the utmost; he was found dead, having fallen from his original kneeling posture on to one side. In a case related by Ogston, 3 the body of an old man was found in a wood with a neckcloth wound more than once round the neck; a walking- stick had been passed through the loop of the neckcloth and twisted so as to tighten it. From the obliquity of the outer fold of the neck- cloth, Ogston at first thought that the body had been dragged along 1 Revixta sperimentale difren. e Tried, legale, 1879. 2 Med. Timet and Gazette, 1876. 3 Lectures on Med. Jwrisp., 187S. STRANGULATION BY THROTTLING. 20 < the ground with the stick ; on careful examination he concluded that the oblique direction of the neckcioth had been produced by a final convulsive struggle; the stick, entangled in a clump of young trees, had held the ligature fast, whilst the movements of the body had drawn it into the position in which it was found. STRANGULATION BY THROTTLING. When strangulation is effected with the unaided hands, the act is called throttling. The experiments made on the dead body by Langreuter (see section on Hanging) illustrate the facility with which the air-way may be occluded by external pressure. It was found that if the thumb and forefinger were placed externally on the two sides of the thyroid car- tilage respectively, the least pressure was sufficient to close the aperture between the vocal cords ; stronger pressure made the cords overlap each other. When strong pressure was made between the larynx and the hyoid bone, the air-passage was stopped, principally through approxi- mation of the ary-epiglottic ligaments. The only points to which attention need be specially directed in relation to throttling are the external and internal appearances pro- duced by the pressure of the fingers on the throat. The general external and internal appearances are those common to other forms of strangulation. Position of the Marks. — They are usually found on both sides of the front of the throat directly below the lower jaw; sometimes they are far back at the angle of the lower jaw. They may be sufficiently detached as to indicate the exact spot occupied by each finger, but not unfrecpiently they are too closely clustered together to be separately identified. They are distinguishable from an interrupted mark of a cord by not being on the same level. The marks may correspond more or less with the shape of the finger tips, but are often irregular in outline, from infiltration of extravasated blood round about. The impressions of the finger nails may be present as c rescentic indents; and if there has been much struggling, the skin of the throat will be scratched and excoriated. T here may be only one mark on on e side and several on the other, respectively corresponding to the thumb and fingers ; if the assailant was right handed, the thumb mark will be on the right side of the neck; if the left hand was used, it will be on the left side. The appearance of the marks, if examined not long after death, is that of bruising; more or less blood escapes beneath the skin and produces the characteristic discoloration. If some time elapses before the examina- tion is made, the marks may present the dry, horny, or parchment-like 208 FORENSIC MEDICINE. look and feel, described as occurring in one form of the cord-mark from hanging; this is due to injury sustained by the epiderm from rough contact with the fingers, which allows evaporation to take place from the denuded surface of the cutis. General signs of violence will probably be visible in some parts of the bodv ; the attack is often made on a victim in the erect posture, and in falling injuries to the head are easily sustained. On section a considerable amount of extravasated blood is usually found in the underlying soft tissues. Fractures of the thyroid and cricoid cartilages and of the hyoid bone are frequently met with. The carotids escape injury. Lacerations of the inner surface of the cheeks from violent pressure against the teeth may occur. It is usually asserted that throttling is necessarily and invariably a homicidal act. Accident as a mode of production may be ignored, and it has been held to be an impossibility for any one to commit suicide by compressing the throat with the unaided fingers. For all practical purposes throttling may be regarded solely from the homicidal stand- point. Still, one solitary case is recorded by Binner x of suicidal throttling. A woman, aged forty, suffering from melancholia, who had previously made several attempts to commit suicide, was found dead crouched in her bed with both hands compressing the throat ; the elbows were supported on the knees, and the back leaned against the wall; there were marks of her finger nails on both sides of the throat. Death resulted from compression of the throat by the fingers. A case of homicidal strangulation was tried at the Liverpool Winter Assizes in 1884. A man and his wife had been in the house a short time together when the man went out and sought assistance, "because his wife had fallen into the fireplace and he feared she was dead." She was found apparently dead sitting in a chair with the head sup- ported by the wall ; marks of blood were on the table, the wall, and the floor of the room. On examination of the body, a bruise was found immediately beneath the lobule of the left ear, and another three-quarters of an inch below the right ear; superficial extravasation was evident in both, together with a second and deeper extravasation half an incli below the surface of the right hand bruise. Other bruises were found over each eyebrow, at the back of the right wrist, over the knuckle of the left little finger, at the inner part of the left elbow, and at each angle of the mouth; within the mouth was a lacerated wound corresponding to the stump of a canine tooth. The tongue and gums were also injured, and one of the teeth in the upper jaw partly loosened. The deeper structures of the throat were not injured. The 1 Zeitschr. f. med. Beamte, 1S88. SUFFOCATION. 209 internal signs were those of death from asphyxia; the brain and mem- branes were intensely congested. The man was found guilty. 1 SUFFOCATION. When air is prevented from entering the lungs by other means than by external constriction of the throat, or by submersion in water, if death results, it is said to be due to suffocation. The modes of death from asphyxia which have previously been con- sidered, are necessarily due solely to external influences brought to bear either accidentally or intentionally ; from these suffocation differs, inas- -^r much as it may result from pathological causes apart from external agency. It is not necessary to enumerate all the morbid conditions which may lead to death from suffocation ; a few will serve as illustra- tions : — In children, spasm of the glottis or accumulation of exudative products in the air-passages ; in adults, oedema of the glottis, paralysis of the vocal cords, bursting of a pharyngeal abscess, or of a thoracic aneurism into the trachea may suddenly cause death from suffocation. Nothing more need be said with regard to these and like conditions, except that the possible occurrence of those which leave no evidence after death must not be forgotten when searching for the cause of death in doubtful cases. Suffocation may be produced from external causes by (a) the introduction of foreign bodies into the air-passages, (b) forcible compression of the chest, (c) covering over the mouth and nose (smothering). (a) The introduction of foreign bodies into the air-passages from accidental causes may occur either in the case of children or of adults; the foreign substance is usually some kind of food, either solid or pultaceous; it may be introduced directly, as in the act of deglutition, or it may be regurgitated from the stomach, and find its way into the air-passages instead of being ejected from the mouth. When food enters the larynx, it is frequently the result of an involuntary movement of inspiration induced by sudden surprise or by a fit of laughter during the act of deglutition. A man who is intoxicated may vomit, and, through diminished reflex activity, no effort may be made to prevent the vomited matter from being drawn into the larynx. In some cases death occurs with exceeding rapidity, especially if the individual is advanced in years, and on post-murtem examina- tion, the signs of death from asphyxia are found to be entirely absent : there is neither cyanosis during life, nor excess of blood in lungs, brain, or right heart after death. It is probable, in cases of this 1 Med. Chron., 1SS5. 14 210 FORENSIC MEDICINE. description, that death results from syncope. Perrin 1 directs attention to the absence of the post-mortem signs of death from asphyxia under conditions which are likely to produce them, and gives illustrative cases. An invalid, G2 years of age, in the midst of a meal suddenly fell on the knees of his neighbour quite dead. On examination, the epiglottis was erect and rigid, and a mass of food as large as a hazel-nut was found in the glosso-epiglottic fossa ; at the fifth ring, the lumen of the trachea was obstructed by a cylindrical mass nearly 2i inches long which reached down to the point of bifurcation. The lungs were normal and free from ecchymoses, the left side of the heart wasT empty and the right side only contained a few spoonfuls of par- tially fluid blood. In another case a man 68 years of age fell suddenly as though struck by lightning when leaving a cafe. At the necropsy, a mass composed of pancake was found to fill the posterior part of the pharynx, and to extend to the glottis ; the epiglottis was raised. It is not necessary that the air-passages should lie blocked up with the foreign substance in order to induce suffocation ; the inti'oduction of a small extraneous body in such a way that it lodges on or between the vocal cords may be sufficient to excite spasmodic closure of the glottis and thus cause death. In the museum of Owens College there is a specimen taken from the body of a man who died under the following circumstances: — The man, when not quite sober, was turned out of a public-house ; he tried to get in again, and in doing so his finger was caught in the door; shortly after he was found dead in the street. The body was taken to the Manchester Royal Infirmary, and Professor Young, who was then the pathologist, made a post- mortem examination, but found no cause for death until on opening the larynx a small piece of skin was discovered just below the glottis. Further examination of the body showed that the fragment of skin had been detached from the index finger of the right hand. What probably happened was that on receiving the injury the man put his finger in his mouth to ease the pain, and the piece of skin in question, being all but detached, was carried away by a quick inspiration and lodged between the vocal cords. Honicidal suffocation from the introduction of foreign bodies into the air-passages is rarely met with, except in infants or young children. In the case of children, various substances have been forced into the air-passages— such as rolled up pieces of cloth, pieces of newspaper, sand, earth, and artificial teats— the last-named to give colour to the assertion that death was accidental. Adults murdered by the introduction of foreign bodies into the air-passages have generally been under the influence of drink at the time : Pouht on Foreign Bodies in Surg. Practice, 1881. SUFFOCATION. 211 or have been aged and feeble persons. Littlejohn 1 records the c:ise of a woman who died suddenly, and at the post-mortem examination a wine-bottle cork (most probably thrusi into the throat when the woman was intoxicated) was found covered frothy mucus and tightly inserted into the upper part of the .larynx ; the sealed en 1 of the cork with the mark caused by the corkscrew was uppermost. The defence was that the woman had drawn the cork from a bottle with her teeth and that it was propelled down the throat accidentally; the fact of the sealed end being uppermost, how- ever, disproved this. The frothy mucus which covered the cork indicated that it was introduced during life. The act was, doubtless, homicidal, but the accused was not found guilty; the Scotch verdict of " not proven " being given. Suicidal suffocation from the introduction of foreign bodies into the air-passages is limited to lunatics. A woman in an asylum, age was found eaidy One morning dead in bed with part of a stocking protruding from her mouth, death having resulted from suffocation; no noise nor disturbance nor anything wrong was noticed by other patients who slept in the same ward. At the inquest a long stocking was exhibited which had been removed with great difficulty from the air-passages. 2 Sankey 3 mentions the case of a male epileptic who committed suicide in an asylum and was found dead lying on his back in btd with a round pebble in each nostril, and a strip of flannel rolled up and stuffed into the throat. (b) Suffocation from forcible compression of the chest may be acciden- tally occasioned when large numbers of people are massed together on occasions of public rejoicing, or in panics, such as follow an alarm of tire raised in a crowded building. A lamentable instance occurred in 1883 in Sunderland. Some hundreds of children in the gallery of a public hall rushed down stairs and were arrested by a closed door; a block took place at the bottom of the stairs and about 300 children were piled up so as to form an inextricable mass some 7 or 8 feet high. About 200 were killed, for the most part from compression of the chest, although in very few instances were the ribs fractured, which may bo accounted for by the flexibility of juvenile bones, and by the absence of powerful struggling, such as takes place in a crowd of adults. Lambert, 4 who examined many of the bodies, states that the appearances after death were almost uniformly — congested puffy face, purple or blackish turgescence of the vessels of the neck, eyelids closed, eyeballs protruding and fixed, pupils dilated to the uttermost, and froth from the mouth and 1 Edin. Med. Journ., 1885. - Brit. Med. Journ., 1882. 3 Brit. Med. Journ., 1883. 4 Brit. Med. Journ., 1SS3. 212 FORENSIC MEDICINE. nostrils. In twenty-four hours much of this had passed off, the face presenting the appearance of peaceful repose. Cadaveric rigidity was universally absent. In almost all the cases urine and fteces had been expelled. Infants are but too frequently accidentally suffocated by pressure caused from overlaying ; a heavily sleeping or, possibly, intoxicated mother encroaches on the infant lying by her side in such a way as to suffocate it. In these cases the cause of suffocation may be two-fold — pressure on the chest, and covering of the mouth and nostrils, each in itself being quite sufficient to quickly produce death. Of 258 deaths from overlaying Templeman 1 found that at the ages of one, two, and three months the numbers were 62, 67, and 66 respectively; at the fourth month the mortality sank to 21, at the fifth to 16, at the sixth to 13, at the seventh to 5, and at the eighth and ninth to 4 each. After nine or ten months old an infant is better able to struggle and to save itself from the risk of accidental suffocation. Homicidal suffocation from compression of the chest has been effected in new-born infants. In adults, unless previously rendered incapable of resistance by intoxication or by debility from age, such a mode of homicide would be scarcely pi-acticable. The oft quoted cases of Burke and of Bishop and Williams were examples of combined suffoca- tion ; they compressed the chests of their victims by allowing the weight of their bodies to rest on them, and at the same time covered the mouth and nostrils with the hauds. Maschka met with the case of a girl of fourteen who was suffocated by pressure on the chest by one man, whilst another perpetrated a rape upon her. (c) Suffocation by covering or compressing the mouth and nostrils is a mode of suffocation usually designated smothering. In the case of infants it may easily occur either accidentally or with homicidal intent by simply covering them over with a thick layer of clothing, such as the bed clothes ; mere continued pressure of the child's face against the mother's breast in the act of suckling has proved sufficient. Adults may be accidentally smothered by immersion in substances composed of loose particles, such as grain, sand, flour, and the like. Falck 2 records the case of a man who was accidentally buried in a large quantity of flour. The mouth and oesophagus were filled with flour agglomerated with saliva, but none obtained access to the stomach ; the lungs and the brain were hyperremic ; particles of flour were found in the bronchi as far as the smallest ramifications. Russo-Gilberti and Alessi 3 found loose particles of the sui-rounding material in the larynx, bronchi, and even in 1 Edin. Med. Journ., 1892. 2 NordisM med. Arkiv., 1891. 3 Archivio per la Scienze Mediche, 1888. SUFFOCATION. 213 the pulmonary alveoli of animals that had been buried alive. Epileptics are not unfrequently smothered during a seizure, either when in bed, from close approximation of the bed clothes to the face, or in the day time, from falling on to some yielding substance face downwards. Janeway records the case of an epileptic who had an attack in a stable- yard and was suffocated by the manure on which he fell, portions of which were found in the larynx after death. Homicidal suffocation by smothering is, doubtless, of frequent occur- rence as regards infants and young children; the modes which have been adopted are described in the section on infanti- cide. Older children, especially when surprised in sleep, easily succumb to smothering. A probable instance of this kind occurred in Manchester in the year 18G2. Three children, aged 12, 8, and 5 years, were found dead, side by side, on the floor of a bedroom ; they had probably been dead two days ; rigidity had passed off, and the first putrefactive changes were developing. No external indications of violence were observed, except that in two of the children there were slight bruises, and in one there was a scratch on the face ; internally there was an absence of apparent cause of death, and there was no trace of poison. Taylor, who investi- gated the case, concluded that death had resulted either from smother- ing or from chloroform vapour, and considered it most probable that the children had been smothered whilst in bed. Adults have either to be taken unawares, or to be asleep, or intoxi- cated to permit of death being homicidally produced by smothering. Plasters made of pitch or other sticky substances have been used for the purpose of rendering persons helpless and incapable of raising an alarm whilst being robbed ; if the plaster is not quickly removed death from suffocation results. Wald * records an instance of homi- cidal smothering of an adult. A man resolved to murder his wife, and took the opportunity while she was asleep in bed to cover her over with several heavy bed-covers, and then laid himself on the top; in a short time, the struggles she at first made ceasedj and the woman was dead. The man then informed a doctor that his wife was attacked with cramps and desired his attendance, but before the doctor arrived he met him with the intelligence that she was dead ; no suspicion was created, and the body was buried. Information was subsequently given to the authorities as to the real cause of death, and the body was exhumed and examined. Signs of (hath from asphyxia were present ; and the murderer subsequently confessed to having perpetrated the crime in the way above described. Suicidal smothering is almost unknown. A case 2 occurred in 1 Gerichtliche Medic in, 1858. - Wald, I.e. 214 FORENSIC MEDICINE. France in which a woman got under the bed-clothes after desiring her little child to bring all the cushions, clothes, and other similar les that were in the room and pile them on the top of her; the child did so, and some hours after when the woman was discovered she was dead. Signs of death from asphyxia were found at the necropsy. The modes in which suffocation can be produced being so varied, the post-mortem signs within certain limits are correspondingly diver- sified. Externally, the appearances comprise all degrees of significancy from those cases in which the mouth and nostrils are found tilled with a foreign substance, down to those in which death has resulted from smothering by graduated pressure with a soft material : the first being obvious at a glance, the second yielding no external trace whatever of the cause of death. Apart from any special indication afforded by the presence of injuries about the mouth or nostrils, or of some of the material by means of which the air-passages were obstructed, o ne or more of the general signs of death from asphyxia may be visible, such as punctiform ecchymoses on the conjunctivae and on the outer surface of the lower eyelids. Turgescence of the face and large vessels, with a cyanotic hue of the extremities, is suggestive of suffocation from compression of the thorax, but the condition disappears in a few hours after death. Internally, there may or may not be the usual signs of death from asphyxia; the amount of blood contained by the lungs and heart is by no means constant, nor is the dark colour and fluidity of the blood invariable. Sub-pleural ecchymoses, which Tardieu erroneously regarded as exclusively due to asphyxia produced by suffocation, are usually present ; the pericardium also may be ecchy- niosed. The degi-ee of hypertemia of the other organs — brain, stomach, intestines, spleen, liver, and kidneys— is subject to great irregularity. It is to be remembered that the absence of the so-called signs of death from asphyxia do not exclude the possibility of death having resulted from suffocation. "When making an inspection of the dead body for medico-legal purposes the air-passages from the mouth down to the bronchi should always be examined, otherwise the real cause of death may remain undiscovered. It is too frequently assumed, if the conditions of the heart, the lungs, and the blood usually associated with death from asphyxia are absent, that there is no need to examine minutely into the state of the respiratory tract. More than once it has occurred that a medico-legal inspection which yielded negative results as to the cause of death has been proved to have been negligently made, by DROWNING. 215 the discovery of a foreign substance in. the air-passages on subsequent and more thorough examination. In addition to the detection of foreign bodies in the air-passages the state of the mucous membrane of the larynx and trachea requires investigation; it is sometimes found injected, and may be covered with frothy mucus, possibly blood-stained ; this would point to an asphyxial mode of death, though its absence would not justify the opposite conclusion. All signs of general violence, such as bruises, scratches, or ruffling of the epiderra are to be carefully looked for. The surroundings of the body, if the examination is made before it is disturbed, may afford valuable indications; if the body is clothed, careful inspection of every detail must be made and notes taken before it is disturbed . It not unfrequently happens that 'conditions subsequently discovered may receive important corroboration from some apparently trifling detail which, without this precaution, would have escaped notice, or from want of aid to the memory afforded by the notes would probably be imperfectly interpreted. DROWNING. Drowning is a mode of death from asphyxia caused by continuous or by intermittent submersion of the mouth and nostrils under water or other fluid, so that access of air to the lungs is either at once or gradually cut off until life is extinct. When asphyxia is caused by hanging or by strangulation, access of air to the lungs is simply obstructed ; when it is caused by drowning, an irrespirable medium is drawn into the air-passages by attempts at respiration, and in this way special changes are produced in the lungs beyond those which are due to uncomplicated asphyxia; these changes constitute one of the principal signs of death from drowning. D eath may result from falling i nto the water and still not from asp hyxia : fatal syncope may occur at the moment of submersion, or in rare instances the head /. or abdomen may strike against a rock or other solid body with suffi- cient violence as to cause immediate death from shock; in such cases the characteristic signs of death from drowning will be absent. From experimental investigations Brouardel and Loye 1 consider that the mode of death from submersion usually attributed to syncope is due to inhibition. They emphasise the distinction between the manner in which the respiratory act is influenced by drowning on the one hand and by external constriction of the air-passages on the other. When asphyxia is produced by hanging, the entire muscular force of the respiratory apparatus is thrown into immediate action in the 1 Archives ds Physiol, norm, et Pathol., 1SS9. 216 FORENSIC MEDICINE. endeavour to obtain oxygen. When submersion is the cause of asphyxia, there is at first an attempt on the part of the animal to breathe as usual ; then, appreciating the clanger, it struggles to escape and at the same time fixes the thorax, voluntarily suspending respiration in order to prevent the water from entering the air- passages ; the respiratory centres, however, are soon stimulated beyond the control of volition, and involuntary respiratory movements are set up by which water is drawn into the lungs and penetrates the alveoli. In addition to the resistance offered by the will, the sensory nerves of the skin and of the air-passages play an important role: — If the trachea of an animal is opened and a tube inserted in the opening, the glottis no longer has control of the air-way, and it might be supposed on submerging the animal that water would at once be drawn into the lungs; the same suspension of respiration, however, takes place as before, from fixation of the thorax, so long as the centres can be kept in abeyance. But if both pneumogastrics are divided high up in the neck, and a tube placed in communication with a vessel of water is introduced into the trachea, the animal continues to breathe as usual for thirty seconds, although water is being received into the lungs in the place of air; then the animal becomes agitated, but still continues to breathe. If, after division of the pneumogastrics, an animal is plunged in water it fixes the thorax almost as though the nerves were intact; this demonstrates that the sensory nerves of the skin and of the naso-pharyngeal tract take part in the inhibition of respiratory movements ; in the preceding experiment they were not called into play. When an animal, chloroformed until the cornea is insensitive, is submerged, it makes no attempt to prevent water enter- ing the air-passages, but continues the movements of respiration as before submersion. From these experiments Brouardel and Loye infer that although volition has to do with the temporary arrest of respiration irritation of the nasal and laryngeal nerves exercises a still more powerful influence by inhibiting respiratory movements. A transient stage of interrupted respiration may exceptionally be replaced by one of permanent inhibition, and death from submersion thus caused with absence of the usual signs produced by the presence of water in the lungs. When death takes place from drowning in the ordinary way, sub- mersion is not usually continuous; even when the individual falls from a height above the water-level, and in consequence of the acquired momentum reaches a considerable depth, if not in some way prevented he generally returns at least momentarily to the sur- face. This is not due to the body being of lesser specific gravity than water, but to involuntary movements of the limbs— apart from DROWN INC. 217 skilled movements, such as are executed by practised swimmers. The specific gravity of the human body is slightly greater than that of water, being about as TOS to 1 -005 or 1 -03, according to the kind of water —fresh or salt. All the constituents of the body are specifically heavier than water, except fat and lungs which have breathed, and these do not suffice to counterpoise the heavier tissues ; still, the difference is so slight that very little movement brings the body to the surface, if only for a moment. The greater the percentage of fat and of lung-capacity in relation to the body-weight, the greater the tendency to float; women as a rule float better than men because of the slighter build of the skeleton and large proportion of fat ; new-born infants if well nourished will scarcely sink unless weighted. The body of a person who has died from drowning is deprived of the buoyancy of the lungs, since the air they contained has been almost entirely replaced by water ; this, together with the absence of move- ment, causes the body to sink and to remain submerged. Submersion continues until the gases of putrefaction are developed in sufficient quantity to reduce the specific gravity of the body below that of the surrounding medium ; the body then rises to the surface unless pre- vented by some mechanical obstruction— such as being covered over with sand or mud, or being caught by weeds, ropes, or the like. Floatation Generally occurs in temperate climes within the first week ; the exact period after death depends upon the initial difference in specific gravity between the body and the medium in which it is submerged— chiefly determined by the amount of fat— by certain intrinsic conditions depending on the degree of vital exhaustion that preceded death, and on the temperature and stillness of the water. A body submerged in deep water will not rise so soon as one lying in shallow water, because the latter will be warmer and will consequently promote an earlier formation of putrefactive gases. A body submerged in a pond is likely to rise earlier than one at the bottom of the river, because the still water acquires more heat from the sun's rays and from the stratum of air above it than the flowing water of a river. Post-mortem Appearances.— When the body of a person who has been drowned is removed from the water within a few hours after death, and is examined forthwith, there is usually little diffi- culty in determining that death was caused by drowning; on the other hand, when the body remains in the water until decomposition is advanced, insuperable difficulties are interposed which may render the formation of anything like a positive opinion impossible. The interval that elapses between the removal of the body from the water and the examination largely influences signs of great diagnostic value :— The froth visible about the mouth and nostrils in the recently 218 FORENSIC MEDICINE. drowned is soon dissipated on exposure to the air; the surface of the body — especially if the clothing is removed — in a short time becomes dry and discoloured : putrefactive changes in the body advance with .-rent rapidity after its withdrawal from the water, and in a com- batively short time completely obliterate the indications which distinguish death by drowning from other modes of death with sub- squent submersion of the body. The following description refers to the bodies of those recently drowned and examined shortly after removal from the water: — External Appearances. — Cadaveric rigidity usually comes on early, in some cases immediately, so that the last position of the limbs during life is maintained after death. The surface is pallid, but not more so than that of a dead body under ordinary conditions. The face is tranquil and the eyes and mouth are partially open. There may be rosy patches on the face and neck, and in some instances the face is of a reddish-blue or violet hue; at a later period after death, its colour may be changed to a dirty red. The skin often presents the appear- ance known as "goose-skin," a condition met with in a variety of sudden •deaths by violence; it is due to vital reaction, the manifestation of which persists after death from the occurrence of instantaneous • cadaveric rigidity in the arrectores pili when in a state of contraction. The skin of the palms of the hands, the soles of the feet and the knees s bleached, sodden, and wrinkled, the result of imbibition ; it is of no significance other than showing that the body has lain in the water for -twelve or more hours. The tongue has been described as being pressed ■forwards between the teeth; it is only exceptionally that this occurs, and as the same condition is found after violent death from other causes it is a sign of little import. The most valuable of the external indications that death has resulted from drowning is the presence of a fine froth on the lips and nostrils. This froth or foam may be white or it may be blood-stained ; it has not been unaptly likened to the finely con- stituted lather produced by shaving-soap. Draper 1 states that it is found after drowning under all circumstances and in all media; he has seen it in the case of an infant drowned in a cesspool. Its con- tinuance however cannot be depended on for more than four days in winter and about three in summer — the body being under water; if it has disappeared from the lips, a little pressure on the chest may cause some to well out of the mouth. The presence of substances, such as weeds from the bed of a river, or of fragments of clothing, clutched in the fingers — due in the first instance to a vital act sub- sequently rendered permanent by instantaneous cadaveric rigidity — is evidence of submersion during life; in practice it is a sign not frequently met with. 1 Boston Med. and Surg. Reporter, 18S5. DROWNING. 219 Internal Appearances. — The Jungs usually exceed their normal volume, so that they almost cover the pericardium, a condition sometimes described as •• ballooni ng" of the lungs ; instead of col- lapsing when the thorax is opened, they protude so as to fill the aperture made by the removal of the sternum. The consistence of the lungs is doughy — they retain the pit produced by pressure of the finger. They are sometimes of a pale grey, with reddish stains produced by transudation of water tinged with blood-colour- ing matter; in other instances the entire surface of the lungs is of a reddish-blue. Draper, in the majority of cases examined by him, observed punctiform subpleural eechy moses, though few in num- ber and mostly at the lower part of the lobes. Most observers state that they are of very exceptional occurrence in death from drowning; Ogston, Junior, met with them in barely 7 per cent, of the cases he examined. On section, the lung-substance is found to contain water which, along with froth, exudes from the cut surface on the slightest pressure ; the bronchi, and possibly the alveoli, contain fine froth of the same character as that on the lips and nostrils. The red stain, if visible on the surface of the lungs, is seen to pervade their entire substance. Two views are held with regard to the condition of the parenchyma of the lungs after death from drowning. According to one, it is infiltrated with water or other medium in which drowning takes place, and this to a certain degree accounts for the increased volume of the lungs. According to the other view, there is but little fluid in the parenchyma, and any that is present is derived from exuda- tion from the vessels producing oedema. Paltauf l states that the water which is drawn into the lungs in attempts at respiration enters the alveoli, and finds its way from thence by the lymph -spaces and occasionally through small lesions in the alveolar walls, into the interstitial alveolar, subpleural, peribronchial, and perivascular connective tissue. Lesser, 2 on the other hand, states that a secretion of mucus, which blocks the finer bronchi, is caused by aspiration of water into the air- passages, which therefore cannot reach the alveoli except in scarcely appreciable quantity. He denies that the parenchyma contains water : if any fluid is there it is derived from the blood-vessels and is a vital exudation product — a true oedema. It is probable that a mucous secretion in the bronchi does occur durinc death from drowning, but only in quantity when the death- struggle is prolonged. Ceradini's 3 experiments ou animals show this, 1 Ueberden Tod durch Ertrinkm, 1SSS. * Atlas d. ger. Med., 1891 j ami Vierteljahr.uchr.f. rjer. Med., 1S84. 3 L'imparzude, 1873. 220 FORENSIC MEDICINE. and also that blocking of the finer bronchi by the mucus is one reason -why the lungs after death from drowning do not collapse when the thorax is opened — the alveolar contents cannot escape. The fine froth contained in the air-passages is composed of a variabl e mixture of the drowning medium with air, mucus, and possibly blood. When the death-struggle has been prolonged more froth is produced and it is of a more lasting nature than when death occurs quickly; this results from the presence of a greater proportion of mucus, which imparts increased tenacity to the bubbles, and from more vigorous ad- mixture of air, water, and mucus, which augments the total amount of froth. According to the observations of Brouardel and Vibert 1 stain- ing of the froth is due to infiltration of blood-colouring matter derived from small extravasations in the parenchyma of the lungs. If, after submersion, the body does not return to the surface until death has taken place, there will be less froth and more water in the air-passages than when the mouth and nostrils momentarily emerge once or more and additional air is inspired; this is supposing that death takes place from asphyxia ; if from syncope or, what comes to the same thing, from permanent inhibition of the respiratory move- ments, no froth at all will be present. The pleural cavities usually contain a quantity of water with or without a cei'tain admixture of I mucus. The mucous membrane of the trachea may be injected, but this sign is more frequently absent after drowning than after other modes of death from asphyxia. The lumen of the trachea is usually filled with froth, which may reach the mouth unless the body has lain for some time in water or is not examined soon after withdrawal from it. The heart usually presents the appearance due to death from asphyxia ; the left side is empty or thereabouts, and the right side filled with blood. The vascular condition of the brain and its mem- branes is not constant, and, therefore, is of no diagnostic value as regards death from drowning. Draper, in 149 examinations, found that injection of the membranes with hyperemia of the brain was present in about half the number of cases. The blood, da rk in colour and containing but little oxygen, is diluted with water, sometimes to the extent of one-third or one-fourth of its total weight (Brouardel and Vibert). The dilution is greater in the left side of the heart than in the right side, because the blood arriving by the pulmonary veins has received a fresh addition of water in passing through the lungs ; the blood in the portal vein may also be much diluted from imbibition by its branches from the stomach, which, as will be presently explained, usually contains a quantity of water. The dilution of the blood is proportional to the duration of life after submersion : — slow drowning 1 Annates d'ffygiene, 1SS0. DROWNING. 221 equals much dilution ; quick drowning equals less; when death from submersion results from syncope, or inhibition of respiration, the blood does not contain any excess of water, unless the body remains long sub- merged. After death from drowning t he bloo d is usually //" >) Obolonsky 4 placed in coloured water the bodies of 18 children of from two weeks to two months old, weighted so that they could not float; they were allowed to remain submerged for from one to three days. In three of the bodies a considerable quantity of the coloured water was found in the stomach, in two others only a small quantity — these Ave bodies had lain seventy-two hours in the water; in the remaining thirteen no trace of water was found in the stomach. Misuraca never found water in the stomachs of animals submerged after death. Fagerlund experimented with a large number of dead bodies of children and animals by placing them in various positions — on the back, on the side, face downwards, etc. — under water ; in some cases the mouth was kept open with pieces of wood, and the tongue was drawn forward and fixed. The result s showed that water finds its way with great difficulty into the stomach after death. Bougier 5 placed the dead bodies of twenty-three human beings and seventeen animals in various coloured fluids without water entering the stomach in any one case. From these experiments and observations the answers to the two questions will be: — (ft) That water is not invariably found in the stomach after death from drowning, (b) That it is possibl e for water to find its way into the stomach of a dead body lying in water. The amount of water found in the stomach is to be noted ; when small it is of doubtful import ; in some cases clear water is found in a separate layer above the other contents of the stomach. Fine froth may also be found in the stomach or oesophagus. The occurrence of fluid in the stomach possessing special characteristics corresponding with the medium in which the body is found may be of importance, 1 Lehrluch der ger. Med., 1887. 2 Edin. Med. Journ., 1SS2. 3 Dictionnaire Ency. des Sciences Mai. 4 Vierteljahrsschr. f. ger. Med., 18S8. s These, Paris, ISSo. DROWNING. but it is not a proof of submersion during life. When submersion is followed by death from syncope uo water is found in the stomach. Absence of water in the stomach after death dors not exclude drowning as the cause of death. I In some cases a portion of the water that has entered the stomach during death from drowning is forwarded by vital contraction into the intestines, and its presence there has been regarded as almost certain proof of submersion whilst living. The questions put in rela- tion to water found in the stomach are equally relevant in the case of the intestines. Fagerlund's very comprehensive experiments as to the conditions under which water may reach the intesti] afford valuable evidence. The outcome of them is that, occasionally, during death from drowning peristaltic movements cause water to pass from the stomach into the bowels; that the pylorus oil a certain amount of resistance to the onward passage of the water; that the water passes into the bowels more easily from an empty stomach than from one filled with food; and that slow drowning appears to favour its ingress. In the dead body water only finds its way from the stomach into the bowels when excessive pressure is brought to bear. As premised, the signs of death from drowning described in the preceding pages are those found in recently dead bodies which are / examined shortly— w ithin twelve or, at the most, twenty-four hours- after removal from the water ; in warm weather even this interval will be sufficient to obscure the more significant indications. When putrefactive changes are advanced beyond the early stages, the frothy contents of the bronchi and trachea will have disappeared ; there may be fluid and a number of air-bubbles, but no lathery-froth. At a certain stage of putrefaction the lungs collapse on opening the thorax, or are already collapsed: in the former case, the softening undergone by the lung-tissue and by the mucus of the finer bronchi permits the alveolar contents to escape under the pressure of the atmosphere ; in the latter, the pressure will have been already produced by transudation of water into the pleural cavities. The colour-changes, both external and internal, resulting from putrefaction are very deceptive, especially in relation to the possible occurrence of bruises, contusions, and the like. After withdrawal of a body from water in which it has lain for twenty-four hours or more, bruises, though present, may not be visible on account of imbibition by the skin j when the skin dries they become apparent. The longer the body has been submerged the less valuable is the presence of water in the stomach or intestines as a sign of death from drowning. Water may find its way to a limited extent into the air- 224 FORENSIC MEDICINE. passages of a body submerged after death, along with mud, or particles of sea-weed ; grains of sand have been found even in the alveoli ; but there is no great increase in the volume of the lungs nor fine froth in the bronchi. Transudation of water into the pleural cavities may buoy up the lungs in the dead body and make them look prominent on removal of the sternum without there being any " ballooning." Epitome of the Important Signs of Death from Drowning. — The only external sign of import is the presence of a fine froth or lather on the lips and nostrils; this sign is of great significance, but its duration after death is limited. An adventitious sign constituted by the presence of weeds or other local objects grasped in the hands is also indicative of submersion during life, but its occurrence is not frequent. The internal signs are — increased volume of the lungs with doughy consistence, water in the pleural cavities, exudation of water and froth on section of the lungs, fine froth in the bronchi and trachea, dilution of the blood, and water (or the fluid in which the individual was drowned) in the stomach, especially if some has reached the intestines. In the event of an investigation made on a dead body removed from water being determinative of death from drowning, the next question is — Was drowning the result of accident, homicide, or suicide ? First, as to probabilities. In the year 1890 the deaths from drowning in the United Kingdom are thus apportioned in the Registrar General's report : — The total number of deaths from drowning was 2,997. Of these accident is accountable for 2,485 — 2,065 males and 420 females ; homicide, 8 — 3 males (all infants under the age of one month) and 5 females; suicide, 504—304 males and 200 females. Reference to these figures shows that by far the largest number of deaths from drowning are due to accident, the male sex con- tributing nearly five times as many as the female sex; this is to be accounted for by occupation - risks, which affect men much more than women. Amongst the very small number of deaths from homi- cidal drowning, all the male victims were infants. Under ordinary circumstances it would be difficult to murder a man by drowning, unless he was in some way rendered incapable of resistance; with women the difficulty is not so great, as they are more helpless when unexpectedly plunged into water. When suicidal is compared with accidental drowning, a marked change is obvious in the proportion of the sexes — females being to males as 2 to 3. With women drowning is the preferred mode of committing suicide, probably because it requires no mechanical con- trivance for its accomplishment; the simple act of falling into water DROWNING. 225 is sufficient. In a certain proportion of suicides among women, the act is the result of sudden impulse, and, in many such cases, the necessity of preparing some means of carrying out their intention would be sufficient to allow of such a revulsion of feeling as to cause them to abandon their purpose; a neighbouring sheet of water solves the difficulty. As a means of ascertaining whether drowning was due to accident, homicide, or suicide, the external relations are of increased importance as compared with those attending other modes of death from viol- ence. If the body is clothed in the usual manner, the condition is consistent with any one of the three; but if the body is without clothing, and the signs of death from drowning are present, either accident or suicide is indicated— the former, if the place and the season of the year are suitable for bathing ; the latter, when one or both are unsuitable. A hasty conclusion is not to be arrived at, even when circumstances seem exclusively in its favour; and, above all, no opinion should be expressed until a full examination of the body has been made. Illustrative of the necessity of this is a case related by Winsor. 1 The body of a woman was found naked in water about two feet deep ; at first it was thought to be a case of accidental drowning, as the woman had been heard to express a desire to bathe in this particular place. On examination, however, an extravasation of blood was found in the right pectoral muscle, but none of the usual signs of death from drowning were present — no water was found in either lungs or stomach. The conclusion arrived at was that death had been caused by suffocation from pressure on the chest (probably by some one kneel- ing on it), and that the dead body had been placed where it was found. Bruises and wounds on the body give rise to suspicion of foul play, but they may result from previous accident or suicidal attempt, or from injuries produced after death by the body being tossed against rocks, posts, or other objects by the current or movement of the water. Draper (I. c.) relates two instructive cases of antecedent accidental injuries which complicated the diagnosis as to the mode of death. The dead body of a brewer was found in a lai'ge reservoir of water in the basement of a brewery; the sole access to the reser- voir was through a shaft, barely two feet square in transverse section, the opening of which was in an upper storey of the building. The body showed undoubted signs of death from drowning, along with contusions on the face and top of the head, which did not seem likely to have been produced by falling down the shaft ; it looked as though the deceased had been rendered unconscious by a blow on the head and then thrown down the shaft. On inquiry it Boston Med. and Surg. Journ., 18S9. 15 226 FORENSIC MEDICINE. turned out that the bruises had been produced two days before death in a drunken brawl, and a letter was found on the body in which the deceased signified his intention to commit suicide. The second case was that of a man whose body was found in a river, with a lacerated and contused wound behind one ear which laid bare the skull; it had the appearance of having been caused, during life, by a sharp stone or other similar object. The signs of death from drowning were present. Here also the indications pointed to a blow on the head having been inflicted by some one, who afterwards threw the unconscious victim into the river. The body was ultimately recognised as that of a man who had fallen down a flight of steps whilst intoxicated, and who, being with- out means of sustenance, had subsequently committed suicide. Injuries may be sustained in the act of jumping into the water; in this way fractures of the vertebrae, of the bones of the limbs, and also of the skull have been occasioned. Ogston states that in a woman who leaped over the parapet of a bridge the perineum was lacerated by forcible separation of the thighs on coming in contact with the water. As previously stated in relation to another mode of violent death, suicides not unfrequently make more than one attempt to terminate their existence which may vary in kind : a man may put a bullet into his chest and then drown himself, or he may cut his throat before doing so. It is by no means an exceptional occurrence for a man or woman to take poison and then to throw themselves into water ; such cases demand great perspicacity in their interpretation, for the unlikely frequently happens. For example, the combination of poison with drowning is suggestive of suicide, but it has been due to homicide. A woman took advantage of another woman's liking for brandy to give her some which she had previously mixed with arsenic ; the brandy was drunk in the open air, and, whilst the victim was sitting on the bank of a river with her back towards the water, her companion losing patience at the slow action of the poison, pushed her in, the body being found three days after. Such a case is clearly beyond the scope of medical evidence, so far as determining whether death was due to homicide or suicide is concerned ; the lesson to be learnt from it is, not to express a decided opinion on a probability, which in this- instance was very great, since the combination of poison and drowning is so rarely the result of an homicidal act that Belohradsky, 1 who relates the above case, only met with it twice in more than a thousand cases. Whilst the probability of such combination is in favour of suicide, the joossibility of homicide must not be ignored. Strangulation is an exceptional method of committing suicide; therefore, if a dead body is found in water with signs of strangulation 1 Maschka's Handhuch. DROWNING. --< and with absence of the signs of drowning, the probability is in favour of homicide by strangulation and subsequent disposal of the body in water. A case recorded by Hofmann l constitutes an exception to this statement: — A girl, about twenty years of age, was found dead in a bath with a piece of thick pack-thread tied round the neck ; the naked body was in a kneeling posture, the head being under water; examination showed that death resulted from strangulation. The bath was in a public institution, and the deceased locked herself in the bath-room, the door of which was under the observation of the attendant ; there could, therefore, be no doubt that the girl had taken her own life. It might be inferred, had the case been one of homicide, that a murderer would have removed the evidence of strangulation before placing the body in the water, but Belohradsky relates an instance which affords a further illustration of the risk of error which is inseparable from inferences founded on probabilities : — a dead body, the neck of which was surrounded three times with a cord, was found in water, but no signs of death by drowning were present ; the case was one of homicide by strangulation, the body having been placed in the water after death. Care must be exercised not to mistake marks produced on the neck at the time of or soon after death for indications of foul play; in one such case the string of a cloak, and in another the branch of a tree produced deceptive appear- ances. Indications of severe blows on the head, having the appearance of injuries sustained during life, may give rise to suspicion of homicide ; the suspicion is strengthened if the signs of death from drowning are absent. The possibility of the injuries being independently produced within a limited period before death has to be taken into account. Except in the case of young children, cut-throat wounds on bodies found in water are strongly indicative of suicide. When a dead body is found in water with a wound caused by a fire- arm, attention must be paid to the position of the wound ; the infer- ence usually is, that death resulted from suicide, but, to make this probable, the wound should be on the front of the body, in the head or chest. If the body is found in still water — as in a pond — the firearm should be near it; if in a river or in the sea, the body may have floated to a considerable distance from the spot where the shot was fired. There is obviously nothing to prevent a murderer from leaving the weapon near the body in order to suggest suicide ; but such a proceeding would be risky, unless he had possessed himself of a fire- arm belonging to the deceased. I njuries pro duced after death occur mostly in moving water — in i Wiener med. Presse, 1S79. 228 FORENSIC MEDICINE. rivers with swift currents, in harbours, or in the locks of canals. Sometimes the injuries strangely simulate in position and extent wounds such as are frequently inflicted during life ; in other in- stances, the body is smashed in a way that is incompatible with even extreme homicidal violence. As a rule, there is no difficulty, but care is occasionally necessary to distinguish between wounds inflicted at the time of death and injuries produced afterwards which co-exist on the same body. The characteristic appearance of wounds made before and after death are described in a succeeding chapter. When injuries to vital organs are found, which from their nature would necessarily be immediately fatal, and the body shows distinct signs of death from drowning, there can be no doubt that the injuries were produced after death. On the other hand, the absence of the signs of death from drowning and the presence of injuries of this type would be suspicious of foul play, unless, from the nature of the surroundings, it might be supposed that the body bad fallen into the water unaided after the victim himself had in- flicted the injuries — a man has been known to blow his brains out on the bank of a river and to fall dead into the water. A suicide who throws himself into the water from a great height, by striking some object may fracture and dislocate the spine in the cervical region ; in such a case the signs of death from drowning would be absent; the manner in which death was brought about would have to be inferred from the surroundings. The possibility of death occurring from syncope on submersion with the subsequent production of injuries by the body being thrown violently against projecting objects must be borne in mind, as in this case there would be the combination of injuries, which, from their nature, might be expected to be immediately fatal, with absence of signs of death from drowning. A case reported by Richardson 1 illustrates some of the points znentioned. The dead body of a man, of about 60 to 70 years of age, was found in the sea ; decomposition was taking place, and was more advanced in the head than in the abdomen. The nasal bones were broken and loose ; the scalp was torn away on each side of the head at the junction of the temporal and parietal bones; the bare skull was rough as though it had been rubbed against some hard substance, but the bone was not fractured. The spine was dislocated between the third and fourth cervical vertebra;, the spinous process of the latter being broken, and the cord crushed. The lungs were dis- tended and spongy, they overlapped the heart, and when cut into exuded bloody froth. The blood was fluid and dark. The stomach 1 Brit. Med. Journ., 1889. DROWNING. 229 contained a pint and a half of fluid, chiefly sea water. It was correctly inferred that death took place from drowning, and that the injuries were caused after death. The cardinal signs of drowning were found associated with an injury to the cervical cord which, had it been produced during life, would have been immediately fatal. Suicide was indicated by the month — -November — together with the fact that the body had stockings on and also the waistband of a flannel shirt. Occasionally a body presenting the signs of death from drowning is found in water only a few inches deep ; such cases are usually suicidal, but they may be accidental, the deceased being intoxicated or under the influence of an epileptic seizure which caused him to fall into the water face downwards in a helpless condition. Except in the case of very young or very old subjects, it would be difficult to murder any one in this way, unless the victim was previously rendered in- capable. Bruises or superficial marks of violence on the body having the characteristics of those produced during life are to be interpreted with caution, as a drunken man may have previously fallen more than once and thus occasioned the injuries, or they may have been produced by clonic epileptic spasms. Drowning has been caused by placing the head only under water contained in a tub or other receptacle ; in the case of adults the act is usually suicidal ; the exceptions are when helplessness, occasioned by previous intoxication or other causes, has been taken advantage of to commit homicide. Infants have been drowned in this way, and their bodies afterwards thrown into a pond or river ; in one such case, the fluid found in the air-passages consisted of dirty water containing soap, which demonstrated that the child was not drowned in the medium in which the body was found. Occasionally death may be due to accident, as when a workman falls head downwards into a cistern and is drowned with the rest of the body unsubmerged. The hands and the feet may be found tied together with, or with- out, weights attached to the cords. The indication is suicide in the event of the signs of death from drowning being present; the body, however, should be carefully examined for marks of violence suggestive of foul play. It sometimes happens that a person taking an ordinary warm bath for ablution is found dead without any external injuries. If the signs of death from drowning are present, the case will be either one of suicide or of accident, the latter being probably the result of an epi- leptic seizure ; if they are absent, death will have been accidental from syncope ; in one case it was due to thrombosis of the pulmonary vein. The question of homicide in these cases arises when there is ground for 230 FORENSIC MEDICINE. suspicion as to the motives and actions of a second person. The medical evidence would be expected to prove the cause of death, which might be due to asphyxia produced in some other way than by drown- ing, and to give an account of the general condition of the body with regard to indications of a struggle having taken place. Men in embarrassed pecuniary circumstances have been known to commit suicide by drowning in such a way as to suggest accident, in order that their famiiies might be benefited by money payable at death under an insurance policy ; at the present time there is no neces- sity for this subterfuge, for reasons explained in the chapter on life assurance. Still, from time to time, suicide is committed in this way, it may be with the object of sparing the suicide's family any reflected odium. Medical evidence can do little beyond proving the cause of death ; the distinction between suicide and accident will have to be determined by circumstantial evidence. RESUSCITATION FROM DROWNING. Since drowning usually results from asphyxia, with certain alterations in the physical condition of the lungs, the possibility of recovery after submersion is dependent upon two contingencies — the duration of the asphyxia, and the stage which the changes in the lung-tissue have reached. In experiments with dogs in which the trachea is suddenly ob- structed, it is found that the movements of respiration continue for about four minutes, the pulsation of the heart persisting for two to three minutes longer, recovery being possible at any period short of that when the heart ceases to beat. The experiments conducted by a com- mittee of the Royal Medical and Chirurgical Society 1 show that the period within which recovery is possible is very much curtailed if drown- ing is the mode by which asphyxia is produced. Two dogs, one with the trachea plugged and the other not, were submerged for two minutes and then withdrawn from the water; the one in which the trachea was plugged recovered, the other did not. The reason for this difference lies in the condition of the lungs : — When the trachea is plugged neither air nor water can enter them, and consequently on removal of the obstruction, they are in a relatively fit state to resume their function; when the trachea is free water is drawn into the finer bronchi and the alveoli in the attempts at respiration, and consequently the lung-tissue becomes sodden and loses its elasticity. In human beings asphyxia supervenes in from one to two minutes alter submersion, and deat h usually before five to six minutes; 1 Med. Chirurg. Trans., 1SG2. RESUSCITATION FUOM DROWNING. 23] cases of recovery after longer submersion are recorded, but it is probable that in them some condition obtained which prevented water being drawn into the lungs. By practice, possibly aided by some exceptional inherent condition, individuals have acquired the capacity <>i enduring a longer period of submersion than ordinary with- out injurious results: in such eases there is obviously no attempt at breathing whilst under water, so that the question resolves itself into a capacity to postpone the asphyxial limit beyond that which is usual. In the description given of the condition of the lungs in drowning, it was stated that the aspiration of water causes a secretion of mucus in the bronchial tubes which tends to block the finer bronchi. After prolonged submersion, although the heart may continue to beat, and the vital condition (so far as the degree of asphyxia is concerned) is not hopeless, yet this blocking of the finer bronchi may prevent air reaching the alveoli after removal of the body from water; so that attempts at artificial respiration merely churn the mucus and froth to and fro in the air-passages without furthering respiration. It is very encouraging to know, however, that with proper treatment perseveringly carried out recovery not unfrequently occurs after pro- longed submersion, even when the case appeal's hopeless. On one occasion a boatman towed the body of a man ashore, and pronounced life to be extinct. A medical man corroborated this opinion; but two more sanguine bystanders began vigorous treatment, with the result that the apparently drowned man entirely recovered from the effects of the submersion. A good deal depends on prompt treatment ; unfortunately, it often happens that among those present no one has a sufficiently practical acquaintance with the method of carrying on artificial respiration as to put it into execution in an efficient manner. The absence of means of supplying artificial warmth on the spot is another cause of failure ; the success which has attended the estab- lishment in Paris of places of succour for the drowned demonstrates the difference between immediate and delayed treatment. Formerly, submersion for two minutes was considered the limit of the probability of success; at present, prompt treatment, with means of applying warmth in the form of hot baths and blankets always to hand, enlarges the limit to five minutes, at which recovery is stated to be certain. The following remarkable instance of recovery alter prolonged sub- mersion is recorded by Pope 1 : — A man was sailing in a boat when it capsized and he fell into the water with some weights on the top of him, so that with the exception of his left arm he was entirely and continuously submerged for from twelve to fifteen minutes; he was resuscitated with considerable difficulty and eventually recovered. 1 The. Lancet, 1881. 232 FORENSIC MEDICINE. The favourable issue was attributed to the weights pressing on the chest, which, together with concussion, so interfered with respiration, as to prevent any water from entering the lungs. ARTIFICIAL RESPIRATION. Silvester's Method.— After emptying the mouth and throat by turning the patient face downwards for a few seconds place him on his back with the head a little higher than the feet, the head and shoulders being supported on a compactly-folded article of clothing ; remove everything tight about the chest and neck ; draw the tongue forwards and maintain it in that position. Grasp the arms just above the elbows and draw them steadily above the head, keeping them on the stretch for two seconds, then reverse the movement, and press the arms firmly downwards against the sides of the chest for two seconds ; repeat these manoeuvres about fifteen times per minute until natural breathing is initiated, or as long as there is any hope of resuscitation. In the meantime friction and warmth are to be applied to the body. Howard's Method.— Turn the patient face downwards with a firm roll of clothing under the stomach and chest ; press with the whole weight on the patient's back two or three times for about four seconds each time, so as to drain the mouth and the air-passages as much as possible of the accumulated water. Then turn the patient face upwards, so that the roll of clothing is just below the shoulder blades, the head hanging back. Place the patient's hands above his head, kneel across his hips, fix your elbows against your hips, grasp the lower part of the patient's chest, and squeeze the sides together, press- ing gradually forwards with all your weight for about three seconds until your mouth is nearly over that of the patient, and with a push suddenly jerk yourself backwards. Pause for three seconds, and then repeat the process, which should be performed about eight or ten times a minute. It occasionally happens that, although automatic respiration is established, the patient succumbs shortly afterwards, or remains in a moribund condition for several hours, and then dies without having regained consciousness. In other cases, a temporary recovery of a more complete character takes place which may last for twenty-four or more hours, followed by death, apparently from exhaustion. The treatment subsequent to re-establishment of respiration will depend on the symptoms manifested; in some cases venesection may be indi- cated to relieve the heart ■ in others, stimulants and external warmth will be more efficacious. ~^S \; develop for ^>]\\:~ time. Even when the blow is inflicted with a formidable object, such as a horse's hoof, there may be no external marks. Hunter 3 saw a boy who had been fatally kicked in the abdomen by a horse ; there were no ecchymoses nor signs of injury externally, but the jejunum was bruised and ruptured. After sustaining rupture of the bowel the injured person may walk a considerable distance. The liver is frequently ruptured by heavy pressure, such as a wheel transmits from a loaded vehicle; the rotating movement of the wheel favours the absence of signs of external injury, and the liver may thus undergo extensive rupture without the skin of the abdomen being ruffled or discoloured; rupture from a blow or kick may occur without external bruising. Death usually results, and it may do so speedily, from haemorrhage into the abdomen, but in spite of copious internal haamor- 1 Vierteljahrsschr. f. ger. Med., xxx. Wiener allg. med. Zeitung, 1864. - Medical News, 1882. 3 The Lancet, 1885. 276 FORENSIC MEDICINE. rhage, the patient sometimes lives several days ; after slight ruptures recovery may take place. A ruptured liver does not necessarily pre- vent movements being made by the patient after receipt of the injury. Rupture of the diaphragm is not common apart from other and severe injuries to the abdominal viscera. In itself it is not likely to be followed by immediate death, but will probably lead to serious results from protrusion of the stomach or bowels into the thoracic cavity. Laceration of the diaphragm usually occurs in consequence of falls from a height or from compression of the trunk by a cart wheel passing over it ; it is generally met with on the left side. Rupture of the spleen is usually fatal. What has been said about the liver applies equally to the spleen. Extensive rupture of the kidneys is always fatal ; slighter rupture may be recovered from. Much bruising of the organs without rupture is likely to be followed by suppuration, which may cause death at a more or less remote period from the receipt of the injury. Rupture of the bladder is a subject of special importance to the medical jurist, because, unlike some of the previously described in- juries, it may be caused by a blow of the fist or a kick that would be inadequate to reach less accessible organs. It is an accident likely to occur to a drunken man, who, on account of the amount of liquor drank and its benumbing effect on the nerve-centres, often goes about with a full bladder ; in this condition a fall down stairs may be .sufficient to causa rupture. The injury is almost invariably fatal when the intra-peritoneal portion of the bladder is ruptured, and but few recoveries take place when the extravasation of urine is outside the peritoneum. Bartels 1 states that 93 out of 94 cases of intra- peritoneal rupture died, and 26 out of 63 in which the mischief was extra-peritoneal. Extensive rupture of the bladder is not necessarily prohibitive of locomotion, the severity of the injury being in some instances concealed for a time. Bartsch 2 relates a case in which a drunken man fell through a window twelve feet on to hard ground. He was found lying on his side and began to joke, making no com- plaints of being hurt; he was placed in an out-house, where he lay for an hour, when he got up, went into the house and walked upstairs to bed. He arose the following morning, after having slept well, and took a walk of nearly a mile ; he then had a rigor and returned to bed, after which he gi'adually became worse and died sixty-three hours after the fall. On section no external injury was seen, but the peritoneum contained about 52 ounces of urine, and there was a tear in the superior and posterior wall of the bladder, 2J inches in length, which went cleanly through the peritoneal coat. Eight hours elapsed 1 Langenbeck's Archiv., Bd. 22. : Vierteljahrsschrf. ger. Med., 1889. INJURIES OF THE ABDOMEN. -<» before indications of the severity of the lesion manifested themselves ; if, in the meantime, this man had quarrelled with anyone, and had in consequence received a blow, his antagonist might easily have been made responsible for his death. A defence likely to be made in cases of rupture of the bladder from alleged criminal violence is that the organ ruptured spontaneously. Spontaneous rupture -of the bladder is of exce ptional occurrence, even in those cases where a diseased condition of the viscus or of the urethra exists as a causal factor, which is capable of being recog- nised as such after death; the conditions alluded to are ulceration of the bladder-wall and organic str icture of the urethr a. Paralysis of the bladder might also lead to spontaneous rupture ; in such a case, the previous history of the patient would help to explain its occurrence. Much is usually made by the defence as to absence of signs of external injury which, it is urged, proves that the organ ruptured from natural causes. This is fallacious; a full bladder— and the organ is always in this condition when ruptured by a blow which does not fracture the pelvis — is, of all the abdominal organs, the most likely to be ruptured from external violence without there being any outward signs of it. Exceptional as is spontaneous rupture induced by previous patholo- gical changes a still rarer event has been recorded — spontaneous rupture without any explainable cause. M'Ewen l relates the case of a young man, aged nineteen, habituated to excessive indulgence in alcohol, who on one occasion, whilst nearly insensible from this cause, was taken to a common lodging-house and put to bed. He remained in bed all the next day ; on the evening of the following day he was drowsy and stupid and complained of pains in the abdomen; he died on the third day. After death the abdomen, free from external marks of violence, was found to contain a large quantity of straw-coloured fluid, of which the bladder also contained a small amount. At the junction of the upper and middle thirds posteriorly an aperture existed in the bladder which would admit the tip of the little finger. There were no indications of disease nor of ulceration nor gangrene, nor was there any peritonitis ; the urethra was healthy and free from stricture or obstruction — a No. 10 sound found its way into the bladder by its own weight. Brown- records another case of spontaneous rupture of the bladder without the presence of a stricture, the urethra allowing a No. 10 catheter to pass. After death, the posterior part of the bladder was found coated with soft lymph, and about an inch below the reflection of the peritoneum, slightly to the right, was an aperture which admitted the forefinger 1 The Lancet, 1S73. - The Lancet, 1SS6. 278 FORENSIC MEDICINE. with difficulty ; the margins were rough from the presence of recent inflammatory lymph ; there was no evidence of ulceration nor of pre- existing disease. Such cases are of extreme rarity, only one or two being recorded. It is very difficult to understand the mode of their occurrence ; the two alternative conditions usually assumed are paralysis of the bladder of functional origin and persistent spasmodic stricture of the urethra; Incised and lacerated wounds of the abdomen are not in themselves dangerous when the peritoneum and viscera escape injury ; the possible occurrence of peritonitis or of suppuration among the muscles and facia? must be taken into account when forming a prognosis. Punctured wounds are necessarily dangerous if they penetrate the abdominal cavity, both from the chance of protrusion of the viscera through the wound, and, to a still greater extent, from the possibility of the viscera themselves being wounded. Small punctures of the intestines are not necessarily fatal, the danger being proportional to the risk of their contents escaping into the peritoneal cavity ; wounds of the small intestines are more dangerous than those affecting the large intestines. Incised or punctured wounds of the solid viscera are dangerous in proportion to the haemorrhage they occasion. Injuries of the External Genitals. — Injuries to the male organs are not usually dangerous to life, although the bleeding is sometimes considerable. Rupture of the urethra in the perineum leads to extra- vasation of urine into the connective tissue of the pelvis, which may be fatal unless surgical aid is promptly afforded. Injuries to the Female Organs. — Incised or lacerated wounds of the vulva and vagina often give rise to dangerous haemorrhage ; apart from parturition, they usually result from accident. Birkett 1 relates two such cases. A lady going into a dark room to micturate sat down on a water-ewer, the handle of which was broken off leaving a sharp and jagged portion projecting about an inch; this produced a lacerated wound of the vagina, in the course of which the internal pudic artery was divided ; death from haemorrhage took place in about an hour after the infliction of the injury. In another case, a woman was knocked down by a man and died in a short time from haemorrhage ; the blood came from the vagina, in the wall of which w^as a wound extending towards the internal pudic artery. At first it was thought that the woman had been stabbed with a knife, but it turned out that she had fallen on and broken a spittoon, a sharp-pointed fragment of which caused the injury. In cases of criminal assault foreign bodies, such as pieces of stone or wood, are not unfrequently passed into the vagina, which may cause serious 1 Holmes & Hulk, A System of Surgery. FRACTURES OF BONES. 279 bruising and rents of the vaginal walls. Violent sexual intercourse with young girls and sometimes with adult women may rupture the vagina, and occasion profuse and even fatal bleeding. The unimpregnated uterus is not frequently injured unless it shares in a general injury inflicted on the pelvic organs; the gravid oi'gan from its prominent position is much more frequently wounded. Pene- trating wounds of the gravid uterus, whether caused by stabs through the abdominal walls, or by punctures inflicted by passing pointed in- struments up the vagina in the attempt to procure abortion, are dangerous from the possible supervention of haemorrhage, peritonitis, and septicemia. Kicks delivered against the abdomen of a woman advanced in pregnancy may produce miscarriage or, by separation of the placenta, may give rise to serious haemorrhage ; violence of this kind may be followed by localised suppuration in the uterine wall or by the formation of clots in the sinuses, which may cause death from embolism of the pulmonary artery. The walls of the gravid uterus may be ruptured by blows, by pressure of the abdomen against hard projections, and by falls, and the foetus may escape through the rent into the abdominal cavity. Such accidents are usually fatal, though in some cases operative interference, and in others natural processes, have relieved the woman of the displaced foetus, her life being spared. Rupture of the uterus or vagina may take place during parturition, either in the course of natural labour, or during the performance of version or of extraction with the forceps. The medico-legal questions that arise relate to the reasonable amount of skill brought to bear in the treatment of the case : — On the one hand, was artificial delivery performed with a reasonable amount of care and skill; and on the other — the uterus rupturing in the course of natural labour — ought artificial assistance to have been resorted to? Such questions are usually referred to obstetrical experts. FRACTURES OP BONES. Simple fractures are not dangerous to life except in certain regions, as the skull and spinal column; from the medico-legal standpoint, the question is rather one of '-grievous bodily injury.'' The defence usually urged in criminal cases is either that the fracture resulted from accident or, if acknowledged to have been directly cause,',, that the injured bone was predisposed to fracture in consequence of d or of some inherent abnormal condition. Apart from diseases affecting the bones which, from their nature, are sufficiently obvious, such as cancerous and sarcomatous growths, rickets, and mollities ossium, there are other general diseases and -sh 280 FORENSIC MEDICINE. conditions which tend to render the bones more fragile than ordinary. It is well known that trophic changes occur in the course of certain diseases of the nervous system ; amongst the structures liable to parti- cipate in these changes are the bones. Chemical analysis shows that the proportion of organic to inorganic matter is inverted as compared with healthy bone ; the inorganic matter from diminution of the phosphates, is reduced to less than half, and the organic matter, in consequence of a large excess of fat, is doubled. When these alterations in the composition of the bones are far advanced, spontaneous fracture of the long bones is not uncommon ; when not so far advanced, a much less violent blow will fracture a limb than would do so in health. The diseases of the central nervous system, with which these trophic changes in the bones are chiefly associated, are locomotor ataxy and some forms of mental disease, especially general paralysis. In some cases trophic changes in the bones appear to take place without the presence of any recognisable disease. Greenwood 1 states that a policeman taking part in a contest of throwing a cricket ball at some sports felt his arm snap in the act of throwing ; on examin- ation complete fracture of the humerus was found to have taken place at the lower third. The bones become brittle in old age from excess of inorganic constituents, and in young children they are liable to " green-stick " fracture from the converse condition. Ribs are Occasion- ed ally fractured by coughing or sneezing. A curious case of apparently delayed completion of a fracture of the rib is related by Skyrme. 2 A man in getting out of an omnibus swung round and struck his right side against a projection; he felt some pain and tenderness, but went about as usual. Six days after, whilst sneezing, he felt something snap in his side, which was followed by severe pain, greatly increased by deep respiration ; the tenth rib was found to be fractured at the junction of the bony and cartilaginous portions. The medical witness may be called upon to state his opinion as to whether certain injuries to bones were the result of direct violence or not. A drunken man after quarrelling with another man is found to have sustained fracture of several ribs and dies from pneumonia ; his adversary is accused of having caused the injuries by blows, but denies that he struck the deceased, stating that he simply pushed him away, and that in his drunken condition he fell helplessly to the ground. Such a question is to be decided on general grounds ; the amount and character of external bruising, the position of the fracture, the number of ribs broken, whether fracture has occurred on both sides of the chest, together with other indications of violence more 1 Brit. Med. Journ,, 1SC0. 2 Ibid., 1891. FRACTURES OF BOXES. 281 than can be accounted for by the simple act of pushing a man away. A similar question arises from time to time in regard to asylums and prisons ; an attendant or a warder is accused of having caused the death of an inmate or a prisoner by violence. The defence usually is that the injuries (often fracture of the ribs) were caused by a fall, or, in the case of a prisoner recently taken into custody, that they existed at the time of his arrest. With regard to the latter point it is possible for a man to go about with fractured rib or ribs without knowing that he has received any such injury. In the case of the insane the possibility of trophic changes in the bones must be borne in mind. The length of time the fracture has existed^ may be of importance as regards determining the question of criminal violence or of accident ; if it is clear that the fracture existed before the alleged violence was inflicted, the fact is, of course, greatly in favour of the accused. The processes which occur in the repair of fractured bones are well known, but their time-values are not capable of exact estimation. Apart from physiological variations, the age and the state of health of the injured person materially influence the rate of repair ; the degree of injury sustained by the fractured ends and the closeness or other- wise of their apposition have also to be taken into consideration. Within the first week after the occurrence of the fracture there will probably be nothing to be seen on post-mortem examination beyond effused blood, with more or less tearing or bruising of the contiguous soft structures ; shortly after, indications of repair begin to manifest themselves. In simple fractures in which the ends of the bone have been kept in apposition from the first, but little, if any, " provisional callus " is thrown out ; it is mostly found in fractures of the ribs or of the clavicle — that is, in bones in which absolute rest cannot be attained. After fourteen or sixteen days, the blood at first extrava- sated will have disappeared or nearly so ; the periosteum at the fractured ends will be very vascular, and beneath it and between the ends of the bone will be a number of cells proliferated from the osteo- blasts amongst which calcification will be in progress. Under the most favourable conditions complete ossification does not take place, as a rule, in less than two months. Evidence of previous fracture is usually not difficult to obtain when the examination is made after death. If on external ex- amination the bone does not yield sufficiently clear indications, a longitudinal section of it will clear up all doubts. In the living an old fracture may easily escape detection. If immediately after receipt of the injury perfect approximation of the broken ends of the bone was secured and maintained until complete ossification took 282 FORENSIC MEDICINE. place, especially if the part is deeply surrounded with soft structures, it will be quite impossible to recognise a remote fracture ; if the fracture is recent it will be easier of recognition. In exposed situations, such as the front of the tibia, the difficulty is lessened. The distinction between fractures produced in the living and in the dead subject is well-marked, unless the fracture is produced imme- diately after death : if it takes place six or eight hours after death, there will be no blood effused round the ends of the bone, unless a large vein has been divided, and, even then, the appearance will be distinct from that caused by extravasation from a number of vessels during life. A fracture caused immediately after death — within a few minutes — may present an appearance indistinguishable from one in- flicted during life. WOUNDS PRODUCED BY FIREARMS. "Wounds produced by firearms differ in appearance in accordance with the size and kind of projectile, the velocity with which it is endowed at the moment it impinges, the distance of the firearm from the body, and the angle at which it is presented. Large bullets, other conditions being equal, produce more extensive wounds than those of lesser size. The old-fashioned spherical bullet is more apt to be deflected in its course than the modern cylindrical bullet with conical front ; the wedge-like properties and higher velocity of the latter missile enable it to make its way through obstacles which would turn a spherical bullet to one side. A conoidal bullet endowed with high velocity causes infinitely greater damage than a spherical bullet, not only because it can penetrate a mass of tissues from side to side that would arrest a spherical bullet half way, but also because its crushing action on the soft tissues and its power < if splintering the bones are vastly greater. When a small conoidal bullet endowed with high velocity passes through some of the soft structures of the body without striking any bone, the difference presented by entrance and exit wounds is not great ; under ordinary circumstances, however, the difference is con- siderable. A larger bullet traversing the body with less velocity pro- duces a much more extensive aperture of exit than of entrance. If the weapon is fired point-blank the entrance-wound will be about the size of the bullet, and will have a more or less circular outline with torn edges which may form angular flaps; the margins will be slightly inverted and ecchymosed, except in parts where there is much sub- cutaneous fat, when they will probably be everted. If death is imme- diate, the surrounding skin may be pallid. The exit-wound will be WOUNDS PRODUCED BY FIREARMS. 283 less regular in outline and larger, with everted e dges showing the sub- cutaneous fat. I f the w e apon is presented .ut an oblique angle to the body the entrance-wound will not present a circular outline ; it will be more elliptical, the skin being ploughed up to one side. A bullet projected from a distance, if not too far spent to penetrate, will cause a larger and more lacerated entrance - wound than if it arrived with greater velocity. Only a limited value can be assigned to this as an indication of the distance from the body at which the weapon was fired; much depends on the kind <»f weapon, and on the amount and the kinetic energy of the explosive used. When a firearm is discharged into the body at a distance of a few inches only, the entrance -wound, in addition to the appearances already described, will be blackened and, possibly, scorched. The wound is diffusely blackened from the smoke of the explosion, and it is also tattooed by undeflagrated grains of powder being driven into it. The flame from the mouth of the firearm may not only scorch the skin, it may also set fire to the clothing in proximity of the wound. If the muzzle of the firearm is in actual contact with the surface of the body, the entrance-wound will be freely lacerated and ecchymosed in addition to being burnt. If a gun loaded with small shot is fired into the body when close to it, a somewhat circular aperture, larger than a bullet wound and rather more irregular and contused at the edges, will be produced. There is nothing definite about the exit-wound, be- cause the whole of the original charge scarcely ever leaves the body ; if it does, the exit-wound will be larger and still more lacerated than that caused by a bullet, and will, of course, be proportionally larger than its own entrance-wound. Usually the pellets are severally deflected within the body, and do not traverse it en masse ; the conse- quence . being that the exit- wound may be less than the entrance- wound ; very often there is no exit-wound at all. If a gun loaded with shot is fired at the body from a short distance, the surface will be more or less peppered by the pellets, with possibly the production of an irregular wound caused by some which have not spread so widely; at a greater distance, there will be isolated pellet wounds only. It is impossible to assign with accuracy the respective distances at which these various results are produced. Some guns carry much closer than others ; the quality of the powder also exercises a considerable influence, and probably the manner of loading. "When both entrance- and exit-wounds are present, a line drawn between them and prolonged on the side of the entrance- wound will enable some idea to be formed as to the situation of the weapon when fired. The information thus obtained is less reliable if the wound 284 FORENSIC MEDICINE. has been produced by a spherical bullet than with a conoidal projectile, because of the greater liability of the former to de- flection. When the position of the deceased at the moment the weapon was fired is known, or can be inferred, the spot from whence it was fired may be approximately ascertained. A man has been shot dead when writing at a table on to which the upper part of the body fell forwards ; in such a case it is not difficult to allot the position from whence the weapon was fired. If the projectile has traversed the body the entrance- and exit-wounds must be differ- entiated. When there is but one wound, the course taken by the projectile within the body may afford a clue as to the relative position of the firearm and the deceased, possible deflection of the bullet being taken into account. Serious wounds may be produced by firearms charged with powder only, especially if the substance used as wadding is of a dense nature. If the wadding penetrates the skin it proves that the weapon was discharged within a few feet of the body. When the bullet remains within the body it is not to be assumed that it was fired from a distance, its momentum being partly spent. A rifle bullet under ordinary conditions would traverse any part of the body if discharged into it at short range ; but it is not so with all revolvers. A long-barrelled rifled-revolver would probably send a bullet through the body if fired at short range ; but small pocket revolvers for the most part leave the projectile within the body ; when such a weapon is fired at the head, in close proximity to it, the bullet remains within the cranium or is embedded in some part of the skull. In estimating the risk to life from wounds produced by firearms it is to be remembered that after the immediate results of the injury are recovered from, secondary haemorrhage and a variety of inflam- matory processes of a kind dangerous to life may set in. Is has been asserted that recognition of an assailant in the dark by the light given off from a firearm discharged near to the person assaulted is not possible. Much depends on the relative position of the parties ; i f the assailant is well within the field of vision of the person at whom he fires, recognition is quite possible; if at the extreme limit, it is doubtful. WOUNDS IN THEIR CAUSAL RELATION. The duty of the medical witness does not end when he has arrived at a conclusion as to the mode of death. In many cases when a dead body is found without any history — death being due to wounding — THE POSITION OF THE WOUND. 285 the question is asked, were the wounds caused by accidental, homicidal, or suicidal violence ? This important and, in some instances, formidable question — for- midable on account of the obscurity of the indications from which an answer is to be obtained — involves the methodical consideration of a number of criteria which universal experience has formulated as aids to diagnosis, and, what is of no less moment, a keen observation of the smallest details which are special to each case. A wound has to be considered in relation to its position, its nature — whether incised, contused, &c. — its direction, and its extent. If the body is examined in the position, and at the place in which it was found, circumstances of external relation are to be taken into account — as footmarks, blood-stains, indications of a struggle having taken place, the presence of a weapon in the hand or near the body of the deceased, a change in the position of the body after death, with other matters that present themselves to an observant eye. A minute investigation embracing every perceptible detail should be made — note-book in hand— before anything is disturbed ; if this precaution is not taken, the unravelling of some important particular may be enhanced in difficulty or even rendered altogether impossible. THE POSITION OF THE WOUND. Almost any part of the body may be wounded by a second person ; certain parts are inaccessible to the suicide, and certain others are preferentially selected by him. These axioms, for the most part, hold good, but they are not without exceptions. The front and more exposed parts of the body are usually selected by the suicide; the throat and chest for incised wounds and stabs ; and the temples, mouth, and cardiac region, when firearms are resorted to. The position of suicidal wounds varies in relative frequency in different countries ; in Great Britain, one of the commonest modes of committing suicide is by an incised wound of the throat; on the continent, cut-throats, in com- parison with other suicidal wounds, are not nearly so numerous. Stal s in the throat are suspicious of homicide, but instances are not wanting in which suicides have inflicted upon themselves wounds of this description. Incised wounds of the throat, apart from any other injuries, point to either suicide or homicide, and away from accident. Stabs in the back are more likely to be homicidal than suicidal, but, with the exception of the area covered by the scapula? and the space between them, a man might stab himself in the back were he so disposed. The ordinary suicide selects an ordinary position on which he inflicts wounds for the purpose of putting an end to his life ; 286 FORENSIC MEDICINE. with lunatics the case is different ; they are just as likely to put an end to themselves in some unheard of way, as they are to adopt one of the more usual methods. Little 1 reports the case of a woman, aged thirty-six, recently discharged from an asylum, who, with a bluni table knife, made a wound in the back of her neck which half severed the head from the trunk ; all the tissues were divided as far as the spinal canal, which was opened, the cord just escaping injury ; she died on the sixth day after inflicting the wound. In another case, 2 a man was found standing with a large gash in his abdomen, from which he was pulling out his intestines ; a coil of the ileum, almost severed, was outside the abdomen ; he lived a few hours. It is interesting to note that a well-marked intussusception of the ileum of several days' standing was present. Contused wounds on the head, when not due to accident, are indica- tive of homicide, but an insane person may inflict such wounds on himself. Smith 3 relates the case of a man wdio placed himself before a looking-glass, and struck repeated blows on the top of his head with a hammer weighing nearly 3 pounds. An area 3 inches in diameter was divested of scalp, and a fracture of the skull 2 inches in diameter, depressed f inch, was produced, the bones being splintered around. Staples 4 gives an extraordinary instance of self-inflicted injuries to the head which came under his notice, and sup- plements it with thirteen others by various observers. A man drove into his head two stone-chisels, each 8+ inches loner, and I inch in diameter, using for the purj)ose a wooden mallet weighing 2| pounds. One of the chisels was driven through the head from right to left, entering in the right temporal region, and emerging on the left nearly in a direct line, the point projecting 1| inch, the head of the chisel being close down to the scalp. The other chisel was driven into the centre of the forehead, penetrating at least \ inch into the frontal lobe. After inflicting the injuries, the man, with the chisels in his head, approached a glazed door, through which he was seen by two persons ; he stooped and tried to unlock the door, but did not succeed in doing so. When the door was broken open, he walked a distance of 40 feet with but little aid, and was able to talk. The chisels were withdrawn with considerable difficulty, and he died about five hours afterwards. There is much to be learnt from these cases as regards the immediate effects of severe injuries to the head. In both, repeated blows were struck without producing unconsciousness, and in the second case the patient was not only conscious, but he could talk and walk in spite of the desperate nature of the injuries inflicted 1 The Lancet, 18S9. - London Med. Recorder, 1S90. 3 Med. Times and Gaz., 1878. 4 Joum. Am. Med. Assoc, 1SS7. THE KATUBE OF THE WOUND. 287 ,on the brain. Such instances are to be remembered by the medical witness when asked as to the possibility of similar wounds being- self-inflicted, and also as to the possibility of individuals retaining consciousness and power of Locomotion and speech after the receipt of severe injuries to tin- bond, whether self-inflicted or not. Suicidal wounds from blows on the head are usually inflicted within a limited area and have more or less the same direction. They are generally on the top or front of the head, being the parts most accessible. The presence of other wounds on the body may be significant — Are they all compatible with suicidal causa- tion, or do they rather resemble homicidal wounds ? Indications of resistance, especially on the hands and arms, should be looked for. Homicidal head-wounds are often on or towards the occiput, the victim 1 .ring attacked from behind. If the victim is not rendered insensible by the first blow, he will involuntarily put up his hands to protect his head, and, consequently, the backs of the fingers will probably be bruised. Accidental wounds on the head are usually on the vertex when produced by falling head downwards, and partake of the nature of an injury caused by a single blow, which, however, if the body falls from a great height, may be of sufficient force as to smash the vault of the cranium into fragments. Accidental wounds resulting from stones and like objects being projected through the air and striking the head may, of course, be found on any part of it. Wounds of the male genital organs, if not accidental, are for the most part suicidal. Ablation of the penis or of the testicles, or even of both, scrotum included, is not an uncommon act on the part of men labouring under sexual monomania, or under some form of insanity which is dominated by the idea that the sexual organs or functions are the cause of their misery. Occasionally, wounds of the male genital organs are criminally inflicted out of revenge. Wounds of the female external genitals are chiefly accidental, or are due to criminal violence. Incised or punctured wounds of the limbs may result from criminal violence or from accident ; in the former case, they are not unfre- quently brought about by attempts at self-protection. Occasionally, suicides make incisions into the arms and legs, with the object of dividing blood-vessels so as to cause death from haemorrhage. THE NATURE OF THE WOUND. Contused wounds are usually either accidental or homicidal; they are rarely of suicidal origin. Incised and punctured wounds maybe homicidal, suicidal, or accidental, the probability in each case being 288 FORENSIC MEDICINE. governed by their position and extent. So far as position goes, the same may be said of wounds produced by firearms. Unusual methods of causing death sometimes betray their homicidal or suicidal origin : and at others, in the absence of circumstantial evidence, or of that of an eye witness, they leave the matter in doubt. Of the former class are those exceptional cases in which a man pre- pares an elaborate apparatus for self-destruction. For example, a man •constructed a guillotine in such a way, that a suspended axe-blade was liberated after a certain amount of water had run out of a can, in the bottom of which was a hole — the loss of weight caused by the water flowing from the can eventually released a detent by which the axe- blade was held up. An open cavity was prepared, in which a large quantity of ether was exposed immediately under the nose of the suicide. The axe fell in due time and decapitated the constructor of the machine, probably after he had been narcotised, or, possibly, was dead from inhalation of the ether vapour. 1 In a case reported by Leadman, 2 a man committed suicide by placing a dynamite cartridge in his mouth, lighting the fuse and then waiting the explosion. The soft palate and tongue were torn and mutilated, the teeth broken off, the superior maxillary bones separated and fractured, and the inferior maxilla was broken into about twenty pieces. Notwithstanding all this, the skin of the lips and cheeks was intact ; the man lived two hours. Other similar cases have occurred. Such a mode of death could only result from suicide or accident, and much more probably the former. As an instance of death caused in an unusual way, which would give rise to suspicion of homicide in the absence of eye-witnesses, the following, recorded by Stephens, 3 is a striking example : — A man suffering from melancholia (who not long before had been discharged from an asylum), whilst at work forging nails, was seen with a red-hot iron rod, about two feet in length, the cool end of which was against the wall, and the heated end against his belly. One of his fellow work- men gave him a push and made him drop the iron ; he said that he should be all right if he was allowed to go on with his work, and he was permitted to do so. Not long after he made the iron white-hot, and succeeded in thrusting it four or five inches into the abdomen ; he died on the following day. THE DIRECTION AND EXTENT OF THE WOUND. Most men and women are right-handed, and, consequently, incised and punctured wounds suicidally inflicted, usually take more or less a 1 Boston Med. and Surg. Journ., 1SS0. "Brit. Med. Journ., 1881. 3 Bristol Med. Chir. Journ., 1888. THE DIRECTION AND EXTENT OF THE WOUND. 289 definite direction, due to the weapon being wielded with the right hand. Apart from exceptions which obviously occur in the case of left-handed persons, the indications afforded by the direction of a wound are not to he regarded as absolutely distinctive. II is quite true that the direction of a wound often enables a correct opinion to be formed as to its suicidal or homicidal origin, but should the direction not agree with that which is held to be characteristic of suicidal wounds, suicide is not, therefore, to he excluded from con- sideration, unless the position and direction are such as to make it impossible for the wound to have been self-inflicted. Experience teaches the necessity of great caution in applying general rules to special cases ; in all doubtful cases allowance must be made for exceptional occurrences. Incised wounds of the throat self-inflicted by rightdianded persons usually run from left to right in an oblique direction, the beginning of the cut being at a higher level than its termination. In producing them the blade of the razor or knife is applied to the left side of the throat ab ove the thyroid cartilage an d is drawn obliquely downwards across to the right. Such is the rule, but it has its ex- ceptions. In a case recorded by Mackenzie, 1 a man cut his throat with a razor ; the wound was on the right side of the throat, and extended from about the angle of the jaw to nearly the middle line of the neck on a level with the hyoid bone, the direction being from l'ight to left. At its commencement the incision was clean, at its termination it was hacked and irregular. The patient was right- handed, and afterwards explained that he held the razor (which was blunt) in the right hand, and cut from behind forwards. Suicidal cut-throat wounds are sometimes made below the thyroid cartilage ; such wounds are usually short in length and horizontal in direction, occupying the middle of the throat, between the sterno- mastoids, which frequently escape injury. At other times a clean sweep is made through the whole of the soft structures of the anterior segment of the neck. In suicidal cut-throat wounds the skin is usually the last structure divided — the wound gradually becoming shallower as it reaches its termination. In homicidal wounds of the throat the end of the wound is often under cut — the skin not being divided as far as the underlying tissues are. Two. statements are frequently accepted in relation to extensive wounds of the throat. One is, that after the carotid artery or jugular vein is wounded the person so injured is at once deprived of the power of movement and dies immediately ; the other is, that in the case of suicides the incision is never deep enough to implicate the bodies of the vertebrae. 1 Brit. Med. Journ., 1887. 19 290 FORENSIC MEDICINE. Both these statements are shown to be incorrect by a case which happened in the Salford Royal Hospital in 1883. A man was admitted for fractured femur and was placed in the hoist for the purpose of being transferred to the ward. A nurse in an upper story, who happened to look down into the hoist as it ascended, saw the man take a pucket-knife out of his pocket and apply the blade to his throat. She gave the alarm, the hoist was stopped and a house- surgeon and a porter seized the man to prevent him doing himself further mischief. He had made a large wound, and, notwithstanding all efforts to restrain him, he succeeded in getting his fingers into it and tearing it further open ; he died in a few minutes. I examined the body immediately after death, and found the right carotid artery and jugular vein divided and the body of one of the vertebra? distinctly notched by the blade of the knife. The fractured femur for which the patient was admitted was due to a fall from a height, which, at the time, was supposed to be accidental ; it really resulted from an attempt at suicide, and having failed the man took the earliest oppor- tunity of effecting his purpose in another way. It is not unlikely that the cries of the nurse increased his desperation and thus caused him to use unwonted force ; hence the injury to the vertebra. The extent of the injuries that a suicide may inflict on his throat is exemplified by another case which was admitted into the Salford Royal Hospital, reported by Lord. 1 A man, fifty-eight years old, was brought to the accident room with a large open wound in the throat ; he died five minutes after admission, having survived the injury rather more than an hour. Shortly after, his son appeared with something in his hand which he said his father had cut out of his own throat ; this turned out to be the entire larynx — the thyroid and cricoid cartilages, together with the first and part of the second ring of the trachea. The whole had been cleanly excised without injuring the large vessels of the neck. Harrison 2 relates a similar case of a woman, aged forty-one, who excised her own larynx, cricoid cartilage, and five rings of the trachea without wounding the carotids ; death quickly followed. An instance of survival for a time from numerous and severe self-inflicted injuries to the neck and chest is afforded by a case admitted into Middlesex Hospital under Hulke. 3 A man committed suicide by attempting to cut off his head from behind with a shoemaker's knife ; as this failed he stabbed himself repeatedly in the chest and finally cut his throat. Crossing the nape of the neck were three deep, jagged, incised wounds. A jagged incised wound crossed the front of the throat from the posterior border of the left J Trans. Path. Soc. Manchester, 1892. 2 Brit. Med. Journ., 1S83. 3 The Lancet, 1SS9. THE DIRECTION AND EXTENT OF THE WOUND. 291 sterno-mastoid to the middle of the right sterno-mastoid, severing the depressors of the hyoid bone and cutting out a portion of the thyroid cartilage. On the front of the left side of the chest were four stabs, two of which penetrated the pleural sacs. The man survived a week. Homicidal incised wounds of the throat, when inflicted by a right- handed man facing his victim, are from right to left, and are usually more horizontal than suicidal throat-wounds. If the assailant stands behind the victim the wound may closely resemble one of suicidal origin, the position and movement of the hand and arm being very like that of a person who inflicts a wound on his own throat. In such a case the incision will be from left to right, and will probably sever the whole of the soft structures down to the vertebra?, one of I which may be nicked. Very deep and extensive division of the soft structures in front of the throat, especially when associated with nicking of a vertebra, is regarded as indicative of homicide. The indication, for the most part, holds good ; but, as already stated, a like condition may exceptionally be met with in suicidal cut-throats. Suicidal stabs of the chest are usually on the left side in the case of right-handed men, and they take a downward and inward direction. I If there is more than one such wound, all will generally be found within a circumscribed area. Multiple stab wounds of the chest of homicidal causation are usually distributed over a wider area, and are more horizontal in direction. They may be from below upwards, which is rarely the case in suicidal stabs. The occurrence of several stab- wounds on the front of the chest, more than one of which may be sufficient to cause speedy death, does not necessarily contra-indicate suicide. An instructive case of this kind is related by Newnham. 1 A man was found dead with the right hand clenched tightly and a small knife lying in front of him on the floor. On the front of the chest, one inch to the inner side of, and three-quarters of an inch above, the left nipple, were five small wounds transverse in direction, each about three-quarters of an inch long by a quarter of an inch wide. Just to the inner side of the nipple was another wound half an inch in length ; about one inch below the nipple was a small wound about half an inch in length. The direction of the six wounds first named was downwards and slightly inwards ; all corresponded externally to the third intercostal space, and they penetrated the thoracic wall in the fourth interspace. On the left side of the pericardium was a transverse wound one inch in length. The left ventricle was penetrated by two transverse wounds each three-quarters of an inch long, and the heart was wounded in three other places. All the wounds were of suicidal origin. The multiplicity of wounds in this case might be regarded as l Brit. Med.Juurn., 1SSS. "292 FORENSIC MEDICINE. indicative of homicide, but against this view is the extremely limited area they occupied; more than one plunge of the blade, which pro- duced a separate external wound, coincided so closely in direction as to make but one large opening in the pericardium, and the two pene- trating wounds of the ventricle were only separated by a narrow tongue of the ventricular wall. It would be extremely improbable that a number of wounds homicidally inflicted could be planted so closely together ; the struggles of the victim to escape would present a fresh part of the chest wall to the knife each time it fell. The fact thai the right hand was tightly clenched, the knife being found on the floor, might, in a doubtful case, have given rise to suspicion. When the weapon that has caused the wounds is found tightly grasped in the hand which corresponds with the position and direction of the wounds, the presumption of suicide is strongly corroborated ; if it lies loosely in the hand so that it can be lifted away without difficulty, no reliable inference can be drawn ; the case may either have been one of suicide, or a second person after inflicting the wounds may have placed the weapon where it was found in order to simulate suicide. Penetrating wounds of the back are very suggestive of homicide ; in exceptional instances they may be due to accident, as when a man falls backwards on a pointed object. As a means of determining between suicide and homicide when death has resulted from wounds inflicted by cutting instruments, considerable importance is attached to the presence of cuts on the hands and fingers ; they are regarded as indications of resistance to homicidal violence, but, exceptionally, they may be met with in suicides. In a case reported by Alexander, 1 an officer was found with two deep incised wounds on the front of the abdomen, and one on the back near the spine. There were twenty-six wounds about the left breast, some penetrating the thorax. Both hands were dreadfully muti- lated. A sword covered with blood and bent to an angle of 45° was lying beside the patient, who survived several hours, and explained that he had tried to transfix himself by placing the hilt of the sword against the wall and then pressing forward on the point of the blade. On failing he tried a second time, when the blade penetrated the abdomen and impinged on the spine ; he withdrew it with great difficulty, his hands being cut in the act of pulling it out. He subsequently attempted to penetrate the heart. A somewhat similar case was admitted into University College Hospital under Beck.- A man placed the point of a sword-stick against the chest, just below and to the outer side of the left nipple, and drove it in by running against a wall. The blade penetrated eleven and a half inches backwards, i The Lancet, 1885. " The Lancet, 18S2. GENERAL CAUSAL INDICATIONS. 293 slightly downwards and to the right; it was firmly fixed, and was removed with difficulty, having probably pierced one of the vertebra? ; at the point of entry one of the ribs was fractured. The man was living when admitted into hospital. Maschka 1 relates a case which furnishes an extreme example of the excess of violence not unfrequently resorted to by lunatics in the suicidal act. A man, aged fifty-one, after being in asylum for two months, had so far recovered as to be entrusted with a knife for the purpose of cutting an apple. He was afterwards found bleeding profusely from no less than 285 punctured wounds, of which 200 were on the left half of the chest, 50 on the inner side of the left forearm,, and 28 on the inner side of the right forearm. The left radial and ulnar arteries were divided. Six of the chest-wounds penetrated the thorax, the left lung being compressed by blood collected in the pleural sac. The man survived nearly twenty-four hours, eventually dying from haemorrhage. GENERAL CAUSAL INDICATIONS. Amongst the indications by which an opinion may be formed, or strengthened, as to whether death was due to accident, homicide, or suicide, are : — the position of the body when found, the presence on it of bruises or blood-stains, the state of the clothing and surroundings, the presence of a weapon, its position in relation to the body, and, in the case of a weapon other than a firearm, marks of blood on it. The position of the body itself may afford a clue to the way in which the wound was caused, especially w^hen considered in relation to the surroundings. When called upon to investigate a suspicious case, careful scrutiny should be made for foot-marks on the floor of the room in which the body is found, and also in the adjoining corridors ; any passing to and fro should not be permitted until a thorough investigation has been made. If blood has flowed on to the floor, it is probable, in the case of homicide, that the murderer will have trod in it and will have produced marks indicative of his subsequent movements. To avoid error the soles of the feet of the deceased should be examined, as a person after fatally wounding himself and soiling the floor with blood might tread in it and then walk about and thus make suspicious footprints. If he has done so, signs of the original haemorrhage will probably accompany the footprints, as blood will continue to flow from the wounded parts whilst the individual perambulates the chamber. When a murderous outrage has been conducted with great deliberation, the murderer or murderers have 1 Prag, mcd Wochenshr., 1S8S. 294 FORENSIC MEDICINE. been known to remain in the house a considerable time after the death of the victim, and to leave distinct imprints in masses of coagulated blood ; these along with other foot-marks should be measured, and, if possible, sketched or traced. Marks produced by blood-stained fingers on clothing, furniture, or walls are to be minutely examined. If the impression left by a finger is sufficiently clear as to show the course of the papillary ridges, the sxibstance on which it exists should be carefully detached and preserved for com- parison and reference. In this relation Galton's l method may be of service as an aid to identification : — The same finger of a suspected person should be pressed and slightly rolled on a slab freshly covered with a thin layer of printer's ink, and afterwards on white paper. Galton states that the papillary ridges on the inner surface of the hands afford twenty-five to thirty distinct points of reference, every one, with the rarest exceptions, being absolutely permanent and persisting throughout life. Marks on the dead body or clothing caused by blood-stained fingers, should be examined with reference to position : a mark on the right side of the body, pi-oduced by the fingers and thumb of the left hand, would be a suspicious indication. Finger-stains may exist on parts of the body where they could scarcely be self-produced; as, for instance, between the shoulders. The appearance of blood-spurts on clothing or on furniture has been previously described. Bruises on the body of the deceased may be of great significance ; they should be especially sought for on the throat, chest, and arms. Notice should be taken of the presence of marks or indents produced by the finger nails ; they may be so well imprinted as to suggest that the assailant had exceptionally long nails and this may serve as a clue. Too much should not be made of slight ill-defined bruises which may have existed sometime before the fatal injury was inflicted. A disordered state of the clothing is suspicious of homicide, but it may be due to frantic movements on the part of a suicide. If the body is in bed, clad in night attire, disarrangement of the clothing is very easily produced, and would only be of significance if . sufficient^ marked as to suggest that a struggle had taken place. On the other hand, if the bedclothes are exceptionally straight, they may have been re-adjusted by the murderer to obliterate previous disorder; in this case, the straightening will probably be overdone. Lunatics, before committing suicide, have been known to throw all the furniture in the room into disorder, giving rise to the appearance of a struggle having taken place ; the fury of the insane person may be so maniacal as to cause him to completely wreck the contents of the room, before 1 Proc. of the Royal Society, 1S91. GENERAL CAUSAL INDICATIONS. 295 putting an end to his life. Excess of damage to furniture, with probably the presence of a single fatal wound on the victim, would be sufficient to clear up the case ; a lesser degree of disorder would be more suspicious, but when a madman begins he usually makes a full end. Stabs or other similar wounds inflicted through the clothing should be carefully inspected, and the wounds on the body compared with the I cuts through the clothing before the latter is taken off. This is [ especially necessary when the body is fully clothed. A tightly-gripped knife in the hand of the deceased has already been pointed out as an indication of suicide ; more frequently it is found lying near the body. When an investigation takes place on the spot, the position of a weapon in relation to the body should be noted before anything is disturbed. In exceptional eases of suicide the knife or razor with the blade closed has been found by the side of the body ; in one instance the razor was found in the pocket of the deceased. Such an unusual disposal of the weapon probably resulted from persistence of an habitual action which customarily follows the use of a pocket-Imife— the folding blade of the razor suo'o-esting the act. When death has been caused by stabs or incised wounds, the absence of a knife or other likely weapon is suggestive of homicide. Sometimes wounds are homicidally inflicted with one weapon and another is left near the body in order to suggest suicide. The implement left is almost always one belonging to the deceased, and it has happened that the only available one was much too small to have produced the injuries found on the body ; for instance a clean sweep of all the soft structures of the neck down to the vertebrae, such as might be made with a carving-knife, could not well be made with a small-bladed penknife. The amount of blood found on the weapon varies ; it may be slight, even when no attempt has been made to remove all trace by wiping or washing it. A long-bladed knife rapidly plunged in and withdrawn may show slight indications of blood, although a large vessel may have been divided. This is partly due to quick withdrawal before the bleeding begins, and partly to the blade being clasped by the skin and thus wiped as it emerges; it is still more likely to be free from blood if the wound is inflicted through the clothing. In such cases the blade presents the appearance of having received a thin coating of red Lacquer, the actual tint produced bein^ yellow rather than red. A short-bladed knife will probably show more blood near to, and on the handle. Directions have been previously given for examining blood-stained instruments. All that it is necessary to say in addition is that before dissolving off the stain, the blade of the 296 FORENSIC MEDICINE. instrument should be scrupulously examined for hairs, !, inches and weighed 74 pounds; two and a half years previously the woman weighed 119 pounds. The brain was healthy, hut there were a few miliary tubercles deposited in the pia mater. The heart was small. The lungs were healthy, except for a small patch of tubercular deposit at the apex of the left lung. The gall-bladder was full of bile. The coats of the stomach were thinned. The intestines were shrivelled and empty. The rectum was hyperaunic for about four inches, the rest of the intestines being pale in colour. There was a total absence of fat with general atrophy of all the organs. The bladder contained about three ounces of urine. Positive medical evidence was given at the trial that death was due to starvation, and the prisoners, who included Staunton's brother and his wife, were convicted and sentenced to death. The medical evidence was subsequently freely criticised, emphatic opinions being expressed that there was no medical proof <>f death from starvation. The line of objection taken was that no proper search had been made for other possible causes of death. The oesophagus was not examined, the urine in the bladder was not tested for sugar, and the adrenals were not examined although there was discoloration of the skin on the face. The absence of thinning of the intestines and the presence of tubercle both in the membranes of the brain and in the lungs was held, on the one hand, to negative death from deprivation of the food, and, on the other, to show the possibility of death from disease. The result was that Rhodes was pardoned and the capital sentences passed on the other three prisoners were commuted. The lesson to be learnt from this case is valuable, and is applicable to all medico-legal investigations : — A medical practitioner should never approach a case with a pre-formed opinion as to its nature ; he should never neglect making a searching examination of all the organs; and he should never ignore pathological indications that do not happen to agree with an opinion that has been formed, but should rather ponder as to their import. The time required for death to result from deprivation of food v aries according to certain conditions. Age exercises a considerable influence; very young children quickly succumb, adults resist better and old people best of all. The better the health and the nutrition of the body at the commencement of the fast, the greater the power of endurance. Drinking water tends to />r<>7ovv an erroneous perc eption or con ception ; unlike the two preceding terms, a delusion necessarily implies disordered intellect. The delusions <>l' the insane are of a personal nature ; in an impersonal way people may labour under delusions without being insane. The perennial sequence of religious 320 FORENSIC MEDICINE. and spiritualistic frauds, for example, is the l'esult of perversion of judgment in a certain type of mind, a type that eagerly embraces unorthodox ideas without question; such people are not necessarily insane, but they are liable to become so. In them the reasoning powers are defective without the perceptions being essentially in- volved ; they see and hear as other people do, but they form erroneous conceptions with regard to what they see and hear, and from them deduce false conclusions. The delusions of an insane person are not grounded on abstract conceptions solely relating to matters outside his entity, they concern himself; if he has delusions about religion, he is convinced that his soul is irretrievably lost, or that he is the Deity incarnate ; if about spiritualism, he imagines that he is ir- resistibly influenced by departed spirits, or is possessed by the Evil One himself. In this way an insane person may be subject to delusions without hallucinations. Some writers use illusion and hallucination as convertible terms, and others use illusion in a different sense to that above defined. The word illusion is unnecessary to the medical witness and need rarely be used. A brief description of some of the recognised forms of insanity is necessary before entering into the medico-legal relations involved. MANIA. This condition is characterised by absence of self-control with more •or less excitement displayed by words and actions. The acute form is divided into (a) acute delirious mania and (l>) ordinary acute mania. There is also a chronic form of mania. (a) Acute delirious mania may develop from ordinary acute mania, or it may begin quite suddenly without premonitory symptoms. It is most common in young persons , especially in those that are of excitable or hysterical temperament. It is sometimes preceded by a period of depression followed by loquaciousness which r apidly passes into a state of acute delirium; if delirious mania develops in this way, it is likely to last longer than when it suddenly bursts forth without antecedent mental disturbance. When the delirium is at its height the patient is violently excited, will attack those who seek to restrain him, will tear his clothes, displaying an utter absence of decency, and will shout and swear or sing until his utterances are absolutely incohei-ent. In this stage there is absence of sleep ; the tongue, from t he first fou l, becomes more and more so, and then dry and brown; sordes are present on the teeth and lips, and the breath is very offensive. The appearance, during the periods of lessened excitement, resembles that produced MANIA. 321 by an attack of enterica, but there is little elevation of temperature. The attack may consist of periods of frenzied excitement with intervals of comparative quiet, and may be accompanied by hallucinations; it may be only of a few hours' or days' duration, or it may last two or three months. During the early stage, if at intervals the patient sleeps for a few hours, the attack may be of short duration, being terminated by a long and profound sleep. The absence of sleep in intractable cases is one of the most marked symptoms; a patient may not sleep for four or five consecutive days and nights. Diagnosis. — It is distinguished from delirium tremens by absence of the half- frightened manner, the tremor, the hallucinations of rats or serpents on the bed, the furtive glances over the shoulders and under the pillows, the constant purposeless picking at the bedclothes, or grasping at imaginary objects — with the retention usually of sufficient intelligence to answer questions — all of which are indicative of that disease. The history of the case will help to distinguish delirious mania from the delirium of a fever or an acute febrile disease. In a fever, or like bodily complaint, there is a period of illness characterised by elevation of temperature, quickened pulse, and other physical dis- turbances before the delirium comes on. The intensity of the delirium is much less than in delirious mania, although in some diseases, as, for •example, in the pneumonia of alcoholic subjects, the delirium is often very violent. From encephalitis the diagnosis cannot give rise to much difficulty ; in this disease there is severe pain in the head, vomiting, rigors, and a tendency to somnolence, which soon passes into coma; the accompanying delirium is less continued and less violent than that of delirious mania. In delirious mania pain in the head is not a frequent symptom, and there is absence of vomiting, rigors, and any tendency to somnolence. Meningitis of the cerebral cortex may give rise to wild delirium, but it is less persistent than that of mania, and it alternates with a state of partial stupor. The pulse is high, 130°; and the temperature also — 103° or more — which is not the case in delirious mania, except in very bad cases. The occurrence of pain in the head, vomiting, and rigors afford further signs of differentiation from acute delirious mania. (b) Ordinary Acute Mania.— This condition, as contrasted with acute delirious mania, presents more the appearance of a purely mental dis- order, there being little or no resemblance to the delirium of bodily disease. Acute mania, unlike delirious mania, is not commonly limited t o the y oung. It may begin suddenly, but usually is preceded by a chain of symptoms leading up to it, such as exalted emotional or intellectual disturbance; more frequently the initial stage is one of depression. The patient suffers from what is supposed to be dyspep sia ; he has a 21 322 FORENSIC MEDICINE. sinking sensation in the region of the stomach with an indefinite dread of something about to happen. He is sleepless and feels a sense of confusion in the head, is fidgety, restless, and irritable, and is unable to apply himself to regular occupation. His tongue is coated and his breath offensive. His appetite fails and he loses flesh ; this stage may continue for weeks or months. Then comes a change; he suddenly feels that he has emerged from under a cloud, he becomes lively — boisterously so — and says that he is once more himself. He is effusive and loquacious, which his friends at first attribute to a natural feeling of joy at recovery from his previous condition, but the loquacity soon passes into incoherence and the elaj rageous behaviour. He is subject to hallucinations and to delusions, usually of an exalted kind. Appetite and sleep are fitful, and the bowels are constipated. The mind at this stage is as unstable as a fallen leaf on a windy day; it passes from subject to subject with phenomenal rapidity, the succession being apparently devoid of coherence. Not unfrequently a certain sequential order may be recognised in the words or phrases uttered, which depends either on association of past experiences or of the words pronounced ; usually it is of a mixed type, a word now calling up a past experience, and now suggesting another word of similar sound or meaning. He is abusive and uses foul language; he destroys all within his reach and tears his clothes to shreds without any regard for decency ; he is exceedingly filthy as to his person and openly indulges in indecent actions without shame. This state may continue for three or four months with partial remissions at intervals. Sleep is irregular; a maniac will pass several consecutive sleepless days and nights, will then sleep for several hours, and recommence his previous behaviour on awakening. The tongue loses some of its coating and the appetite often becomes voracious, notwithstanding which the patient grows thinner. Power of endurance is the most extraordinary feature in cases of mania; the continuous violent movements, shouting and singing that are kept up night and day surpass anything of the kind that can be accomplished by a sane person. Acute mania may end in recovery ; _or it may pass into the chronic form, from which recovery rarely takes place, although there may be periods of remission. Chronic mania is more or less associated with dementia into which state the patient may lapse, or he may do so directly from the acute stage. In other cases, mania is succeeded by melancholia. MELANCHOLIA. 323 MELANCHOLIA. This morbid state is characterised by mental depression associated with delusions, with special tendencies, or with agitation. Melancholia may constitute a disordered mental condition in its entirety ; or it ma\ be one phase of a morbid state, which presents several aspects. Simple Melancholia. — Few people, however healthy, pass through life without- experiencing at some time or other unaccountable waves of depression which temporarily' darken the out-look, and the oft question involuntarily presents itself — is life worth living? Such a phase may he produced by an adequate cause — a great hiss or disappointment; but it may also creep. over the mind without any ex- ternal impulse, the usually offered explanation being that the person so troubled is "bilious," or that he is over- worked. Allowing due weight to these possible causations, there are cases in which the most careful investigation fails to afford any clue to the source of the depression. Some individuals are more prone than others to this feeling, and, if subjected to severe mental strain, are apt to fall into a condition of true melancholia. The melancholic temperament is strongly heredi- tary ; whole families frequently present marked indications of it. There is a condition of aggravated hypochondriasis which is very difficult to differentiate from actual insanity, and which passes almost imperceptibly into melancholia. The distinction is one of degree only; the hypochondriac frequently has a number of maladies or troubles which he dreads, but he shows more anxiety to submit to treatment than the melancholic who takes a gloomier view of his more limited ailments. The symptoms of simple melancholia are depression of spirits, dread of some unknown evil, sleeplessness, and loss of appetite which eventu- ally leads to the patient refusing to take food. As the disease advances the complaints about his health, which the sufferer at first reserved for the ears of an interlocutor, are uttered without regard to the presence of any one — he moans and repeats a set phrase with ceaseless reiterat ion : or, on the other hand, he sits absorbed in his misery sighing unutterable woe. Hallucinations and delusions are common; one patient declares that he has a reptile in his inside; another that his brain is fermenting and giving off gas; a third that his abdominal viscera are putrefying and passing away in the dejections, in proof of which he will instance their alleged cadaveric odour. In some cases delusions are among the earliest manifestations of melancholia, and they play a special part throughout the entire course of the disorder. Such delusions are usually of the fixed type — the same morbid idea prevailing from first to last. To this class belong 324 FORENSIC MEDICINE. those cases of alleged persecution or ill-treatment which, at first, are looked upon as due to an absurd infatuation, the outcome of prejudice; the individual possessed with such ideas (before they have become sufficiently pronounced as to proclaim his insanity) will write defam- atory letters or post-cards complaining of the actions of certain persons. Medical men are occasionally the recipients, of communications of this kind, accusing them of having ruined the health of the writer by im- proper treatment; he asserts, for example, that he has been salivated, and that his body is so saturated with mercury that the metal exudes through the skin ; or that medicines have been administered that have destroyed his sexual powers and caused wasting of the organs concerned. If legal proceedings are instituted against the writer, his friends readily seek to shelter him behind the plea of irresponsibility, an excuse that previously they would have indignantly repudiated, although his mental condition at that time was not one whit different. This unwil- lingness on the part of the friends of a person mentally afflicted to acknowledge his condition, except to absolve him from responsibility, places another difficulty in the way of medical men. When a delusion ■occurs at an early period of melancholia, the general disorder of the mind is either overlooked by the friends of the patient or is regarded as a result and not the cause of the delusion; they think that there is probably some ground for the delusion, and consequently they do not attach sufficient importance to the general condition. If at this stage of what may be really insanity the patient is certified to be insane and taken charge of accordingly, there will be no lack of evidence to testify to his sanity should he subsequently enter an action against the medical men who signed the certificates. The delusions of melancholic patients often centre on religious matters. They select some of the denunciatory texts in the Bible and apply them to their own case : — they have committed the sin unto death ; they have grieved the Holy Ghost ; the sentence of everlasting punishment has already and irrevocably been pronounced against them ; and so forth. In times of religious revivals people ■with morbidly emotional minds rapidly develop delusional melancholia with this tendency ; it has received the name of religious melancholia and is supposed to be a very unfavourable type. A suicidal tendency is often prominent in melancholia. The depressed and hopeless state of the patient leads him to commit suicide as a means of escape ; this is to be distinguished from true suicidal impulse, which may exist without melancholia. It is to be observed that melancholies sometimes make futile attempts at suicide which are suspicious of a desire on their part to deepen the interest of those around them in their cases. A homicidal tendency is much less frequent in melancholia than the tendency to suicide. ACUTE DEMENTIA. ?>'!■> Melancholia with agitation is characterised by incessant movement, which results from an agonised terror-stricken condition of the mind; the patient moans and sobs aloud, wringing his hands, tearing his hair, and showing all the signs of the acutest mental anguish. Some patients thus afflicted hurry to and fro in the search of escape from their misery, others sit huddled-up in a corner rocking the body with ceaseless agitation to the accompaniment of heart-rending moans and utterances. Melancholies of this class are exceedingly prone to suicide. Melancholia with Stupor. — In this condition the patient remains for hours in the same attitude without speaking, taking no notice of anything, and apparently overwhelmed with a sense of woe. Some patients thus affected are passive in the hands of their attendants ; they allow themselves to be dressed and fed, and will walk if con- ducted, but show an entire absence of appreciation of external impressions. Others doggedly oppose any interference, they will not walk if the attempt is made to lead them nor will they take food. Although the state is one of absolute apathy, the tendency to suicide is very pronounced ; such patients should never be left to themselves. as the impulse to self-destruction may assert itself at any moment. Attacks of melancholia and mania may alternate in the same indivi- dual. A degree of periodicity may be observed in most cases of chronic insanity, though in the greater number, the mental state merely undergoes fluctuations without reversal of character ; when the amplitude of fluctuation is great, the state of depression is con- verted into one of exaltation, which in its turn is succeeded by renewed depression. In some cases the alternation is broken by the intercalation of a period of sanity, either between the stage of depression and that of exaltation, or vice versa ; for example, mania is succeeded by melancholia, and then comes a lucid interval, the sequence being periodically repeated; in the inverse order it will be melancholia, mania, lucid interval. The term "circula r insa nity" has been applied to these alternations ; it is of exceptional occurrence, and is most frequent in women. ACUTE DEMENTIA. Acute dementia may be sequential to melancholia, or it may be a primary disorder. The state of mental abstraction evinced in melancholy with stupor is replaced by absolute apathy ; the patient stares at vacancy by the hour, his expression being one of entire absence of intelligence, not that of an intelligence overwhelmed with misery. He does not resist the efforts of his attendant to clothe or care for him, but he requires feeding, and attention to all his bodily 32G FORENSIC MEDICINE. wants. The physical condition is one of extreme languor; the circulation is feeble and the extremities are consequently cold and livid. Sleep is not wanting, though it may be irregular. RECURRENT INSANITY. Attacks of insanity may succeed each other at more or less prolonged intervals, the patient being free from mental disorder meanwhile; the periods of remission are designated by lawyers as "lucid intervals." In many instances, perhaps in the greater number, the patient is not abso- lutely free from a tinge of insanity ; he might pass in a crowd, but if carefully examined, some eccentricity, or peculiarity of intellect, or instability of temper would be discovered. A patient may have as many as eight or ten or more attacks, with lucid intervals between, varying in duration from a few weeks up to as many years. There is a tendency for the patient at each succeeding insane outbreak, to commit deeds of violence of the same nature : as homicide, suicide, rape, or destruc- tion of goods. The attacks often commence very suddenly in an outbreak of excitement, during which the patient is liable to per- petrate some act of criminal violence ; the condition may closely resemble epileptic mania, and in some instances probably is of that nature. DELUSIONAL INSANITY. Delusional insanity is frequently called monomania, and by lawyers partial insanity. The term Paranoia is also used to indicate chronic delusional insanity, which is almost invariably of a primary nature. In its typical form delusional insanity is characterised by a fixed delusion of a limited kind, the patient being more or less rational on other subjects ; when the delusion is of an innocent and very restricted nature, the behaviour of the patient resembles that of a harmless eccentric individual. Clouston 1 mentions such a case in which the patient was intellectually acute, and morally irreproachable, but he believed that twice two were not four, but four and a quarter. He spent his whole time not devoted to keeping the asylum accounts — which he did accurately on "the old system" in deference to prevailing prejudices — to making elaborate calculations by his own system as to the distance of the stars, and in formulating new tables of logarithms ; his manuscripts filled two large chests which he solemnly left by will to the University of Oxford. In another class the delusions are of an exalted type, the patient 1 Clinical Lectures on Mental Diseases. DELUSIONAL INSANITY. 327 Fancying himself some great historic personage, and comporting him- self with a corresponding degree of hauteur; whatever the delusion may be, the position taken is defended in many cases with logical •-consistency. Such patients are absolutely impervious to demonstration or argument directed against their dominant ideas, and often exhibit an unmitigated contempl for the mental capacity of those who pre- sume to differ with them. The ideas of such patients are inconsistent with the actual state of things, but the deductions drawn from these ideas are often quite rational: grant them their premiss and the rest tails in, in orderly sequence. A woman fancies that she is the Princess of Wales; she conducts herself with what she believes to be a befitting degree of dignity, decks herself with fictitious jewellery and adornments, and exacts a deferential behaviour from those who come in contact with her. A man believes that he is endowed with the power of healing by the laying on of hands ; he makes his power known by inflated addresses written and oral, calling upon all who have charge of sick folk to bring them to him to be made whole. Delusions associated with depression, and ideas of persecution, are very common in delusional insanity. Patients so afflicted often fancy themselves the victims of some occult agency directed against them by certain people, who are often not specified, but vaguely spoken of as "the villains " or "those mesmerists." One man believes that if he allows people to touch him, or even to come near him, they can read his thoughts ; consequently he keeps everybody at a distance as far as he can. Another believes that there is an attempt on the part of some malicious agency to inflate him with gas, so that he will sad away like a balloon, and be lost ; in consequence he will not sit down for months but walks about, or leans against objects, ready to start away should an attempt be made. In another class of cases suspicion is directed against individuals ; a man suspects the chastity of his wife and believes that, with the aid of her alleged paramour, she is in some secret way depriving him of his mental and virile power. Those who are subject to delusional insanity may be able to conceal their delusions under the influence of a strong incentive to do so; •even without any effort to disguise their ideas, if their interlocutor does not happen to touch upon the subject of the delusion, they may be able to maintain a rational conversation for a considerable time without betraying themselves. Maudsley 1 quotes the case of a Com- missioner who was sent to an asylum to liberate those whom he judged to have recovered. He examined an old man, who gave no indication of incoherence nor insanity in any way and an order was 1 Responsibility in Mental Diseases. 328 FORENSIC MEDICINE. prepared for his release to which he had to put his signature ; he took the pen and wrote " Christ." Hallucinations of hearing are common in delusional insanity ; the patients constantly complain of voices proceeding out of the cellar and through the walls. Hallucinations of taste and smell are also frequent and give rise to notions of being poisoned or suffocated with noxious gases. Delusions which have for their foundation some nerve irrita- tion arising in the genital organs are met with mostly in young women, in consequence of which they accuse men of having made improper advances to them, or worse ; such ideas are sometimes very fixed, and a woman subject to them will persistently write com- promising letters to the man whom she imagines has wronged her, and even to other people, making known his alleged misdoings. EPILEPTIC INSANITY. Apart from the tendency to progressive deterioration of the intellect in epileptics, the disease may produce psychical disturbances of an acute kind, which bear a certain relation to the periodic attacks. According to Hughlings- Jackson 1 epilepsy is "a sudden, rapid, excessive, occa- sional, and local discharge of the cerebral cortex." In the ordinary epileptic seizure, the first indication of the discharge is manifested by a sensory disturbance — the so-called aura ; further recognition of development in this direction is checked by immediate loss of con- sciousness; the discharge then expends itself in the motor tracts. Inasmuch as the discharge may take place at any part of the cortex,, the relation between the psychical and motor effects is not constant. In the ordinary epileptic seizure the psychical disturbance is limited to the aura which precedes and the lethargic sleep which succeeds it. In the cases which are of interest to the medical jurist the motor effects are negligible, and they may be entirely absent ; his attention is concentrated on the disorder of the higher centres by which the mental attitude and the actions of the individual are effected. The psychical disturbances occur either before or after the motor discharge, and, what is of the greatest importance from the forensic standpoint, even in its absence. During a variable period before an epileptic seizure the individual often displays a restless, irritable, morose disposition, with delusions, in which suspicion of the motives of those about him plays a prominent part; less frequently there is elation. This mental change is easily recognisable by those who are in daily contact with the patient, and from it they infer that an attack is imminent. After a fully developed seizure the patient usually sleeps profoundly for a 1 West Hiding Asylum Rep., vol. iii. EPILEPTIC INSANITY. 329 variable period, and on awakening is in his former condition, except that he feels sore and fatigued; in some cases, automatic movements are made before consciousness returns. A man may have a fit in the street and, after it is over, may get up and walk a considerable distance without any perception of his surroundings; when he comes to himself he finds that he is in a neighbourhood quite unknown to him. Whilst in this condition he may perform a variety of actions of a purposive nature which demand complicated movements for their execution. The actions performed are determined by the influence of past co- ordinations on the motor centres acting in the absence of the restraint imposed under normal conditions by the highest controlling centres, the latter being in a state of passivity from exhaustion. Many of these actions present all the appearance of volitional movements, and yet the individual, both at the time and afterwards, is quite unconscious, of having performed them; although described as automatic they are probably initiated by a slight peripheral stimulation, or by one of internal origin. There is a tendenc y to resume an action interrupted by i he seizure, hence a person who is walking at the moment the attack comes on, may recommence doing so as soon as the motor exhaustion is recovered from, but before the psychical centres have regained their activity. After an ordinary epileptic seizure has occurred and the subsequent comatose sleep has passed off, the patient, instead of regaining his previous mental state, may be furiously maniacal; this condition may come on at any time within twenty-four hours or more after a fit; it may immediately succeed the coma, but more frequently some hours elapse. It may follow a single fit, but is more likely to occur after several have taken place in rapid succession. In the absence of the higher control, the lower centres are let loose and give rise to a display of blind ungovernable frenzy which is in the highest degree dangerous to the patient and to those around; whilst under its influence the patient, without cognisance of the act, may commit deeds of brutal violence. It is important to remember that a dislike, or suspicion, aroused during the stage of irritability that precedes an attack, may determine the action after it ; an animus thus conceived against any- one may lead to his being assaulted after the fit is over, whilst the patient is still unconscious of his actions. Occasionally the mental disturbance after an ordinary epileptic seizure takes another form, the patient being simply excitable — talking, gesticulating, and behaving extravagantly — but without violence. The condition of " automaticity " may occur during a slight epileptic seizure without motor symptoms — the so-called petit mal. During an attack of this description there may be no perceptible movement of 330 FORENSIC MEDICINE. the body nor limbs; the face will become pale for a moment or two and subsequently flushed, and that is all that usually is to be seen. The patient himself may, or may not, perceive a momentary loss of consciousness; if he is talking at the time the attack comes on, he stops and hesitates for an instant, and then resumes the conversation ; if he is writing, the pen probably drops out of his hand, but the whole affair appears so insignificant that it might easily be mistaken for an accidental slip of the fingers. If he is doing something at the time the seizure occurs, he either continues the action on the same lines, or he does something absurd or incongruous which has a certain relation to the original purpose. For example, a woman who was toasting bread had an attack of petit mal ; she thrust the toasting-fork with the slice of bread on it between the bars and vigorously stirred the fire. This association of ideas has an important medico-legal bearing ; during or after a seizure that does not produce motor disturbance there seems to be a tendency to perform some action. If, at the time, the person is not manually occupied, he may do something that has a strong resem- blance to a purposive unlawful act, without volition or cognition; the mere sight of an object may be sufficient to suggest picking it up and putting it in the pocket. This may be done in such a way as to resemble secret theft, but the action is not unfrequently committed without attempt at concealment. Colman 1 gives an instance in which a man had an attack of petit mal whilst in an ironmonger's shop ; he placed a large coal-scuttle on each arm and deliberately walked out of the shop. A patient under the influence of an attack of petit mal sometimes displays another tendency which may bring him within the sphere of the law ; he is seized with a desire to micturate, and regardless of the surroundings, unfastens his clothes and deliberately performs the act in public, with the result that he is taken in charge for inde- cently exposing his person. Colman relates the case of a woman who whilst at a public entertainment had an attack of petit mal, in the course of which she lifted her clothes and there and then urinated; her friends had much difficulty in convincing the police that the act was not one of wanton indecency. Occasionally the patient commences undressing in public ; Growers accounts for this on the supposition that a feeling of illness experienced after the attack "suggests" the pro- priety of going to bed. The cortical discharge, which under ordinary conditions determines an attack of epilepsy with clonic spasms, may be apparently entirely expended on the mental centres, producing a state of maniacal excite- ment like that already described as occurring after an ordinary seizure, 1 The Lancet, 1890. GENERAL PARALYSIS OF THE INSANE. 331 but without the usual fit. Individuals thus affected will commit the most brutal acts of violence, being at the time perfectly oblivious both to the injuries they inflict on others and to the damage they themselves may sustain. For two reasons, no insane condi tion i s more dang erous t han thi s :— First, the immediately antecedent state of the individual who is subjected to its influence may be one of perfect sanity, and therefore he may be at liberty to attack the first person with whom he comes in contact without let or hindrance; second, his uneorernable fury knows no bounds and he "goes for" his victim regardless of conse- quences. This condition is sometimes called masked epilepsy, a term which is also applied to a state of unconsciousness accompanied by automatic actions without violence. GENERAL PARALYSIS OF THE INSANE. This disease is much more frequent in men than in women ■ the subjects of it are usually strong, vigorous, and in the prime of life from 35 to 45 years of age. Persons of a sanguine temperament are more liable to be attacked than those of a melancholic type; it is probably more common in the lower than in the higher ranks of society. Among the predisposing causes are :— syphilis, abuse of the sexual function, and excessive indulgence in alcohol. Among the exciting causes are — prolonged mental strain, especially when followed by disappointment ; shock to the nervous system, such as is caused by the sudden occurrence of a domestic or business trouble; less frequently brain-disturbances of a physical kind due to mechanical injur v, or to sun-stroke. The symptoms are divisible into psychical and physical, both kinds being highly characteristic when the disease is present in a typical form. As in other forms of insanity, there is an incipient period which in this disease presents special features of a distinctive nature. A vigorous, healthy man, of sanguine temperament, who is fond of what is called "company "—i.e., good eating and drinking— becomes more than usually jovial and loquacious. His friends probably think that he is indulging too freely in alcohol, and, indeed, the condition very closely resembles that produced by slight excess of this kind. The patient is obtrusively familiar with people with whom he has but a slight acquaintance; he will call upon them at their houses and harangue them at great length about his private affairs ; he will talk by the hour about himself, his family, or his possessions in an inflated style, describing everything as the superlative of excellence. He is prone to do outre things, the outcome of extreme self-complacency ; he 332 FORENSIC MEDICINE. will "drop in" uninvited to dine with a family with a member of which he is merely on speaking terms. He becomes very forgetful, neglects appointments, and is irregular in his daily habits. An early indication, which is often the first to rouse the suspicions of the patient's friends as to his sanity, is extr avagance in purchasing useless articles. If he sees a watch that pleases him, he will buy half a dozen ; he will give orders to trades people for all sorts of goods, many times in excess of his requirements and income. Acquisitiveness may also be dis- played by stupid thefts committed without attempt at concealment, the articles appropriated being often, though not invariably, useless. The sexual proclivities usually assert themselves in a manner that demonstrates the loss of moral control ; a man in the early stage of general paralysis will commit an indecent assault on a woman in a most casual way, without any of the cunning displayed in other forms of insanity. He does not appear to be driven to the act by sensual impulse ; but, the opportunity being present, he avails himself of it out of mere caprice without considering the consequences, just as he senselessly commits a theft. In a less objectionable way he may show his inclination towards the fair sex by proposing marriage to several women on the same day. A good deal of this folly seems to depend on impairment of the memory as well as on exaltation of the sexual feelings, though there is an undoubted vein of lubricity present, which is evinced by a tendency to libidinous conversation. The memory and the power of concentrating the attention is always seriously impaired, even in an early stage of the disease ; the mind, butterfly-like, flits from object to object, and the one on which it last settles excludes, for the moment, its predecessors. A good way of testing the memory is to get the patient to write a letter ; if the disease is at all advanced the writer will omit words, especially short words, such as articles and prepositions. So far, although his conduct has been characterised by a variety of reprehensible actions, chiefly remarkable for their silliness, he may not have shown any decided indications of downright insanity. About this stage of the disease the physical symptoms are usually first observable; they may appear earlier, before the mental condition is so far advanced, or they may be delayed. The first indication is afforded by the speech ; a man in the early stage of general paralysis blurs his words, or some of them, just as a person does who is slightly under the influence of drink. There is more of a hesitancy than a stammer, as though the muscles concerned in articulation co-ordinated badly ; in the act of talking the lips quiver, imparting an appearance aptly compared by Bucknill to that of a person about to burst into weeping. If the tongue is protruded, fibrillar tremors of its muscles GENERAL PARALYSIS OF THE INSANE. 333 j'A will .probably be visible. The pupils are frequently unequal in size, or they may be extremely contracted or considerably dilated. As the disease progresses the mental symptoms increase in intensity; bombastic utterances are supplemented by delusions which have a like tendency. The patient fancies himself wiser, stronger, <>r richer than other men ; his wealth amounts to millions of pounds ; he has country residences in every county of England; he can outstrip the fastest horse on foot. Delusions chase one another through his mind; he recurs to the same idea, but modifies or alters its expression; and, after a time, he takes up other grandiloquent notions. If taxed with the absurdity of his statements, he makes little attempt to defend or justify them, but maunders on regardless of controversion; he thus differs from melancholic and other insane patients who hold to their delusions and insist on the truth of their utterances. By this time the memory is so impaired that the patient is incapable of comparing ideas; he cannot perceive the least incongruity in his state- ments ; they represent what to him actually exists. His face glows with transport as he recounts his heroic deeds and enumerates his vast possessions ; in repose it presents the exactly opposite look of a half-demented person — stolid and fatuous. The speech is now distinctly impaired, and subsequently becomes mumbling and difficult to understand. Before this stage— sometimes quite early — the patient will have V suffered from epileptiform seizures, varying in degree from a mere " faint " (petit nut/) up to well-marked convulsions, and even true epileptic attacks. The ribs are sometimes fractured without the patient being aware of it, due partly to trophic changes in the bones producing unnatural fragility, and partly to insensitiveness, which blunts the perception of pain. The last stage i s one of paralysi s and dementia ; the patient may be able when supported to totter about for a little longer with a well- marked ataxic gait, and then he is confined to his bed, and lies with the knees drawn up against the abdomen, with body and mind para- lysed until death occurs. The duration of the disease varies from a f ew months to three or, possibl y, five years. Exceptional Forms of General Paralysis. — In the early stage, and very rarely subsequently, the condition is melancholic instead of exalted. In the ordinary type of the disease the patient's life may be cut short soon after the psychical symptoms are first developed. Sankey 1 describes the symptoms in these cases as resembling those of acute meningitis. In a limited number of cases remissions occur, and, for a time, the 1 Lectures on Mental Disease, 1S84. 334 FORENSIC MEDICINE. patient is supposed by his friends to have recovered. Blandford l states that he has seen a wonderful disappearance both of bodily and mental symptoms, the improvement lasting for some time, and that amongst these cases he has seen some which certainly would not have been pronounced insane by a jury ; they had either lost their delu- sions, or were competent to deny and conceal them. If such cases remain free from mental work, they may slowly decline without return of the acute symptoms ; if they attempt to occupy themselves with their former avocations, the acute symptoms return and the relapse is progressively and quickly fatal. TOXIC INSANITY. ALCOHOLIC INSANITY. Mental disorder due to alcohol is either acute or chronic. Acute alcoholism is divisible into two types — Delirium ebriosum, and Delirium tremens. e initiated by convulsions, which often occur at the time of teething. Traumatic injury, such as the head sometimes sustains during difficult parturition, may give rise to imbecility or idiocy in combination with spastic paraplegia ; this is due to meningeal haemorrhage causing compression of parts of the cortex, which become flattened and atrophied. Idiocy may be accom- panied by epilepsy. In the ordinary idiot the palate is narrow and highly vaulted; there are rarely more than twenty-eight teeth. Pronounced bodily deformity— cretinism and myxcedema— is some- times associated with mental deficiency — the former with idiocy, and the latter more frequently with imbecility. Idiocy comprises all grades of mental deficiency, from a state of mere automatic existence, with considerably less intelligence than that displayed by domestic animals, upwards, through the lesser degrees of imbecility, to the confines of normal mental development. The mental condition of many persons classed amongst the sane is scarcely, if at all, distinguishable from the milder forms of imbecility. Idiots of the lowest type are absolutely devoid of any intelligence ; they are incapable 'of attending to their natural requirements, and pass their time in rocking themselves to and fro, or moving their limbs 1 Idiocy and Imbecility. a Brain, 1S83. SENILE DEMENTIA. 341 about in a purposeless manner. If slightly less debased, they display a marked tendency to cruelty — fchey will torture insects and small animals in a diabolical manner. They are mischievous, dirty, and utterly without sense of shame; some are irritable and dangerous to those whom they have power to harm. Imbeciles of a less pronounced type often give rise to an infinity of trouble by running away from home and associating with the criminal classes. As they grow up, they show depraved tastes; they drink, gamble, are riotous, and are addicted to the company of prostitutes and thieves; along with this shameless depravity, there is a considerable amount of low cunning and of knowledge of a certain type. Individuals of this class, or a little above it, who display a degree of sanity, often come under the notice of the medical jurist in relation to their fitness to manage their own property and affairs. A totally different type of imbecility is characterised by a gentle tranquility of conduct, the mental defect showing itself in a purely negative manner. SENILE DEMENTIA. Senile dementia is not an invariable accompaniment of advanced age, and therefore no limit can be assigned at which the mind begins to give way from physiological decay. Some men retain their mental vigour in a high degree until far advanced in life ; they display a wonderful power of abstract reasoning, and of memory for words of highly specialised meaning, such as proper names, which being least organised, soonest undergo dissolution. A man of less mental vigour shows signs of decay and loses coherence of ideas ten or twenty years sooner. If signs of dementia occur before the age of sixty years, there has probably been some cause other than age which has interfered with the nutrition of the brain ; defective memory frequently betrays itself at a much earlier period, but the reasoning powers remain active. A certain dulness of intelligence, as compared with that which formerly existed, is frequently the precursor of dementia. In this stage, a man of considerable attainments will be unable to solve at the moment a question involving abstract thought, which would formerly have given him little trouble; if the question is written down, and ho is so minded, he will arrive at a, correct answer when left to himself foratime; the power of abstract reasoning is dulled, but not destroyed. This applies, though not so directly, to minds of lesser culture, and should be remembered when examining cases which are supposed to display great mental weakness. When dementia follows a progressive course, the mental boundaries may slowly contract without other change than gradual intellectual 342 FORENSIC MEDICINE. dissolution. In some cases, phases of excitement or of depression occur at intervals ; there is always more or less loss of self-control, and, frequently, excessive irritability of temper. Hallucinations and delu- sions are not uncommon, and there may be a tendency to suicide. Erotic impulses may be present, which are not unfrequently the cause of unchaste behaviour on the part of old men to young girls. Dementia may be the final stage of any of the forms of ordinary insanity, such as mania or melancholia ; this is known as secondary dementia. The condition is that of mental enfeeblement, advancing to one of complete abolition of intelligence. There may be occasional waves indicative of the causal psychosis, the patient being excited or depressed at intervals. The animal propensities, uncontrolled by reason, may display themselves ; or the patient may be impassively tranquil unless annoyed, when he blazes up into a momentary fit of passion. Dementia due to coarse brain-lesions is usually characterised by p ronounced emotional instabil ity. The lesions thus designated comprise those which give rise to ordinary hemiplegias — embolic or hemorrhagic ; tumours, and necrotic softening. The emotional weakness is chiefly displayed by bursts of weeping without any cause whatever ; whilst answering a casual enquiry after his health, a hemiplegic thus affected will burst into tears, quickly brighten up again and continue the con- versation. This is but an automatic representation of emotion, the patient at the time is incapable of true emotional feeling. MORAL INSANITY. In many of the forms of mental disease described in the preceding pages, the moral aspect of the patient undergoes certain changes before the intellect becomes involved, although the subsequent insane condition is due to intellectual disorder. Moral insanity is said to exist when, without disturbance of the intellect, perversion of the moral sense occurs to a degree inconsistent with due control of the actions. It is denied by some that absence of the moral sense in itself constitutes insanity. Blandford 1 considers that those who have most strongly upheld the doctrine of moral insanity and morbid perversion of the moral sentiments have often underrated, or neglected, the intellectual defect or alteration observable in the patient. Hack Tuke 2 regards the term " moral insanity " as unfortunate, so far as it induces the belief that the moral feelings are themselves necessarily affected by disease, the other mental functions being sound; he looks upon the condition as one that 1 Insanity and its Treatment. - The Journal of Mental Science, 1891. MORAL INSANITY. 343 oftentimes is caused by weakening of the higher centres involving paralysis of the voluntary power, and thus transfers the seat of mischief from the feelings themselves to the volitional or inhibitory power. In moral insanity the higher levels of cerebral development are either imperfectly evolved from birth, or after evolution become diseased and more or less functionless, the result being that, although the intellectual capacity is not seriously affected, the emotional and automatic functions have more than normal play. Such constitutes the mental condition which pervades the criminal classes, and here comes the difficulty, viz., to distinguish between moral depravity and moral insanity, for the former merges into the latter without any absolute line of demax'cation. The question has been discussed from extreme standpoints : — one is, that the mere commission of a flagrant crime without remorse demonstrates moral insanity ; the other is, that unless the reasoning faculties are so far weakened that the person who commits the crime cannot distinguish between right and wrong, he is responsible for the act ; in other words, he is not insane. To countenance the first view is to place a premium on depravity. That individuals whose moral control is so far weakened as to place them in the ranks of the insane commit crimes of the vilest nature without remorse is perfectly true ; but to accept the crirne as a proof of insanity is another matter. The second opinion, which is held by lawyers, will be discussed presently. Without entering into a discussion as to how far the emotions may determine the actions without implication of the reasoning powers, I experience necessitates the conclusion that, for all practical purposes, the moral perceptions may be so far perverted as to render the indi- vidual irresponsible for his actions without signs of mental disease being present, either in the form of delusions or of intellectual enfeeble- / ment. By this it is not meant that the intellect is absolutely intact, but that it is not weakened so far as to betray its condition, except by being unable to control the mural sense. Absence of the inhibitory influence of the higher levels by which moral control is effected may be the r esult of bad traini ng, as well as of developmental defec t or of morbid proces ses. In order that bad training should paralyse the influence of the higher levels within a single lifetime, it is probably necessary that a certain predisposition to succumb should be present ; among the criminal classes, taken as a whole, this pre-disposition exists — in them the higher levels are innately reduced. Defective moral control may exist in various degrees, so that at one extreme the effect is displayed by vicious conduct and at the other by insane acts. That a certain disposedness is necessary seems probable from the existence 344 FORENSIC MEDICINE. of retained moral control on the part of some who have been brought up amidst the most unfavourable surroundings, and that others who have lost moral control may regain it when transplanted to favourable soil — that is to say, that their higher levels are unstable and disin- tegrate or reintegrate in accordance with the external influences brought to bear. The instances of moral insanity which most forcibly demonstrate its existence are those occurring in early life in spite of the most favour- able external relations. A short time ago I was consulted with regard to a young lady of only fourteen years of age, who had been "withdrawn" from boarding-school for repeated thefts from her fellow pupils, although she was abundantly supplied with pocket-money. She had not the least regard for truth, and took a malicious pleasure in fabricating statements which brought trouble upon innocent persons. When at home she behaved indecently with her own brother, and made improper overtures to her father's groom. Intellectually she was bright and clever; her schoolmistress reported that she was able to keep pace in classes with other girls o£ her age, but was fickle and lacked application. The evil strain came from her mother, who took to drinking after she was married, and eventually eloped with a man of low social position ; the girl was born about a year after the mother gave way to intemperance. This is an instance of defective evolution of the higher mental levels; the finer traits of character were entirely absent, but there was no lack of a certain cleverness, which conveyed the impression that if the girl only had application and perseverance she could acquire as much knowledge as any of her compeers; moral lapses apart, her friends regarded her as sane enough. Hack Tuke 1 relates a very typical case of moral insanity, of which the following is a condensed abstract : — A man, who in his youth was sullen, uncommunicative, idle, sly, and treacherous, at an early age evinced a disposition to torture domestic animals and to cruelly treat younger members of the family. On one occasion he took a younger brother into the fields, undressed him, beat him with long lithe willows, and bit and scratched him about the arms and upper part of the body, threatening to kill him with a table-knife if he cried out. Shortly after he was apprehended for cutting; the throat of a horse, belonging to a neighbour, and confessed that he had maimed several other animals, and had twisted the necks of fowls and then concealed them in wood-piles ; he was sentenced to twelve months imprisonment. On his discharge from prison he attempted to suffocate a little child by piling clothing, &c, on the top of it ; he then stole some money from his father's desk, for which act he was sentenced to 1 Journal of Mental Science, 18S6. IMPULSIVE INSANITY. 345 seven years in a penitentiary. After his liberation, being again at home, he saw his father accidentally cut his hand so that it bled profusely; this seemed to excite him, and he went to a neighbouring farm-yard and cut the throat of a horse, killing it. He escaped, and, whilst hiding in a wood, saw a young girl, seized her and committed a criminal assault on her. After being about ten years in prison for this offence, he was set free, and on his way home from prison he caughl a horse, tied it to a telegraph-pole and mutilated it in a shocking manner, cutting a terrible gash in the neck, another in the abdomen, and taking a piece off the end of its tongue. For this he was tried and acquitted on the ground of insanity, and was transferred to an Asylum. After hem- there for five years he made his escape, and was only absent from the asylum about an hour, when he overtook and attempted to outrage a young girl almost in sight of the pursuing attendants. Beside all this he was guilty of innumerable acts of cruelty to fellow-patients in the asylum, and also to dogs, cats, fowls, &c; he was a great coward and was never known to attack any person that would be likely to offer resistance. The sight of blood had a strange effect on this man ; his face grew pallid ; he became nervous and restless, and, unless watched, lost control over himself and indulged in the proclivities for which he was notorious. If so situated that he could not indulge his evil pro- pensities he was a quiet and useful man ; he had had a fair education and enjoyed reading the newspapers and letters sent to him. IMPULSIVE INSANITY. Impulsive insanity may lead to the commission of homicide, suicide, theft, acts of destructiveness, and other criminal actions. A distinction is to he drawn between insanity with an impulse and i mpu lsive insanity. Mania, melancholia, and delusional insanity are all prone to be associated with impulse; but by impulsive insanity is meant a condition of loss of inhibitory control, which allows of abnormal energising of the higher, but not the highest levels, by which a si \>n\g or ungovernable impulse to do some irrational act is devel without delusion or loss of general self-control. An erroneous idea exists that such impulses are necessarily of momentary growth — an idea probably derived from a totally different cause of irrational impulse, such as is exemplified by a man in a paroxysm of anger, who. especially if subjected to renewed excitation, may suddenly develop an impulse to kill his opponent. His anger, which for a time is furious enough, is expended in words and gesticulations; suddenly he loses, self-control and is seized with an impulse, to which he immediately yields, and the deed is done. The condition depicted partakes of the 346 FOKENSIC MEDICINE. nature of a temporary mania which culminates in an explosive act, the result of loss of general control. The condition usually understood by the term impulsive insanity is not of this high-tension type. An individual may be sensible of an impulse and yet retain sufficient self- control as not to yield to it, at any rate for a time; he may either seek the help of external control, or, after struggling for a time, the impulse may overcome him, when he obeys its dictates whatever they may lie Indicative of the ebb and flow of self-control in such cases is the revulsion of feeling which not unfrequently occurs to the insane person in the midst of carrying the impulse into effect. Homicidal Impulse. — A woman develops an impulse to kill all her •children, and resists it for a time, possibly thinking about the matter for days ; that is to say, the thought keeps continually recurring. At last she acts ; but, after killing one of her children, control is re-established, she throws away the knife and bursts into tears. Such a case was tried before Lord Blackburn; 1 the woman, after cutting the throat of one of her children, was checked in her homicidal career by the child next in turn to be sacrificed throwing her arms round her mother's neck and speaking to her in a caressing manner. The woman subsequently explained that she was going to kill the child, but that, after the caress, she "had not the heart to do it." Although she evidently knew right from wrong and also the character of the act, the judge told the jury that there were exceptional cases, on the strength of which ruling a verdict of not guilty, on the ground of insanity, was returned. Maudsley 2 relates a very instructive example of homicidal impulse. Dr. Pownall, a medical practitioner, was admitted to an asylum on certificates which stated that he had made a murderous attack on his mother-in-law, whom he usually respected and loved. He had an attack of mental disorder when he was twenty-two years of age; a second after an interval of fourteen years, and a third (the one for which he was now placed under restraint) after a further interval of four years and a half. Between the attacks he successfully conducted a large medical practice, and was so much respected by his fellow- townsmen as to be elected to the office of mayor. During his second attack of derangement he shot a gentle- man with whom he was out shooting, and, although the coroner's inquest resulted in a verdict of accidental death, there were some who thought differently. He remained in the asylum for four months ; during the whole of that time he betrayed no symptom of mental disease and, consequently, was discharged as recovered. Twenty days after leaving the asylum he killed a female servant by cutting her 1 Cited by Orange, Joum. of Ment. Science, 1884. - Responsibility in Mental Disease. IMPULSIVE INSANITY. 347 throat with a razor, having shown no indication of insanity up to within a few hours of the act. Acquitted at his trial on the ground of insanity he was sent to Bethlehem Hospital as a criminal lunatic, and the medical officer, after an observation <>f several months, said that he could not attach any particular symptom of insanity to him, and that supposing he was a private patient, and the Commissioners in Lunacy asked why he was detained, he could give no definite reason for it. In another class of cases, the homicidal impulse exists along with, or rather in consequence of, pronounced delusions. A man falsely believes that a certain person has done him some great wrong, and, in consequence of this delusion, he murders him. Such cases are a common result of delusional insanity, and are usually easy of recogni- tion, as the insane person makes no secret of his delusion. Occasionally, however, an extraordinary capacity is displayed to conceal delusions, which are yet sufficiently powerful as eventually to lead to a homicidal outbreak. Maudsley thinks it probable that Dr. Pownall was able successfully to conceal his delusions when he had a strong motive to do so. Suicidal Impulse. — According to the popular notion, the suicidal act in itself constitutes evidence of insanity. This is fostered by the stereo- typed addendum to the verdict of the coroner's jury of "temporary insanity," devised probably as a means of escape from the verdict of felo-de-se, which formerly carried with it certain penalties. The suicidal act is n ot necessarily indicative of insanity ; it may be the result of a rational resolve. If a man of high social position, and by repute of great wealth, is discovered to have embezzled money or forged monetary documents, and is stared in the face by the inevitable consequences, he may prefer immediate death to penal servitude. The misery — mental and physical — he seeks to avoid is real and tangible; the question is one of balance of evil; the remedy is a desperate one it is true, but so is his condition, and the outcome is, that he determines to avail himself of the only means of escape at his command, and puts an end to his life. lake homicidal impulse, insane suicidal impulse may exisl either with or without delusions or other disorder of the mind ; the impulse may be controlled for a time, or the patient may ask to be protected against himself. Suicide from impulse differ s fro m that with delusions inasmuch as the patient appears to he sane on all but the one point. The tendency may be recurrent, the patient being free from mental disorder meanwhile. Instances have occurred in which an unsuccess- ful attempt to carry out the intention has been sufficient to restore control, and free the patient from the impulse. A case is related of a 348 FORENSIC MEDICINE. man going towards a river with the set purpose of drowning himself; he was attacked by thieves and defended himself lustily, and, having got away, he returned home cured of his suicidal impulse. The impulse may take a certain definite direction to the exclusion of all others ; a man will neglect knives and razors, or other means at hand, to go a considerable distance and place himself on a line of rails and allow a train to pass over him. The impulse once fully developed may recur, even after a long interval of apparent perfect sanity. A case is recorded in the Commissioners' Blue Book (quoted by Newington 1 ) of a man who had been fourteen years under supervision ; for the first part of that time he had heen absolutely suicidal, but he improved, and used to go out and enjoy himself. At the end of fourteen years his mother sent him an old writing-desk ; in it was a secret drawer, from which he took a bottle containing poison that he had placed there fourteen years before. He did not swallow the poison at once, but walked off into a wood, and there took it and died. Before the arrival of the desk, he had plenty of opportunities of procuring poison had he been so disposed. When the impulse to suicide is the outcome of melancholia or other mental disorder, there is, us ually, a definite delusion; the patient hears a constantly recurring command bidding him to kill himself, or accusations of horrible crimes are ceaselessly made by voices from the sound of which he seeks, in death, to escape. The delusion of per- i secution is a common cause of impulse to suicide. Heredity exercises a powerful influence in predisposing to suicide, the tendency often asserting itself about the same time of life in the child as in the parent. Ill-health reduces the higher inhibitive powers, and if there is a latent proneness to suicide, it is then likely to assert itself; the same remarks apply to business worries, loss of money and disappointments of all kinds. In the latter instances the impulse is of a mixed origin, and approaches in character that which determines the suicidal act in a sane person. If a man labours under the delusion that he is the victim of a secret society, whose agents are persecuting him and rendering his life unbearable, and in consequence of this delusion he puts an end to his life, the act is that of an obviously insane person, because he believes a delusion and acts upon it, as though it was a real occurrence. If a man has lost a great deal of money and is consequently obliged to retrench his household expenses, he may take such an exaggerated view of his difficulties as to develop an impulse to suicide ; although a delusion determines the impulse it is one that is founded on an actual occurrence, and would not have come into play under more favourable external relations. The man with 1 Journ. of Mental Science, 1S86. IMPULSIVE INSANITY. 349 hallucinatory delusions is liable to develop the suicidal impulse in spite of his surroundings ; the other, only in consequence of them. The approach of the wave of depression which allows the impulse to develop may he felt by the patient; in some instances he requests that he may be taken care of until the depression is passed. Further evidence of consciousness of loss of self-control is afforded by the fact, that, in some instances, the patient himself will lock up knives and other instruments, which from propinquity might tempt him; this teaches an important lesson on the subject of irresponsibility. Sugges- tion may exercise a powerful influence on a prg-disposed mind : hearing of the suicide of an intimate friend, or even of that of an individual personally unknown to the patient, may be sufficient to incite him to the same act. The impulse may be controllable at one time and not at another, which further complicates the question of responsibility. Threats to commit suicide made by a person suffering from some distressing bodily ailment are not unlikely to be put into execution. Manning 1 relates the case of a perfectly sane man who was admitted into hospital for liver disease and dropsy. He told his wife that, if he ascertained from the doctor that his disease was incurable, he would commit suicide ; and that he had at first thought of shooting himself with a pistol ; but, considering that it would be a cruel shock to his fellow-patients in the ward, he had resolved to adopt another method. One day after this conversation, he learnt on enquiry from one of the resident medical officers that his case was hopeless; he watched his opportunity, went on to a balcony outside the ward, and deliberately flung himself over and broke his neck. Medico-legal Relations of Suicide.— The law regards the suicidal act as felonious, unless the individual is held to be irresponsible on the ground of insanity. A person who aids an d abets another person to commit suicide is guilty of murder; the crime is not lessened if two persons mutually agree to commit suicide at the same time and in the presence of each other. If one dies and the other survives, the survivor is guilty of murder; the fact of his making a simultaneous attempt on his own life does not affect the crime committed against the deceased. If a person, in the attempt to commit suicide, occasions the death of another person (he himself recovering) he is guilty of manslaughter. A man jumped into a canal with the intention of committing suicide, but was rescued by a passer-by, who unfortunately was drowned in the act of rescue. The intended suicide was found guilty of manslaughter in spite of an attempt to prove him insane. (Reg. v. Gatliercoh). Kleptomania, or impulse to steal, is of dubious existence apart from l Journ. of Mental Science, 1SS6. \^ 350 FORENSIC MEDICINE. an insane condition due to general mental disease. That an insane person may have a raven-like propensity to steal is well-known ; but that, because a person steals without a transparently obvious motive for doing so, he is therefore to be regarded as insane is simply to encourage vice. If the propensity to steal is really due to an insane state, there will be other evidences of mental disease apart from the act of theft; a person will not be absolutely sane in every respect save the desire to appropriate articles that do not belong to him. Acts of theft, we have seen, are not uncommon in the early stage of general paralysis, or after an attack of minor epilepsy, and they are usually traceable to their causation. Moral insanity with impulse, which is usually alleged in defence of the culprit when kleptomania is brought in question, is to be regarded with great suspicion. It is, of course, quite possible that a person who is the subject of moral insanity may pilfer, as well as do other acts contrary to the moral code, but it is improbable that loss of the highest control will solely exhibit itself in such a narrow channel — there will be other evidences of its existence. When kleptomania is pleaded in defence, it is usually manifest that no evidence worthy of the name is advanced to prove any antecedent disorder of the mind ; the most that is urged is that the accused was quite capable of paying for the stolen articles, and therefore that the act was due to an insane impulse. MEDICO-LEGAL RELATIONS OP INSANITY. The medical terms by which the various forms of insanity are designated are not recognised in law. The legal terms are : — Dementia naturalis, which is equivalent to idiocy and imbecility, and Dementia adventitia or acquired insanity ; both of these are included in the term Lunacy. A further designation, non compos mentis, or unsound- ness of mind, is used to indicate an indefinite condition of a lesser degree of insanity than the two preceding. The subject of insanity comes under the notice of the medical jurist in relation to (a) criminal responsibility, (b) lunacy certificates, (c) commissions of enquiry, (d) testamentary capacity, (e) feigned insanity. (a) CRIMINAL RESPONSIBILITY. The commission of a criminal act involves punishment, but if the person who commits a criminal act is proved to be insane at the time he committed it, he is held to be irresponsible to the law for what he has done. The questions that arise out of this statement are : — What CRIMINAL RESPONSIBILITY. 351 constitutes insanity, and to what extent must the accused be under its influence in order that he should be held irresponsible ? No definition of insanity has ever been formulated that can In- applied as a touch-stone to the individual, and his sanity or insanity thereby determined. In order to meet the difficulty, certain features assumed to indicate insanity, have been selected by the administrators of the law and converted into a test, to be applied to each indn idual case. This "legal test," after having undergone certain modifications in the course of time, now stands as follows : — " To establish a defence on the ground of insanity, it must he clearly proved that at the time of committing the act the party accused was labouring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or, if he did kuow it, that he did not know he was doing what was wrong." The first points that present themselves in relation to this test are : — That mental oblivion as regards certain external relations is assumed to be the necessary accompaniment of an exculpatory degree of insanity of all kinds, and that its occurrence alone affords evidence of irresponsibility. A slight acquaintance with the various forms of insanity is sufficient to show the inadequacy of the terms laid down to determine irresponsibility. A man may be so dominated by an im- pulse to homicide as to carry it into effect in spite of the knowledge that he is doing wrong and, therefore, is liable to punishment. At the Shropshire Winter Assizes in 1885, a man called Ware, who had been a patient in an Asylum, and had killed another patient with an iron bar, was indicted for murder. It was proved by the depositions that the prisoner was perfectly aware of the nature of the act he had committed at the time he committed it : he acknowledged that he had killed some one, and demanded a promise from the attendant that he should not be punished if he gave up the iron bar. The case did not conic before the jury as the man was previously removed to the criminal lunatic asylum at Broadmoor, but Mr. Justice Hawkins made some remarks which are very pertinent to the question at issue : — " It would be impossible to say that Ware did not know that he had killed a man, because he said himself that he had, and it would be impossible for anybody to urge that he did not know it was wrong, for he wanted a promise that he should not be punished, but unless one put a totally different construction on the law. that would have to be proved, although no man in his senses would suppose that any jury would find Ware responsible for what he had done." It is well known to medical men that a man may be under the influence of a delusion or of an insane impulse which urges him to 352 FORENSIC MEDICINE. commit an act that he knows is punishable by law ; if the delusion or impulse is sufficiently powerful to overcome his self-control he commits the act — that is to say, he is unable to restrain himself. Loss of self-control from mental disease is equally causative of irrespon- sibility as is want of knowledge between right and wrong, therefore any one subject to such loss of control ought not to be held answerable for his actions. The legal test as interpreted by almost all the judges will not admit of this. In Reg. v. Cole (C. C. 0., 1883), for murder of a child, Denman, J., allowed " that it was established in evidence that the prisoner had been suffering from delusions [that there were men under the floor, and in a cupboard, who sought to injure him] ; but that he knew that he was doing wrong, and he knew that he acted contrary to the law of this country." In his History of the Criminal Law of England, 1883, Sir James F. Stephen puts a much more liberal interpretation on the legal definition of insanity as a plea for criminal irresponsibility : — In his opinion the law allows that a man, who by reason of mental disease is prevented from controlling his conduct, is not responsible for what he does; and that the existence of any delusion, impulse, or other state which is commonly produced by madness, is a fact relevant to the question whether or not he can control his conduct. The late Lord Chief- Justice Cockburn did not view the law in this light; but he expressed himself to a select committee of the House of Commons to the follow- ing effect: — "I have always been strongly of opinion that, as the pathology of insanity abundantly establishes, there are forms of mental disease in which, though the patient is quite aware that he is about to do wrong, the will becomes overpowered by the force of irresistible impulse ; the power of self-control when destroyed or suspended by mental disease becomes, I think, an essential element of [ir-j respon- sibility." If the law thus stood, as one judge maintains it does, and another states that it ought to do, the sentences of the higher criminal courts would not subsequently be annulled as they often are by the influence of public opinion. The medical view is, that a man who is the victim of mental disease may know that a certain act is wrong, and is punishable by law ; but that an insane impulse, whether arising from a delusion or not, may overcome his self-control and he may commit the act, not because he does not know that he is thereby doing wrong, but because he cannot prevent himself from doing it. In many instances the plea of insanity is abused; the mode of procedure being partly in fault. If a man who commits murder is arrested, he is taken before the magistrates, and no matter how insane he may be he is committed for trial at the assizes. If the mental CRIMINAL RESPONSIBILITY. 35:"! disorder is of such a decided nature as to render it unadvisable that he should remain in jail, he may, by order of the Secretary of State, be removed to an asylum ; such cases of course could give rise to no differ- ence of opinion at the trial. The cases which admit of difference of opinion are not sufficiently pronounced as to be removed, and the prisoner probably remains until the trial without anything being said, or any steps taken, in relation to his mental condition. It is to be noted, however, that if after committal insanity is- alleged, the public prosecutor if informed will direct an investigation as to the state of the prisoner's mind to be made by two medical men of experience, with whom an official referee may be associated. It does not follow that at the trial these gentlemen will be retained on behalf of the Crown, although the Home Office orders and pays for the investigation; in some instances, one or more of the examiners have been subpoenaed for the defence, their evidence being favourable to it. At the trial, even if the prisoner has been examined under the authority of the public prosecutor as to his mental condition, some judges will only allow the medical witness to state what he saw and heard during his interview with the prisoner; they will not admit any expert evidence, ruling that the jury alone are competent to express an opinion as to his sanity or insanity. Other judges accept expert evidence. If the prisoner is so obviously insane as to be unable to plead on arraignment, he is sent to a criminal lunatic asylum until he recovers, when he is again brought before the Court; or if he does not recover he remains in the asylum. A less obvious degree of insanity, however, is not regarded as a bar to pleading, but it forms part of the defence, and is not unfrequently urged for the first time after the prisoner is condemned. The absence of systematised procedure is productive of evils in a variety of ways. The prisoner is rarely examined by an expert until a considerable time after the commission of the act for which he was arrested ; the law demands proof of insanity at the time the act was committed, therefore the nearer to it an examination into the state of the prisoner's mind is made, the more likely is it to remove doubts. Again, evidence as to sanity, or insanity, may be given by any medical man who happens to have formed an opinion on the subject ; this fosters a dangerous tendency to push expertism too far, and with the aid of the prisoner's counsel, to strive to carry the point at all costs. Much stress is usually laid on real or assumed heredity, the im- portance of which may be over-estimated ; the question is forcibly put by Bucknill 1 when discussing the plea of insanity in the case of Guiteau, the assassin of General Garfield, President of the United States. 1 Brain, 1883. 23 354 FORENSIC MEDICINE. "The argument in favour of insanity founded upon the supposed trans- mission of an hereditary tendency to mental disease has of late been used in most absurd and unjustifiable excess, and I do not know that the interests of justice would be damaged if it were to be excluded al- together injudicial inquiries; for if it could be clearly shown that both a man's parents, and all four of his grand parents, and all his uncles and aunts had been unquestionably insane, it would afford no proof whatever that the man himself had been insane. Such evidence would at the most strengthen the presumption that he had been so under circumstances which would otherwise be more doubtful." Recurrent insanity may be pleaded as a bar to criminal responsibility, and if the plea is sustained, the death penalty is not inflicted even when murder is committed in what lawyers term a lucid interval. If the accused is proved to have been actually insane at some previous period of his life, it is allowed that the mind might be so far diseased at the time the deed was done, as to render him irresponsible for his actions. This statement does not mean that the prisoner is never found guilty and sentenced ; he may be, but if so the convict's mental condition is subsequently investigated, with the result that he is probably detained in a criminal lunatic asylum "during Her Majesty's pleasure," instead of undergoing the capital sentence. If the prisoner is proved to have been insane shortly before committing the deed, although at the trial he might present all the appearances of sanity, he would probably be acquitted on the ground of irresponsi- bility. Moral insanity is invariably a stumbling-block to lawyers, who usually regard it as the medical definition of unmitigated depravity. From what has already been said on the subject, it is to be admitted that there is some excuse for this view, inasmuch as the two con- ditions are not capable of precise distinction. There exists what Maudsley terms "a borderland between crime and insanity, near one boundai'y of which we meet with something of madness, but more of sin, and near the other boundary of which something of sin but more of madness." It was asserted in an early section of this subject that delusions are indicative of insanity ; it is none the less true that insanity may exist without delusions. This is a hard thing for lawyers to accept, and many of them decline to accept it. To establish the plea in cases of simple moral insanity, the past family and personal history of the accused must be relied on to a great extent, and in those cases in which the absence of moral perception is due to the onset of a progressive mental disease — as in general paralysis — the concomitant symptoms must be sought for. CRIMINAL RESPONSIBILITY. 355 The case of Reg. v. Edmunds (C.C.C, 1872) is a good example of moral insanity leading to the perpetration of criminal acts, by which the lives of innocent people are sacrificed without scruple or re- morse in order to avert suspicion from the criminal, and to direct it against those who have done no wrong. Christina Edmunds, aged forty-three, was charged with the wilful murder of a little boy named Barker. The boy ate some chocolate-creams, which were bought at a respectable confectioner's shop ; half an hour after he died with symp- toms of poisoning by strychnine, the presence of the alkaloid being subsequently detected in the contents of the stomach. It was proved that the prisoner had obtained a considerable amount of strychnine under false pretences, had got possession of the druggist's poison-book, and had torn out leaves which recorded the purchase. It appeared that she incorporated part of the poison with some chocolate-creams, and then asked a small boy to purchase some more creams for her ; when he brought them she said they were too large, and sent them back to be changed. Unknown to the boy she substituted poisoned creams which, when returned to the confectioner, were placed with his ordinary stock to be sold in due course. One or more of these poisoned sweets caused the death of the boy Barker, who was totally unknown to the prisoner ; she also distributed poisoned sweets to many children who became ill. At the inquest which was held on the body of the deceased (before being suspected of the crime) she volunteered evidence in order to implicate the confectioner who had sold the sweets ; she also wrote anonymous letters to the father of the deceased, inciting him to take legal proceedings against the confectioner. This was not done through malice towards the man, but to divert suspicion from herself. She had previously been accused of endeavouring to poison a lady, for whose husband she had conceived a regard, and the whole of this elaborately carried out public-poisoning was apparently the result of a scheme to make it evident that the lady's indisposition was also due to poisoned sweets owing to carelessness of the confectioner. It was proved in evidence that the prisoner's father on two occasions had been under restraint^ and that he died in an asylum ; that one brother had epilepsy and died in Earlswood Asylum; that a sister was hysterical, and had tried to throw herself out of a window, and that other members of the family had suffered from various psychoses. Expert physicians were called to prove that the prisoner was morally insane : she was without intellectual defect and was free from delusions, but she was indifferent to her position and to the enormity of her crimes. She was found guilty and was sentenced to death, but the sentence was subsequently changed to detention in Broadmoor Asylum. This is a typical case of moral insanity, all the more so because of its ■356 FORENSIC MEDICINE. marked resemblance to unbridled depravity. One of the medical witnesses spoke of her being on the border-land between disease and vice ; there can be little doubt that mental disease, in the form of im- perfectly evolved higher centres, deprived her of the self-control of a sane person, and was the true cause of her criminal conduct. Impulsive insanity fares little better as a plea unless associated with some other manifestation of mental disease ; in relation to this form of insanity it is to be noted that the insane person may be able to govern the impulse at one time and not at another, and thus a further difficulty is introduced. The bench is disposed to assume that if a man, alleged to be insane, can control himself at one time under certain conditions, he ought to be able to do so at another under like conditions ; and further, that if he can control himself at all he ought to be able to do so always. An illustration of the way in which recurrent insanity with homicidal impulse is dealt with in courts of law is afforded by the case of Beg. v. Cooper (Norwich Assizes, 1887). The prisoner was a curate who, without any reason whatever, murdered his vicar, who was paralysed, by cutting his throat whilst in bed. Nine years before the prisoner had been under restraint and had developed homicidal mania. Whilst in the asylum he was very violent and attempted without provocation to cut the throat of another patient ; he also attempted to throttle a second patient. Between his committal and trial the prisoner was examined by two experts employed by the Crown, and they certified to the Home Secretary that he was insane. The experts had an interview with the prisoner on the morning of the trial ; but having previously had opportunities of satisfying themselves as to his insanity, they did not then specially test him for delusions. At the trial the judge would not allow any expression of opinion on the part of the experts but restricted their evidence to what had occurred at the interview held that same morning, and insisted that the jury should hear word for word the questions put by the witnesses and the answers made by the prisoner. The result was distorted evidence at variance with the real state of things ; the prisoner was represented as taking part in a rational conversation and displaying no delusions, the witnesses not being allowed to 1'efer to previously obtained ample evidence of their existence. Delusional insanity appeals more cogently to the legal mind than the varieties just discussed ; but even when delusions are present, it is demanded that they shall be of such a nature as to take away the power of distinguishing between right and wrong. Lawyers attach much importance to the presence of delusions as a sign of insanity, and -admit that they may be so dominant as to disturb the judgment to a CRIMINAL RESPONSIBILITY. 337 degree inconsistent with sane conduct. Martin, B., when summing up in the case of Rey. v. Townley (Derby Winter Assizes, 1863), said that " what the law meant by an insane man was a man who acted under a delusion, and supposed a state of things to exist which did not exist, and acted thereupon." Thus mere delusions, whatever proof of mental disease they may afford to medical men, afford no proof in the eyes of the law unless the individual is thereby rendered unconscious of the nature and quality of the act of which he lias been guilty. Delusions of a lesser type are called partial delusions by lawyers, and are not regarded as doing away with the responsibility of a criminal act. Delusions which frequently bring the subjects of them within the grasp of the law are those of persecution, or of a sense of wrong or injury inflicted that imperatively demands justice. It is to a case of this kind that we owe the legal test of insanity which at present deter- mines the ruling of the judges. In the year 1843 a man named M'Naughton shot Mr. Drummond, whom he believed to be conspiring with others against his life and character. M'Naughton was acquitted on the ground of insanity, and as there was a general outcry at the supposed failure of justice, the House of Lords propounded certain questions to the judges in order to elicit an authoritative ruling with regard to the plea of insanity. The answers to these questions constitute the law on the subject, as explained in the preceding pages. Illustrative of the loss of self-control caused by a delusion is the case of Reg. v. Dodwell (O.C.C., 1878). The prisoner was a clergyman who became involved in legal proceedings, and, after quarrelling with his legal adviser, conducted his own case in such an irregular manner that he did not obtain what he desired. On the strength of this he conceived that he had a grievance against the Master of the Rolls. One morning he awaited the arrival of his Lordship and fired a pistol at him ; no injury was inflicted, as the pistol was only loaded with powder and wadding, the prisoner declaring that his sole object was to direct public attention to his wrongs. At the trial the Master of the Rolls stated that the prisoner was incoherent and irritable, and that he appeared to be under a delusion; no medical evidence was called on either side, and the jury returned a verdict of "not guilty on the ground of insanity." In this case there was no legal evidence of insanity; the prisoner's action might have been due to irascibility and culpable neglect to curb a violent temper; all the evidence went to prove that he knew perfectly well the quality of the act and that he was doing wrong. Possibly the heinousness of the offence — firing at a high legal functionary — was regarded as sufficient in itself to constitute proof of insanity. Dodwell's subsequent history is not without interest in relation to the recurrence of insane impulses, for, although he did not come up to the legal test of 358 FORENSIC MEDICINE. insanity, he was none the less a victim of delusional insanity judged from the medical standpoint. After the trial he was transferred to Broadmoor, and in 1882 he committed a murderous assault on the chief physician of the asylum by dealing him a heavy blow on the crown of the head with a stone slung in a handkerchief. The motive which instigated him was identical with that which prompted him to fire the pistol at the Master of the Bolls: he stated that as the previous act had not proved sufficient to redress his wrongs, he made up his mind to commit some still more serious act, and had come to the conclusion that nothing less than murder would be sufficient to deliver him from the conspiracy of which he imagined himself the victim. In relation to the duties of medical men when called upon to pro- nounce as to the sanity or otherwise of a prisoner, it is to be observed that in many cases it is impossible to arrive at a reliable conclusion without having the individual under observation for some time. Usually several interviews are allowed, for which, and for obtaining the family and personal history of the case, every facility is afforded. In some cases more than this is required but is not obtainable. It should be possible to have such cases placed under skilled care not only of expert physicians, but of attendants also, who are accustomed to the insane; by close and continuous observation a trustworthy opinion might be formed as to the real nature of the case. No medical man is justified in going into the witness-box, and (if allowed) delivering himself of dogmatic statements as to the insanity of a prisoner after only a casual interview, unless indeed the mental state is so obvious as not to admit of doubt. J n every respect it would he advantageous if the plea of insanity was disposed of before the trial. The presenl stale of the law is a stumbling-block to this proposal : as interpreted by the judges it will not allow what the Secretary of State is subsequently obliged to concede to public opinion. This leads to those unseemly discussions in the daily papers which so frequently follow a death-sentence. In one class of cases the outcry is the result of a genuine conviction that a judicial blunder has been made; in such cases the end doubtless justifies the means; the result is, that if there is reasonable ground for doubting the convict's sanity he is sent to Broadmoor instead of being hung. Encouraged by such cases philanthropists, and pseudo-philanthropists rush into print in season and out of season whenever a capital convic- tion takes place. No matter how utterly incongruous the pretence of insanity may be, the plea is promptly ui'ged in not too moderate language, and it is echoed by those who on abstract grounds are opposed to capital punishment. Petitions are signed amid much display of sentiment, and frequently unfair pressure is brought to bear upon those DRUNKENNESS IN RELATION TO CRIMINAL RESPONSIBILITY. 359 in power. That sentiment, or prejudice, rather than equity, is the stimulant which determines such a display of ill-directed energy, is shown by the fact that if murder is associated with rape, the murderer is invariably left to his fate; he is too unclean to become sentimental over, or even to be mad. An able address on Insanity, in relation to offences against the Criminal law, delivered by Orange at the annual meeting of the Medico-psychological Association, with the discussion thereon, is con- tained in the Journal of Mental Science for 1884. Drunkenness in Relation to Criminal Responsibility. The law lays down no definite rules with regard to the plea of drunkenness as a bar to, or in mitigation of, punishment for crime committed under its influence. The principles which usually guide ' the judges when dealing with crimes of magnitude are — that simple intoxication affords no excuse for the commission of crime, but if by prolonged drinking the mind is impaired, the condition is regarded as being on a par with ordinary insanity, and may be pleaded as a defence against criminal responsibility. The view taken is — that simple intoxication cannot be held to excuse an offence committed whilst under its influence, because the loss of control was produced by the drunken man's own default. In the case of Beg. v. Williams (Old Bailey, 1886), Denman, J., ruled as follows : — that a crime com- mitted during drunkenness was as much a crime as if it were com- mitted during sobriety, and that the jury had nothing to do with the fact that the man was drunk. The prisoner was supposed to know the effect of drink, and if he took away his senses by means of drink, it was no excuse at all. Quite recently Sir Henry James 1 expresses the opinion that the man who chooses to drink to excess, and when drunk from time to time commits acts of brutal violence, must be taught that he is answerable both for being under the influence of alcohol, and for the acts such influence induces. The fact that drink does noi always affect people to a like degree constitutes a great difficulty. A man either from natural or acquired susceptibility may become maniacal under the influence of an amount of drink that would but slightly afl'ect an ordinary man; such a man, under the influence of drink, is much nearer the condition of true insanity than that of outrageous drunkenness. The reply obviously is — that a man so constituted should not take drink, and that if he does, it is at his peril. Morally, the question is hard of solution ; but the administrators of the law act in accordance with the view just 1 The Times Newspaper, Jan. 4, 1S92. 3G0 FORENSIC MEDICINE. enunciated, and punish the drunkard for committing a crime when he is partly drunk and partly insane, as though he was wholly the former. They are justified in doing so by the evil which would result if those who drink to excess were encouraged to believe that crimes committed under its influence would be lightly dealt with. When mental aberration is due to the remote effects of alcohol, as in delirium tremens, judges usually allow that the condition is one of insanity, and it is dealt with accordingly ; but even then the legal test for insanity may be applied, and the prisoner's criminal responsibility estimated by it. Great stress is laid by many judges on the permanency of the mental disorder which accompanies delirium tremens, but the exact meaning they attach to the term "permanent" is doubtful. Pre- sumably, it refers rather to a continuance of the symptoms for a definite time after the individual has ceased to indulge in alcohol, than to an absolutely permanent insane condition. In Reg. v. M'Gowan (Manchester Assizes, 1878), Manisty, J., ruled that "a state of disease brought about by a person's own act — as delirium tremens, caused by excessive drinking — was no excuse for committing a crime unless the disease so produced was permanent." Recently a much less restrictive ruling has been given in the case of Reg. v. Raines (Lancaster Assizes, 1886), by Day, J., who said " that the question was whether there was insanity or not ; that it was immatei'ial whether it was caused by the person himself or by the vices of his ancestors ; and that it was im- material whether the insanity was permanent or temporary.'' Mr. Justice Day further ruled — " that if a man were in such a state of intoxication that he did not know the nature of his act, or that his act was wrongful, his act would be excusable." This ruling is in marked contrast with that previously given by Denman, J., and also with that given by Bramwell, B., in Reg. v. Rums (Liverpool Assizes, 1865), "that drunkenness was no excuse, and that a prisoner cannot by drinking qualify himself for the perpetration of crime ; but if through drink his mind had become substantially impaired, a ground of acquittal would then fairly arise." The term " substantially " in this ruling replaces the term "permanent" in the ruling given in Reg. v. JPGowan, above quoted, and seems to point to an impaired mental condition, which, although caused by drinking alcohol to excess, is not due to the immediate presence of alcohol in the system, but to more lasting changes produced in the higher levels of the brain, by which the power of self-control is lowered or entirely lost, and the individual is thereby rendered subject to delusions, and is deprived of the knowledge of the nature and quality of his actions. LUNACY CERTIFICATES. 3G1 (b) LUNACY CERTIFICATES. Before a person of unsound mind can be legally placed under re- straint, certain conditions specified by Act of Parliament must be fulfilled. The law jealously safeguards the liberty of the subject, and imposes a number of stringent regulations upon those to whom power is given of placing and receiving insane persons in institutions, or private houses, for the purpose of treatment and of preventing them doing injury to themselves and to others. Two recent Acts 1 have considerably modified and altered the mode of procedure previously in force. The subject, being of the highest importance to medical practi- tioners, demands careful and detailed consideration. Lunatics may be placed under restraint by the following modes of procedure, which are varied to suit the exigencies of each individual case : — Reception Orders on Petition. Urgency Orders. Orders after Inquisition. Summary Reception Orders. Orders for lunatics wandering at large, and for pauper lunatics. Reception Orders by two Commissioners. . Reception Orders on Petition.— This is the usual mode of procedure in the case of private patients. The Order for the reception of the patient is to be obtained bv priyate application from a "Judicial Authority:" that is to say, either a specially appointed justice of the peace, judge of county courts, or magistrate; lists of judicial authorities are published. A petition for the order must be presented to the Judicial Authority, if possible by the husband or wife, or by a relative of the alleged lunatic ; if by another person the reason for this departure must be explained. No person may present a petition unless he is at least twenty- one years of age, and within fourteen days before its presentation has seen the alleged lunatic. The petition must be accompanied by a statement of particulars, and by two medical certificates. Printed forms for all these documents are to be obtained. The Judicial Authority if satisfied may make the order forthwith without seeing the patient, or he may appoint a time not more than seven days after the presentation of the petition for enquiries and consideration ; he may also visit the alleged lunatic. At the time appointed for the consideration of the petition, he may either make an order or may adjourn the same for any period not exceeding four- 1 Tlie Lunacy Act, 1890 (53 Vict., cb. 5) and the Lunacy Act, 1891 (54 and 55 Vict., ch. 65). 362 FORENSIC MEDICINE. teen clays, and if he thinks fit he may summon further witnesses. If the Judicial Authority dismisses the petition, he must give the peti- tioner a statement in writing containing his reasons for doing so. A reception order ceases to be valid after the expiration of seven clear days from its date, except when suspended by a medical certificate of unfitness of lunatic for removal, in which case the lunatic may be received within three days after the date of a medical certificate to the effect that he is fit to be removed. Urgency Orders. — In cases of urgency where it is expedient that the alleged lunatic (not a pauper) shall forthwith be placed under care and treatment, he may be temporarily received without the intervention of a Judicial Authority, upon an urgency order, accompanied by a state- ment of particulars, and one medical certificate. If possible, the urgency order should be made by the husband or wife, or by a relative of the alleged lunatic ; it may be signed either before or after the medical certificate. If the urgency order is not signed by one of the persons named, it must contain a statement of the reasons why it is not so signed, and of the connection of the person signing it with the alleged lunatic. No person may sign an urgency order unless he is at least twenty-one years of age and within two days before the date of the order has seen the alleged lunatic. An urgency order remains in force for seven days from its date ; or, if a petition for a reception order is pending, until the petition is finally disposed of. The medical certificate must contain a statement that it is expedient for the alleged lunatic to be forthwith placed under care, with the reasons for such statement. Orders after Inquisition. — A lunatic found so by inquisition (the procedure will be explained subsequently), may be received upon an order signed by the committee of the person of the lunatic, or upon an order signed by a Master in Lunacy. f Summary Reception Orders. — Every constable, relieving officer, and overseer of a parish, who has knowledge that any person within his district or parish, who is not a pauper and not wandering at large, is deemed to be a lunatic, and is not under proper care and control, or is cruelly treated or neglected by those in charge of him, shall within three days give information on oath to a justice being a Judicial Authority under the Act. Such justice may visit the alleged lunatic, but whether he does so or not he shall direct two medical practitioners to examine and certify as to his mental state, and shall then proceed as if a petition for a reception order had been presented to him. A lunatic as to whom a summary reception order has been made, may be taken care of by a relation, or friend, with the consent of the Justice who makes the order, or of the visitors of the asylum in which the lunatic is, or is intended to be, placed. LUNACY CERTIFICATES. 363 5" Orders for Lunatics Wandering at Large. — Every constable and relieving officer and every overseer of a parish who lias knowledge that any person (whether a pauper or not) wandering at large within his district or parish, and deemed to be a lunatic, shall immediately apprehend and take the alleged lunatic before a justice ; or the justice, if information on oath is tendered to him, may require such constable, relieving officer, or overseer to apprehend and bring the alleged lunatic before him. The justice shall then call in a medical practitioner, and if he signs a certificate and the justice is satisfied that the alleged lunatic is a lunatic, and is a proper person to be detained, he may issue an order to that effect. If the medical practitioner certifies in writing that the lunatic is not in a fit state to be removed, the removal order shall be suspended until his fitness is certified to. If a constable, relieving officer, or overseer is satisfied that it is necessary for the public safety, or the welfare of the alleged lunatic that he should be placed under control before the above-mentioned proceedings can be taken, he may be removed to the workhouse of the union in which he is, and detained not longer than three days ; before the expiration of that time the proceedings required by the Lunacy Act shall be taken. Reception Orders by two Commissioners. — Any two or more Com- missioners in Lunacy may visit a pauper lunatic or alleged lunatic not in an institution for lunatics or workhouse ; they may call in a medical practitioner, and if he certifies with regard to the lunatic, and they are satisfied that the pauper is a lunatic, they may order his removal to an institution for lunatics. With the exception of the two last named these regulations do not apply to pauper lunatics or alleged lunatics. The usual proceeding in the case of pauper lunatics is for the medical officer of the union to give notice in writing to the relieving officer, or if there be none, to the overseer of the parish where the pauper resides, that a pauper resident within the district is a lunatic and a proper person to be sent to an asylum ; this he is bound to do within three days after obtaining knowledge of such pauper lunatic. Every relieving officer, or if there be none, overseer of the parish in which the lunatic resides, who has knowledge either by notice of the medical officer, or otherwise, that a pauper resident within the district or parish is deemed to be a lunatic, shall within three days give notice to a justice having juris- diction in the place where the pauper resides. The justice then orders the pauper to be brought before him and calls in a medical practitioner to examine him ; and if the medical practitioner signs a certificate and the justice is satisfied that the alleged lunatic is a lunatic and a proper person to be detained, he orders his removal to an institution Hh 364 FORENSIC MEDICINE. for lunatics. Thus it will be seen that in the case of pauper lunatics only one medical certificate is required. If any lunatic who is detained, escapes, he may be re-taken at any time within fourteen days without a fresh order. A reception order remains in force for periods of one, two, and three years, for successive periods of five years. At the end of each period respectively, it may be continued by the Commissioners in Lunacy, on certification by the medical officer of the institution, or by the medical attendant of a .single patient, that the patient is still of unsound mind and is a proper person to be detained under care and treatment. A patient may be discharged on the direction of the petitioner for the reception order, or, if dead or incapable, by the nearest of kin, or by a Commissioner, unless the medical man in charge certifies that the patient is dangerous and unfit to be at large. Two Commissioners may order the discharge of any patient. The principle which governs the provisions of this Act is that no person can be legally placed under restraint as a lunatic without an order obtained from a Judicial Authority. Exceptions to this principle are constituted by cases which are dealt with by inquisition, and by two Commissioners. Urgency orders are made without the intervention of a Judicial Authority, but they are only temporary and provisional, being intended to prevent harm happening to or by the lunatic until the necessary formalities have been observed to permanently place him under restraint ; so that although an alleged lunatic has been admitted into an institution for lunatics on an Urgency order, the entire procedure relating to obtaining a reception order on petition has to be gone through just as though the alleged lunatic had not been previously dealt with. Medical Certificates in Lunacy. Apart from lunatics found so by inquisition, lunatics wandering at large, pauper lunatics, and lunatics who are temporarily taken care of on an Urgency Order, two medical certificates are required before any person can be placed under restraint as a lunatic. Every medical certificate must state the facts on which the certifier has formed his opinion that the person to whom the certificate refers is insane ; he must distinguish facts observed by himself from facts com- municated by others, and it is important to note that a reception order will not be made upon a certificate founded only on facts communicated by others. In respect to orders on petition each medical practitioner who signs a certificate nuist have personally examined the alleged MEDICAL CERTIFICATES IN LUNACY. 365 Nft lunatic within seven clear days before the date of the presentation of t he petitio n, and in all other cases within seven clear days before the date of the order. Where two medical certificates are required, each medical practitioner must examine the alleged lunatic s eparately from the othe r. I n the case of urgency orders the practitioner must have examined the alleged lunatic not more than two clear days before his reception. A medical certificate may nol be signed by the petitioner for an order, nor by the person signing the urgency order, nor by any near relative, partner, or assistant of the petitioner or person. One of the medical certificates accompanying a petition for a reception order should be under the hand of the usual medical attendant of the alleged lunatic ; if this is not practicable the reason must be stated in writing by the petitioner to the Judicial Authority to whom the petition is presented. No certificates shall be signed by persons interested in the institution or house to which the lunatic is going, nor by any near relations of such persons, nor by two medical men related to or in partnership with each other, or standing in the relation of principal and assistant. A medical practitioner who has signed a certificate upon which a reception order has been made shall not be the regular professional attendant of the patient while detained under the order. A person for whom a reception order on petition has been obtained may be placed in a "single-patient house," that is, a house in which one lunatic only is detained on payment, exactly as in an asylum, or in a licensed house — i.e., private asylum. Under special circumstances the Commissioners may allow more than one patient to reside in the same house under the same conditions as if each of them were a single patient. If the usual medical attendant of the lunatic desires to continue in attendance during the detention of the lunatic in a single-patient house, he must not only not sign either of the certificates, but neither he, his partner, nor any of his near relatives must derive any profit from the charge of the patient. The Commissioners may direct how often a single patient is to be visited by a medical practitioner ; until such direction is given the patient must be visited once at least i'mtv two weeks. Any two Commissioners may dh'ect that the medical attendant of a single patient shall cease to act in that capacity, and that some other person shall be employed in his place. The Commissioners may at any time require from the medical attendant of a single patient a report in writing as to the patient, with such particulars as the Commissioners may direct ; this is in addition to any periodical reports required by law to be sent to the Commissioners. The Commissioners may require a report of the mental and bodily condition of a lunatic, or alleged lunatic, who, without order and certifi- 36G FORENSIC MEDICINE. cates, is detained or treated as a lunatic by any person receiving no pay for the charge, or who is in any charitable, religious, or other estab- lishment, not being an institution for lunatics ; the report is to be furnished by a medical practitioner, and repeated periodically if required. The Commissioners may also visit such patient, and may exercise all the powers (except that of discharge) given to them as to patients in an asylum or as to single patients. If they think fit they may inform the Lord Chancellor, who may make an order for the discharge of such patient, or for his removal to an institute for lunatics. This is a departure from the former custom, which was that the Commissioners had no control over patients treated in private houses where no one derived any pecuniary benefit from their deten- tion. Examination of Alleged Lunatics in Relation to Lunacy Certificates. — The objects of the examination are: — to determine whether the indi- vidual is or is not insane, and if insane whether he is a fit and proper person to be placed under restraint. The distinction is important as a person may be undoubtedly insane, and yet neither his language nor his actions may justify a medical practitioner in certifying that he ought to be sent to an asylum. The printed forms of certificates have mar- ginal- or foot-notes explanatory of the mode in which they are required to be filled up; a reference to the appended form will at once show what is meant. Any practitioner who is not accustomed to fill up these forms should carefully read over the directions, and be sure he fully understands them before commencing to write. It is to be remembered that the law requires absolutely literal accuracy, the least omission is sufficient to invalidate the whole document. When examining an alleged lunatic — which is best done in the character of a medical man, although in exceptional cases it may be advisable to personate a casual caller or some one other than a doctor — if his words or actions do not at once reveal insanity the examiner will soonest obtain an opportunity of judging as to his mental state by directing the conversation to personal matters. Should the case be one of delusional insanity some information previously obtained as to the nature of the delusion, or delusions, will materially help the in- vestigation. Delusions may be of two kinds : they may carr y th eir own refutation, or they may present no abstract inconsistency. If, in a certificate, it is stated that the patient says he is the Holy Ghost, comment is superfluous ; but if it is stated that he says he is starving for want of money, no delusion is evident unless information is added, such as the further statement that he is really a wealthy individual with an income of a thousand a year. The officials into whose hands the certificates come know nothing, beyond what is contained in them, MEDICAL CERTIFICATES IN LUNACY. 367 LUNACY ACT, 1890. CERTIFICATE OF MEDICAL PRACTITIONER. In the Matter of A- B. of 1 in the County- 3 an alleged lunatic. I, the Undersigned, C. D., do hereby certify as follows : 1. I am a person registered under the Medical Act, 1858, and I am in the actual practice of the medical profession. 2. On the day of 189 , at 1 in the county 5 of [separately from any other practitioner], 6 I personally examined the said A. B., and came to the con- clusion that he is a [lunatic, an idiot, or a person of unsound mind,] and a proper person to be taken charge of and detained under care and treatment. 3. I formed this conclusion on the following grounds, viz. : — (a.) Facts indicating insanity observed by myself at the time of examination, viz. : — "' (b.~) Facts communicated by others, viz. : — s [If an urgency certificate is required it must he added here.] 4. The said A.B. appeared to me to be [or not to be], in a fit condition of bodily health to be removed to an asylum, hospital, or licensed house. 9 5. I give this certificate having first read the section of the Act of Parliament printed below. Signed of 10 Dated, Extract from Section 317 of the Lunacy Act, 1890. Any person who makes a wilful misstatement of any material facts in any medical or other certificate, or in any statement or report of bodily or mental con- dition under this Act, shall be guilty of a misdemeanour. 1 Insert the residence of Patient. 2 City or Borough, as the case may be. 3 Insert profession or occupation, if any. 4 Insert the place of examination, giving the name of the street, with number or name of the house, or should there be no number, the Christian and surname of occupier. 5 City or Borough, as the case may be. 6 Omit this where only one certificate is required. 7 If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them in a separate paragraph. "The names and Christian names (if known) of informants to be ints have to be considered in relation to the effect produced by a given dose of a poison ; the rapidity of absorption and the rapidity of elimination. If a poison is eliminated as rapidly as it is absorbed, and the rate of absorption is too slow to immediately bring the system under its lethal influence, no permanently deleterious effects are produced. For this reason some poisons can be received into the mouth, and even swal- lowed with impunity, in amounts that would be lethal if introduced under the skin. Curare, some kinds of arrow-poison, and the venom ejected from the fangs of poisonous serpents are examples of poisons of this type. The wound inflicted by a poisoned arrow may have a sufficient amount of the poison deposited in it as to cause the death of the wounded person if left to his fate ; but if a second person immediately and vigorously sucks the wound, no mischief results to either of them. The same immunity follows if the wounded individual himself is able to suck his wound, and does so at once. The poison sucked out of the wound is at once spat out, and thus only comes in contact with the mucous membrane of the mouth, the absorptive capacity of which is too limited to allow, during the period of contact, of the introduction •of an amount of poison into the system sufficient to cause mischief. The poison extracted by the suction might probably be swallowed with impunity, as it would be eliminated by the kidneys as quickly as the gastric mucous membrane took it up. The law makes no distinction in r elation to the mode in which a poison is introduced into, or acts upon, the system. Hypodermic, or POISONS IN THEIR GENERAL ASPECT. 385 endermic administration of a poison, or the injection of it into the bowel, with intent to commit murd< .-. are regarded precisely as though the poison had been given by the mouth. The chemical combination in which certain poisonous substances l^ exist, and the degree of concentration in others, exercise a powerful influence on their lethal potency. Silver nitrate and hydrochloric acid are both energetic poisons when taken separately, but when combined the resulting salt — silver chloride — is inert, or thereabouts, because of its insolubility. In some instances the action of the poison is entirely altered by chemical combination, another effect being substi- tuted for that which is characteristic of it in the uncombined state. Strychnine alters the rate of transmission of stimuli from cell to cell hi the spinal cord, or possibly increases the excitability of the cells, the result being the occurrence of clonic muscular spasm. If strych- nine is so treated as to become a methyl derivative, it no longer acts on the cord, but it paralyses the motor nerve-endings, like curare. In the case of poisons, such as the mineral acids, which act directly on the tissues with which they come in contact, the degree of concentration is an important factor. An amount of concentrated acid that would be sufficient to cause death, might be swallowed with impunity if lai'gely diluted with water. When poisons are taken by the mouth, the state of the stomach as regards presence or absence of food, considerably modifies the rate of ibsorption and the intensity of local action. A person has been known to swallow more than a lethal dose of undissolved white arsenic with impunity, because the stomach was well filled with oatmeal porridge. When a poison is received into a full stomach the usual symptoms are delayed much beyond the customary time of onset, and if the poison is one that is quickly eliminated by the kidneys an average fatal dose may be survived although the whole of it is eventually absorbed. On the other hand an empty stomach and bowel quickly absorb any poison received, and the onset of the symptoms is accelerated. Classification of Poisons. — A comprehensive classification is scarcely feasible without involving great complexity and, when accomplished, is of little use. The division of poisons into inorganic, and organic, with the sub-division of the first into corrosive* and irritants, and of the second into irritants and neurotics, affords a basis sufficiently broad for practical purposes. Both organic and inorganic groups comprise poisons which act by disintegrating, or by interfering with the function of the red corpuscles of the blood. 386 FORENSIC MEDICINK. THE DIAGNOSIS OF POISONING. The effects severally produced on the living organism by variou poisons differ within limits in accordance with the kind of poison taken. Common to almost all forms of poisoning, however, are a number of symptoms, or effects, some of which are intrinsic, affecting the indi- vidual ; others are accidental and do not personally implicate him. In the first group is sudden occurrence of acute symptoms in a person previously in hisTusual health. In relation to this indication it is to be remembered that the initial symptoms produced by many poisons bear a certain resemblance to those due to disease: — Arsenic causes symptoms which have been mistaken for those of cholera or of gastro-intestinal catarrh; strychnine for those of tetanus; morphine for those of apoplexy ; belladonna for those of acute delirious mania. Errors of the opposite kind have been fallen into : the rapid onset of an acute disease in a person who appeared to be in good health up to the time when the symptoms showed themselves has been mistaken for the effect of poison. Among diseases" of this nature are— an acute gastric ulcer which ruptures, perforation of the bowel, rupture of an abdominal aneurism, the'formation of a peri-uterine hematocele, acute intestinal obstruction with persistent vomiting, choleraic diarrhoea, haemorrhage into the pons. Some of these conditions could only give rise to momentary doubt, others may cause prolonged anxiety to the medical attendant. The occurrence of symptoms of an anomalous nature shortly after eating or drinking, or taking medicine is a suspicious indication, which for its interpretation requires considerable discrimination. Violent vomiting and purging may be due to some change undergone by the food itself before cooking. The food may be in its norma] condition, but the state of the recipient's stomach may be at fault: a person who has fasted long beyond his usual meal time, if In hurriedly eats some food difficult of digestion, may forthwith be attacked by vomiting and pain which closely resemble the effects of an irritant poison. An unsuspected gastric ulcer may give way under like conditions. Poison may be intentionally added to medicine which is being taken by a sick person, and the ill results which follow every dose may be attributed by him to its legitimate therapeutic action. When attending a case in which anomalous symptoms repeatedly recur, tin medical practitioner should be silently observant, unless the indica tions of foul play are conclusive, or the state of the patient is becom critical; in either of these events it is his duty at once to take such measures as are necessary to prevent further mischief. The position •,- an extremely delicate one. It is a very serious matter for a practitioner THE DIAGNOSIS OF POISON IXC 387 to make an unfounded charge against an innocent person : but to allow a patient to be poisoned under his eyes is infinitely worse. If the medical attendant's suspicions arc aroused, he should especially distrust the ministrations of any one who is studiously attentive to the invalid; who prepares all his food and insists on giving it to him with his or her own hand, and who displays an exaggerated interest in the treatment of the patient, and in the visits of the doctor. Such a person will stand by the invalid as he takes his food, and will throw away what is left, under the pretext that everything partaken of should he freshly prepared. All this is not inconsistent with innocence and a genuine for the welfare of the patient, but when incongruous symptoms arise which are at variance with the natural course of disease, such a person is to be regarded with suspicion and carefully watched. The patient should be cautiously, but not mysteriously, interrogated as to the food or -fluids that he has partaken of, and the times when he felt any accession of the suspicious symptoms. The most practical safeguard in cases of suspected foul play is the engagement of a couple of trained nurses for night and day duty respectively. They should be instructed not to leave the patient when on duty, and to prepare and give all food and medicine with their own hands. In giving strict injunctions to this effect, it is not necessary that the nurses should be taken into the confidence of the doctor, unless mdition of matters is critical, or for some other reason he deems it advisable. A twenty-four hours' supply of the patient's urine should be obtained and submitted to chemical examination for the suspected poison; this may he done without giving rise to suspicion, as doctors frequently require specimens of urine for examination in i he course of ordinary diseases. To take away food or Leverages prepared for the patient would of course be to reveal suspicion, and should only be resorted to when the conviction of foul play is very strong and concealment is no longer possible. If the urine, or other substance, is sent to an analyst, it should be accompanied by a statement of the kind of poison it is suspected to contain. The state of the medical attendant's mind when he believes that an attempt is being made to poison his patient, may be described as having two stages : — first, one of suspicion, and then one of con- iriction, supposing that his suspicions are well founded. These states of mind have different obligations. When, from symptoms irreconcilable with the ordinary course of the disease, or on Of some suspicious circumstance, or chain of events, the idea daw: upon the medical attendant that his patient is the victim of a s< poisoner, he is not therefore justified in immediately proclaiming his suspicion. It is quite possible that be maj be wrong, and as 388 FORENSIC MEDICINE. a statement to the effect that lie believes some one is attempting to commit murder, cannot be made without implicating people who may be innocent, such a statement is not rashly to be made. The practitioner would also render himself liable to legal proceedings on the part of those whom he had directly, or by implication, accused of the crime. Errors of interpretation, or of judgment, are easily fallen into, and, under circumstances such as are being discussed, it would be unwarrantable, on the first feeling of mistrust, to act as though the matter was beyond all doubt. The steps to be taken when suspicion is aroused, but no evidence has been obtained, are to protect the patient in the way previously described, and to keep a sharp look out for renewed attempts. If the matter has gone further, and the medical attendant is fully convinced that poison is being administered, what is he to do 1 There are three courses open : — to tell some member of the family, other than the suspected person ; to tell the patient himself ; or to inform the police. A fourth plan has been recommended ; it is to tell the person believed to be the culprit, that proof of the administration of poison has been obtained (without accusing him of being the administrator), and that, in the event of any further attempts being made, it will be necessary to inform the police. This would probably put an end to the matter, but it comes too near compounding a felony to be justifiable. Strictly speaking, it would be the duty of the medical attendant to inform the police as soon as he is fully convinced that a criminal attempt is being made on the life of his patient. Circumstances may make it advisable for him to take a member of the family whom he can trust into his confidence before doing so. Just as precipitancy was deprecated in the stage of mere suspicion, so is promptness necessary when that suspicion is converted into certainty. The medical atten- dant's duty is clearly defined, and he is bound to fulfil it without fear or favour. Indications of poisoning may be shown by circumstances apart from the symptoms which affect the individual. A number of healthy persons may be simultaneously attacked with analogous symptoms after a common meal ; this may be due to intentional or accidental admixture of poison with the food, or to abnormal constitution of one or more of the food-stuffs partaken of. Another way in which suspicion may be aroused, apart from any symptoms manifested by the patient, is by the discovery of an unusual appearance or odour possessed by the food or medicine which has been prepared for his use. When a medical man is in attendance on a case in which he suspects poisoning, he should note down all he observes immediately after each visit; such notes may be of the utmost value should the case end fatally. THE GENERAL TREATMENT OF POISONING. 389 If the conviction of foul play is believed to be well-founded, medicine- bottles, specimens of foods and drinks provided for the patient should be taken possession of, and guarded until handed over to the police or to the analyst. Vomited matter, and sheets or other fabrics stained therewith, should also be impounded. THE GENERAL TREATMENT OF POISONING. The conditions To be fulfilled are: — to empty the stomach of any poison it may contain, or to neutralise it ; to combat the effects of that which has been absorbed, and to promote its elimination ; to keep the patient alive until the effects of the poison have passed oil': to alleviate general symptoms. There are two ways of forcibly emptying the stomach- -by means of an emetic, and by means of the stomach-pump. Emetics. — Half drachm doses of zinc sulphate dissolved in warm water, repeated if necessary, act quickly without causing depression ; if not at hand, a dessert spoonful of mustard may be. given in a tumbler of warm water. For children, a teaspoonful of ipecacuanha wine is a good emetic. In any case the patient should drink copiously of warm water, which materially aids emesis and washes out the stomach. Tartar emetic and copper sulphate are to be avoided; the former is a depressant, and both would tend to add to the difficulty of a subsecpient chemical analysis, should it be necessary. An exception is to be made with regard to phosphorus poisoning in which copper sulphate may be given. Instead of giving an emetic by the mouth. a hypodermic injection of a solution of apomorphine hydrochlorate may be administered; the B.P. solution for hypodermic injection contains two grains in one hundred minims, of which five minims — one-t enth of a grain — is a proper dose to inject in a case of poisoning. This method of procuring emesis is convenient, especially in cases of narcotic poisoning where there is great difficulty in making the patient swallow. In the absence of an emetic, the fauces may be tickled with a leather, or even the finger, and copious draughts of warm water given. The stomach-pump, or tube, is an efficacious mode of emptying tin stomach independently of physiological function, and is therefore entirely under the control of the operator. If the mouth of the patient can be kept open, there is little difficulty in passing the tube of the instrument down the (esophagus, keeping ii well against the posterior wall. It may be necessary to forcibly open the jaws, ami to keep them open with a gag. Before withdrawing any of the co ntents of the s tomach, a pint or so of warm w ate r should be injected ; the same > 390 FORENSIC MEDICINE. amount is then withdrawn, anda further supply injected, which is also withdrawn. The object of this is to wash the stomach out, and to make sure that it is not entirely emptied, which might lead to injury of its coats. If the stomach-pump is not to hand, five or six feet of india-rubber tubing, such as is used for small gas supplies, fitted with a funnel at one end, may be substituted. The free end is then passed down the patient's throat and, when in the stomach, a pint or more of warm water is poured into the funnel, which is held as high as the length of tubing will allow. When the funnel is almost empty the tube close to it is pinched between the finger and thumb, and the funnel depressed until it is lower than the stomach ; on removing the finger and thumb the tube acts as a syphon, and evacuates the stomach. The process is to be repeated as with the stomach-pump until nothing but clear, non-odorous water comes away. When the stomach contains much solid matter of a lumpy consistence, it may be advisable to give an emetic before using the pump or tube, in order to avoid clogging. Neither the stomach-pump nor emetics are to be used in cases of cor- rosive poisoning; the proper treatment in such cases is to neutralise the poison. The passage of the tube is exceedingly risky in any case where the walls of the oesophagus and stomach are softened and corroded ; for this reason, the stomach-pump requires using with great caution in the case of certain irritants, especially if the patient is not seen for some time after the poison is swallowed. In cases where the proper treatment is to empty the stomach, and the introduction of the stomach-pump, or tube, would be risky, an emetic is to be given. The stomach-pump is especially useful in cases of poisoning by opium, alcohol, chloral hydrate, chloroform in the liquid state, the vegetable, and most of the mineral irritants, phosphorus (if the case is seen shortly after the poison is swallowed), and the alkaloids. In strychnine-poisoning it will probably be necessary to place the patient under chloroform before the tube can be passed. In the absence of the stomach-pump, or tube, an emetic may be administered in appropriate cases; but where time is of importance the mechanical method is preferable. Antidotes are remedies which counteract the effects of poisons. The}' act either mechanically, chemically, or physiologically. Flour and water, or chalk -mixture, act as mechanical antidotes, when given in poisoning by phosphorus or cantharides. Magnesia and chalk are chemical antidotes to the mineral acids ; as are the alkaline sul- phates to the salts of lead and barium. Physiological antidotes will be discussed separately, under the heading of "antagonism of poisons." The elimination of the poison that has been absorbed is to be assisted ANTAGONISM OF POISONS. 391 by purges (when not contra-indicated) diuretics, and special remedies in the case of certain poisons. The patient, if possible, is to be kept alive until the effect of the poison has passed off: by artificial respiration and cold douche (hydro- cyanic acid), by being kept awake (opium), by external Warmth (chloral hydrate and carbolic acid) and by stimulants. General symptoms, as excessive pain, exhaustion, useless vomiting and purging, are to be combated by appropriate remedies. ANTAGONISM OF POISONS. This term is applied to the power certain poisons are supposed to possess of counteracting the effects of other poisons, either by the exercise of an opposing influenc e — if a poison paralyses a certain tissue, its antagonist stimulates it — or, as suggested by Ringer, 1 by chemical displacement. The latter hypothesis supposes that a poison which acts as an antagonist to another poison, has a .stronger affinity for the tissue attacked, and that it displaces the poison towards which it is an antagonist, substituting its own action for that of the poison. In its full meaning the term "antagonism" includes more than mere reversal of some of the affects produced by a poison; it comprises c ounte raction of the influence of the poison step by step in the tissues originally attacke d. This is altogether different from setting up at a distance an opposing force or obstacle, which only changes or reverses outward indications, leaving the tissues originally attacked still under the influence of the primary poison — merely blocking the way to external manifestations. For example, morphine slows the action of the heart and atropine quickens it; therefore, so far as outward appearances go, atropine in this respect acts antagonistically to mor- phine. But morphine slows the heart by excitation of the vagus at its origin in the brain — as shown by the fact that if the vagi are divided before morphine is given, no retardation occurs. Atropine quickens the heart's action by paralysing the terminations of the vagi, and also the inhibitory ganglia in the heart — as shown by absence of slowing on irritation of the vagi in animals under the influence of atropine. Under these circumstances it is clear that the influence exerted by morphine, in the direction of slowing the heart, is not removed by atropine, it is simply arrested at a point distant from the seat of action. Again, a true antagonist would counteract in every direction the influence of the p oison to which it is opposed; it is not enough for it 1 Handbook of Therapeuli . 392 FOREKSIC MEDICINE. to combat some effects, and to leave others unopposed. It is prob- able that atropine is truly antagonistic to morphine as regards the respiratory function : atropine stimulates the respi ratory cent re and morphine depresses it. Unverricht, 1 however, denies that atropine is a stimulant for the normal respiratory apparatus, and cites some experiments by Orlowski 2 in support of his views. Atropine also at first stimulates but subsequently depresses the v asomotor ce ntre ; opium in large doses depresses it from the first. In regard to other functions the action of the two poisons, though apparently anta- gonistic, is not really so ; and in others again there is not only absence of antagonism, real or apparent, but similar results are produced, though not in the same manner. As is well known opium contracts the pupil and atropine dilates it. In this relation it is probable that opium acts centrally and atropine peripherally, paralysing the terminals of the oculo-motor nerves. Both poisons cause dryness of the mouth — opium by lowering reflex excitability, and atropine by paralysing the secretory fibres of the chorda tympani. Opium causes sweating by stimulating the central nerve-apparatus concerned ; atropine arrests it by paralysing the nerve terminals in the sweat glands. Opium, after causing an initial increase in the intestinal movements, arrests them probably by lowering the reflex excitability. Atropine is believed ultimately to deprive the intestines of movement by paralysing their motor nerves and, finally, the muscular elements themselves. The terminals of the inhibitory fibres of the splanchnics are also paralysed by atropine. Thus, although in respect to one or two prominent symptoms, atro- pine and morphine are opposed in their action, they are not true antagonists. Their modes of action are different ; broadly speaking, atropine acts peripherally, morphine centrally. Morphine, in poisonous doses, depresses the excitability of the ganglionic cells of the cerebrum, and probably of the cord also, and lessens reflex function. This is disputed by some ; Unverricht 3 states that opium does not lower, and may increase, the irritability of the cortex. Atropine stimulates the central nervous system, and in this way increases the reflex function ; but it also paralyses many of the peripheral nerves, and thus cuts off the organs supplied by them from their centres. The ulti mat e effect of both poisons is to paralyse the motor and the sensory nerves . Morphine, when used as an antagonist to atropine, is much feebler in its effects than atropine is when used to antagonise morphine. Notwithstanding the absence of proof of antagonism, many cases are 1 Centralbl. f. Mm. Med., 1891 and 1892. - Einwirkung des Atropins avf 'die Resp., 1891. 3 Centralbl. f. Hin. Med., 1891. ANTAGONISM OF POISONS. 393 recorded in which life is believed to have been saved by the adminis- tration of atropine to patients suffering from poisonous doses of opium, When active treatment is successful, there is a tendency to attribute the good results to some specific cause, and the remedy, or the means used, that is apparently the most active, is the one selected for this purpose. .V careful study <>f the recorded cases of treatment of opium- poisoning with atropine occasions great doubt as to the correctness of the inference drawn by those who advocate the treatment. It is quite excusable for a medical man, after administering atropine, to be greatly impressed by the recovery of a patient from an apparently moribund condition, the result of a poisonous dose of opium. It is not customary, however, in such cases to trust to one remedy solely, no matter how much importance is attached to it ; other treatmenl is actively carried out during the critical period, and the effects of such treatment are often ignored, or underrated. There are grave reasons for believing that too active treatment of opium poisoning with atropine has some- times been the means of hastening, rather than preventing, the fatal issue. Lenhartz 1 states that out of 132 cases of opium poisoning, of which 59 were treated with atropine, and 72 without, 38 per cent, of the former died, and only 15 per cent, of the latter. In three cases that came under his own observation, subcutaneous injection of atropine produced no effect beyond dilating the pupils and increasing the rapidity of the heart beats, the unfavourable symptoms persisted. Recovery ultimately took place in two ; the third died, and the cumulative effect of the atropine was regarded as not being beyond suspicion of having exercised a deleterious influence. Without going so far as to deny the possibility of benefit from the use of atropine in the treatment of opium poisoning, the exercise of great caution is strongly urged, as the repeated heroic doses that have been given are altogether unjustifiable in the face of the known ultimately mutual effects of the two poisons. It is to be remembered that whatever antagonistic effect small closes of atropine may exercise, its ultimate effect is to paralyse the heart. Perhaps the best illustration of antagonism between poi sons is a Ho rded by atropine and physostigmine. Frazer's 2 experiments have demon- strated that physostigmine increases the excitability of the vagi, while atropine diminishes and suspends it ; physostigmine lowers arterial tension, atropine augments it ; physostigmine increases glandular secre- tion, atropine diminishes, or arrests it; physostigmine contracts the pupils, atropine dilates them. In the greater number of these instances,. the antagonism is real, being effected in the same structures and in the same order. 1 Archiv.f. exp. Path. u. Pharm., 1887. 2 Transactions of the Royal Soc. Edin., vols, xxiv., xxvi. 39-t FORENSIC MEDICINE. Limited antagonism between poisons may be advantageously utilised for antidotal purposes. The effects' produced by strychnine on the respiratory centres and on the reflex mechanism of the cord are, within limits, capable of being antagonised by chloral hydrate. Reciprocally chloral poisoning maybe beneficially treated by the administration of strychnine ; atropine is also a limited' antagonist to chloral hydrate- Muscarine antagonises atropine by stimulating the endings of the oculo-motor nerves, the endings of the secretory fibres of the chorda tym- pani, and the inhibitory cardiac ganglia, at the same time paralysing the cardiac muscles. It also depresses the activity of the respiratory centres. Muscarine ultimately paralyses the inhibitory action of the vagi, and is thus finally in accord with, instead of antagonistic to, atropine. Other poisons are accredited with a limited degree of mutual an- tagonism, such as atropine to aconite, digitalis to aconite, chloral hydrate to picrotoxine, atropine to pilocarpine, aconite to strychnine, morphine to hyoscyamine, strychnine to nicotine. Theine and its con- geners, caffeine and guaranine, to some extent antagonise morphine. GENERAL SYMPTOMS OF CORROSIVE AND OF IRRITANT POISONING. Before considering the evidences of poisoning that are available in the dead body, it will conduce to their due appreciation if a general description is first given of the symptoms which occur during life. The poisons which give rise to the most characteristic post-mortem appear- ances are corrosives and irritants. A corrosive, as the name indicates, is a substance which destroys tissue by direct chemical action; a corrosive also acts as an irri- tant, and, if administered in a dilute form, it may do so exclusively, without producing any corrosive effects. When a poison which acts as a corrosive is swallowed, an immediate and violent sensation of pain is produced, which extends from the mouth, along the oesophagus to the stomach, and then radiates over the abdomen. Uncontrollable retching and vomiting comes on within a few minutes, the appearance of the vomited matter being determined within certain limits by the nature of the corrosive; shreds of mucous membrane, coagulated mucus, and blood are always present, the colour of the blood being sometimes altered by the chemical action of the poison. During this first stage the patient is frequently partially or wholly convulsed, a reflex symptom caused by the excruciating pain. There is intense thirst, with difficulty or impossibility of swallowing, each attempt to do so causing increased vomiting. The patient is in a condition of extreme collapse — the surface is pale, cold and bedewed with clammy sweat; GENERAL SYMPTOMS OF CORROSIVE AND OF IRRITANT POISONING. 395 fche features are pinched; the eyes, sunk into their sockets, have a wild, terrified look. The voice is hoarse, or there may be complete aphonia; in the latter case ii is probable that some of the corrosive has reached the larynx. The mouth is filled with ropy mucus ; the salivary -lands secrete profusely ; the lips are swollen, and. along with the corners of the mouth, may show signs of the local action of the corrosive. The mucous membrane of the mouth is detached and the underlying tis-mes are corroded, the colour of the surface varying with the nature of the corrosive. The abdomen is usually distended. The breathing is Laboured and noisy; attempts to clear the air-passage give rise to a distressing cough; which has a peculiarly hoarse, laryngeal sound. The pulse, thread-like, and of low tension, is scarcely perceptible at the wrist. The bowels are confined; the urine is diminished in amount, or entirely suppressed, and attempts to relieve the bladder are painful and futile. The mind usually remains clear to the em\, death taking place from extreme collapse; in some cases death is preceded by convulsions. In an acute case, as above described, death takes place within twenty-four or thirty-six hours. An irritant poison is one which by its specific action sets up inflam- mation in the intestinal tract. A pure irritant does not produce corrosion, although some substances classed as irritants may act as corrosives. When a substance that acts solely as an irritant i 3 swallowed, the symptoms do not come on in the act of swallowing nor immediately after, as is the case with corrosives; an interval elapses of from half an hour to an hour or more. In the case of metallic irritants (the symptoms they produce being taken as a type of irritant-poisoning) there may, or may not, be an astringent or metallic taste perceived at the time the poison is swallowed. The presence or absence of this symptom depends partly upon the nature of the poison itself, and partly upon the medium in which it is ad- ministered. The first symptoms are those of gastro-intestina] irrita- tion ; violent and persistent vomiting and purging, with severe gastric and abdominal pain. The vomited matter probably at first consists of food, then it becomes bilious, and finally may be blood-stained. There is intense thirst, and attempts to allay it provoke further vomiting. A hot burning sensation along with a feeling of constrict ion is felt in the throat. The purging is accompanied by violent tenesmus, and the dejections may be blood-stained; they are sometimes colourless, of the rice-water type. The symptoms of collapse appear : the surface is cold and clammy, and the pulse feeble and intermittent ; occasionally the skin is hot and dry, probably due to an attempt at reaction. There is great restlessness and anxiety, the mind often remaining clear to the last. The patient may be troubled with violent cramps in the 396 FORENSIC MEDICINE. legs, or he may have general convulsions. In fatal cases, death from exhaustion takes place in from one to four days. EVIDENCE OF POISONING FROM THE DEAD BODY. As the symptoms of poisoning during life vary according to the nature of the poison that has been taken, so do the post-mortem appearances diner when the result has been fatal. The two classes of poisons which yield the most characteristic post-mortem appearances are corrosives and irritants. All corrosives and all irritants do not produce the same after-death appearances, but certain characteristic indications are usually met with in each class respectively. In making a post-mortem examination on a case of suspected poison- ing, it is important to distinguish between the effects of poison, and those due to disease on the one hand and to incipient putrefaction on the other. The post-mortem indications afforded by corrosive and irritant poisons are to be sought for along the digestive tract. They comprise hypercemia, softening, and ulceration of the mucous mem- brane, with perforation of the wall of a viscus either due to ulceration or, more frequently, to the direct action of a corrosive. The ordinary effect of an irritant poison is to cause hyperemia of the mucous membrane of the oesophagus and stomach, and possibly of that <>f the small intestine. The hyperemia may either be diffuse, or isolated in patches ; it is usually most marked about the cardiac end of the stomach ; more rarely is the pyloric end affected. With some irritants there is a tendency to the formation of small hemorrhagic points, or stria?, or there may be large dark patches, which stand out in contrast with the neighbouring and less deeply coloured mucous membrane. The hyperemia may be most intense along the summits of the rug* of the gastric or intestinal mucous membrane ; or the entire mucous coat of the stomach may he hyperamiic and thickened, presenting a velvety appearance — frequently seen in acute arsenical poisoning. The mucous surface may be covered with viscid secretion, which may be blood-stained. Softening of the mucous membrane of the stomach when due to poison is usually caused by corrosives ; indications of the same con- dition are to be found in the esophagus and possibly in the mouth as well. It is not a common result of poisoning ; when it occurs it is chiefly due to the direct chemical action of the poison. All corrosives do not cause softening; carbolic acid corrugates and hardens the mucous surfaces with which it comes in contact, and some other corrosives occasionally do the same. Softening is an almost invariable result of poisoning by the alkalies. THE LOCAL EFFECTS OF POISON. 397 Ulceration of the mucous membrane of the stomach i- occasionally seen as a result of irritant poisoning; it appears to be chiefly due to the local action of a portion of the poison on a limited surface of the membrane. In this way phosphorus may set up ulceration as a primary result, apart from its secondary effects. Sometimes ulceration is due to infarcts, the result of inflammatory processes causing blood stasis. Removal of patches of mucous membrane by the direct action of corrosives is to be distinguished from ulceration — the former is due to chemical destruction of tissue, the latter to pathological proces Perforation, as a result of poisoning, is usually due to the direct chemical action of a corrosive on the coats of the stomach, or more rarely of the small intestine. The appearance of a perforation thus caused is characteristic; there is no indication of limitation by in- flammatory processes, the margins instead of being thickened, are partially disintegrated, a condition that extends some distance from the aperture, which is usually large andjis irregular in outline ; the edges of the opening and the contiguous parts (when the perforation is due to sulphuric acid) are blackened and^charred. Ulceration due to irritant poisoning may he followed by perforation, but such an event is of exceptional occurrence ; the appearances would more nearly resemble those met with when an idiopathic gastric ulcer has given way. The poison which most frequently causes perforation is strong sulphuric acid. THE LOCAL, EFFECTS OF POISON CONTRASTED WITH THOSE OF DISEASE AND THOSE PRODUCED BY POST-MORTEM CHANGES. Some of the above described appearances cannot be distinguished from similar appearances which are due to disease, others are only met with as the result of poisoning. Acute idiopathic inflammation of the mucous membrane of the stomach is exceedingly rare, so that the inflammatory appearances described, when distinctly present, arc always suspicious of irritant poisoning; on the other hand, such ap- pearances maybe absent, or feebly marked, after death from an irritant poison. The colour of the gastric mucous membrane should always be noted at the time the stomach is opened, as it becomes redder on exposure to air. The colour alone is /of t,> l„ ,-< l'i> d <,n as an indication of inflammation; it may result from food or medicine which contain pigmentary matter. Some fruits, such as black cherries and elder- berries, will colour the gastric mucous membrane, which is also reddened during digestion of food, and it is said, by copious draughts of ice-cold water. Post-mortem staining produces redness, but it is 398 FORENSIC MEDICINE. limited to the posterior part of the stomach — the body being on its back ; the mucous membrane is not thickened, there is no glairy mucus on its surface, and the general appearance is unlike that due to inflammation. Incipient putrefactive changes produce softening of the mucous membrane of the stomach along with colour changes. These changes commence at the posterior part, at the seat of post-mortem staining, the softening affecting the entire thickness of the coats of the stomach. When softening is the result of poisoning it is either limited to the mucous membrane, or, if it extends to the muscular coat, the mucous membrane will probably be detached in patches over the parts that are softened. In post-mortem softening the mucous membrane is rarely detached — the several coats of which the stomach is composed soften together usually without separating from each other. Ulcer of the stomach is much more frequently due to pathological conditions than to poisoning. The idiopathic gastric-ulcer is small, sharply defined, and very frequently is situated along or near the lesser curvature. The floor of the ulcer is formed by the muscular coat or, if this is perforated, by the peritoneum, which, at the spot, may or may not be adherent to the liver or pancreas. The opening in the mucous membrane is circular and cleanly "punched out,"' and is larger than that through the muscular coat. In the early stage of the forma- tion of a gastric-ulcer the edges are not raised; subsequently they may become so; the mucous, muscular, and serous coats are firmly adherent for some distance from the ulcer. If the ulcer gives way a small opening usually forms through the floor, so that, in vertical section, the ulcer is V-shaped — the aperture being at the apex. All this points to gradual formation. An ulcer caused by an irritant poison is usually more quickly produced, and presents the appearance of an erosion with surrounding signs of recent inflammation, which are generally absent in the idiopathic ulcer. There is less tendency to thickening round the margin, which is more irregular and not so cleanly "punched out." When perforation is due to the immediate action of a corrosive, the comparatively large size of the aperture, the irregular and ill- defined margin, the surrounding softening and friability of all the coats, and the discoloration of the structures make the diagnosis easy. Perforation of the stomach wall may take place from the action of the gastric juice after death. This could not be mistaken for the effect of a corrosive poison, as there is entire absence of an indications of inflammation, and the edges of the aperture, though irregular, are free from the colour changes which characterise the action of corrosives. The surrounding mucous membrane is often swollen and gelatinous. The appearance presented by the mucous membrane of the stomach EVIDENCE OF POISONING. 399 in cases of suspected poisoning is to be interpreted with caution, especi- ally in relation to colour-changes. Mere redness of the surface is too often assumed to indicate the occurrence of inflammation, which is at once attributed to the effects of poisoning; as previously stated, some thing beyond this is required to warrant such an inn rpretation. The post-mortem appearances after death from narcotics, eon vulsives, and deliriants are mostly limited to hyperaemic conditions of the nervous centres and their membranes, and are relatively of little diagnostic value. EVIDENCE OP POISONING PROM CHEMICAL ANALYSIS OF THE VISCERA AND THEIR CONTENTS. The substances obtained at the post-mortem examination of a case of suspected poisoning are sent to the analyst in bottles, or jars, duly secured and sealed, as directed when the method of making post- mortems in medico-legal cases was described. Before opening the jars an inventory of them should be taken, and the covers and seals should be carefully scrutinised, in order to ascertain whether they have been tampered with ; once in the possession of the analyst the jars and their contents must be kept under lock and key. After each jar is opened its contents are to be measured, or weighed, in accordance as to whether they are fluid or solid. A careful examina- tion of the physical appearance of the various substances should then be made, a lens or microscope being used if necessary. All food-stuffs present should be noted, and the odour of the contents of each jar ascertained; should any crystals or particles of inorganic matter be present, a few should be picked out and submitted to a preliminary examination ; any seeds or fragments of leaves of plants that may be observed should be removed and investigated as to their nature and source. When the symptoms observed during life are either obscure or are not indicative of a special poison, or in cases where no history is forth- coming, it may be necessary in the absence of post-mortem indications to make a systematic analysis of the viscera and their contents. Usually some clue is obtainable as to the nature of the poison suspected to have been administered, and in such cases the chemical investigation is chiefly directed to such poison. The amount of material at the disposal of the analyst being limited, it is very important that he should be made acquainted, as far as possible, with the nature of the poison, as 1 indicated by the symptoms during life and the appearances after (hath. It does not follow that the chemical enquiry is to be restricted to the discovery of a suspected poison ; the possible presence of other poisons 400 FORENSIC MEDICINE. is not to be ignored. "Usually, however, only one poison is present, ■and, if the analysis is from the first directed towards its discovery, the probability of success is much greater than if the investigation has to include the whole series of poisons. This is of special importance as regards quantitative analysis, and in criminal trials much importance is not unfrequently attached to the amount of the poison obtained from the dead body. Only a portion of the organs and substances at the disposal of the analyst should be used in making the analysis ; unless the amount is too small half should be reserved for a corroborative investigation by another expert. In making a systematic analysis attention is first to be directed to the possible presence of volatile poisons. The chief volatile poisons are — hydrocyanic acid, oil of bitter almonds, nicotine, conine, phos- phorus, alcohol, chloroform, benzene, and its derivatives nitro-benzene, anilin, and phenol. If the odour of any of these bodies is present in the substance under investigation, the clue thus afibrded is to be followed up ; in any case their presence or absence must be deter- mined. The next step is to ascertain whether any alkaloids are present : for this purpose, one of the many modifications of Stas' process for the separation of alkaloids from organic matter may be resorted to. The ! principles on which this process is founded are — that the salts of the alkaloids are soluble in water and in ethyl alcohol ; but not in ether and some other solvents, as amyl alcohol, benzene, acetic ether, and chloroform. On the other hand, the uncombined alkaloids (or most of them) are nearly insoluble in water, but are more or less soluble in ether and in the other solvents named. This property of the alkaloids is made use of to extract them from organic admixture in the following wa y : — The alkaloid present is dissolved with the aid of slightly acidulated alcohol, with which it is digested for several hours at a moderate temperature. The liquid is then filtered off and evaporated down to a syrup at a gentle heat. When cold, the syrupy mass is treated with absolute alcohol, the object being to precipitate as much of the foreign matter as possible, and to retain the alkaloid in solution. The process of evaporation and subsequent treatment with absolute alcohol may have to be repeated several times before the bulk of the ■extraneous matter is got rid of. Finally, the last alcoholic extract is evaporated down to a syrup, which is then dissolved in a small quantity of water, with the result that any alkaloid in the original substance i will be held as a salt in aqueous solution. As long as this solution remains acid it may (except in the case of certain alkaloids and active principles) be shaken with ether without parting with the alkaloid, and by repeated shaking-out with ether, more of the remaining organic EXTRACTION OF ALKALOIDS. 401 impurities, chiefly fatty matter, may be removed. When this is accom- plished, the aqueous solution is made alkaline, and is once more shaken out with ether. The addition of the alkali displaces the acid of the alkaloid, and, being insoluble in water but soluble in ether, the free alkaloid is taken up by the ether, which is then separated and evapor- ated to dryness, leaving the alkaloid in a sufficiently pure state for testing. So much for the principles on which Stas' process is founded ; in putting them into practice several important details require attention, and on the skill with which they are carried out success depends. Stevenson's 1 great experience has enabled him to develop and to refine Stas' process as follows : — The substance under examination is digested with twice its weight, or, if fluid, twice its volume, of rectified spirit, at a temperature of 35° ; after several hours the fluid is poured off (the solid matter being subjected to pressure), and is replaced with fresh spirit, which is allowed to digest as before. After decantation of the second extract the process is repeated several times more with spirit acidulated with acetic acid. The extracts obtained with the acidulated spirit are mixed together, but are kept apart from those obtained without the acid, which are also mixed together. The extracts separately are quickly raised to a temperature of 70°, allowed to cool, filtered, and the residue on the filter washed with spirit. The extracts are then evaporated to a syrup at a temperature not exceeding 35°, excess of acid being neutralised with soda. The syrupy liquid is drenched with 30 cc. of absolute alcohol, and well stirred in a mortar; the alcohol is poured off, and the process is repeated with successive quantities of 15 cc. of alcohol until it comes away colourless. These extracts are filtered and evaporated to a syrup, as before. The syrupy extracts from the acid and from the non-acid digestions are each diluted with a small quantity of water, filtered, and then mixed together. The united extracts, whilst still acid, are shaken with twice their volume of ether, the operation being repeated until the ether, on evaporation of a few drops, leaves no residue. The ethereal solu- tions are washed by vigorous shaking with 5 cc. of water, to which a few drops of HoS0 4 have been added. The acid aqueous solution which was washed with the ether, and the water which was used to wash the ether after separation, are mixed and alkalised with sodium car- bonate. They are then exhausted, first with a mixture of one volume of chloroform and three volumes of ether (which previously has been well washed with water), and subsequently twice or thrice more with washed ether alone. The ethereal extracts are washed with 5 cc. of water, then with 10 cc. of water acidulated with H S0 4 , and again 1 Watts' Dictionary of Chemistry, 1890. 26 402 FORENSIC MEDICINE. with 5 cc. of water alone. The acid liquid and the final wash-water are washed once or twice with a little ether, re-alkalised with sodium carbonate, and well extracted with washed chloroform and ether, and afterwards with ether alone. These ethereal extracts are washed with water barely alkalised with sodium carbonate, filtered through a dry filter, and evaporated in an oven under 35° in tared glass basins. When evaporation is complete, the basins may be dried at a tempera- ture of 100°, then cooled over sulphuric acid and weighed. To extract morphine Stevenson uses a well-washed mixture of equal volumes of acetic and ethylic ether. The object of these repeated washings and transferring of the alkaloid from water to ether, and from ether to water, is to get rid of fatty and other matters which seriously interfere with the colour-tests, and also to enable a correct estimation to be made of the amount of alkaloid present in the substance under examination. When an alkaloid is sufficiently freed from organic matter the usual tests are applied to establish its identity. When extracting an aqueous fluid containing an alkaloid with a fluid that is insoluble in water, care must be taken not to agitate the two fluids to such an extent as to cause them to emulsify. Some fluids which retain small quantities of organic matter in solution very readily form emulsions with the solvent used for extraction, especially after alkalisation. Various methods have been devised to promote separation of the fluids after emulsification, such as the addition of more of the solvent, the immersion of the containing tube for a few minutes in a freezing mixture, or in hot water, imparting a rotary motion to the tube, or a series of slight shocks by repeatedly tapping it with the finger nail — any of which may or may not be successful. The best plan is to avoid emulsification by first cautiously inverting the tube two or three consecutive times, and observing the rate at which the fluids separate ; if they show a disposition to blend, the process of extraction must be conducted with great deliberation, time being allowed for separation after every two or three inversions of the tube. The process of extraction may be conducted in a stoppered tube, like a large test-tube, or in a small tubular-separator, furnished with a stop-cock, through which the lower stratum of fluid may be with- drawn. The separator is most convenient when the solvent is heavier than water; when a tube is used the solvent has to be pipetted off. The amount of solvent in toxicological work is usually small, and may be conveniently dealt with by means of a pipette furnished with an india-rubber ball attached to its upper end by a short piece of rubber tube, on which is placed a spring pinch-cock, as shown in Fig. 21. Before EXTRACTION OF ALKALOIDS. 403 using the pipette the pinch-cock is opened, and the ball compressed so as to empty it of air ; the pinch-cock is then released. The pipette is passed down to the lowest stratum of the fluid to be re- moved, and the pinch-cock gently pressed open when the ball expands and draws up the fluid into the pipette. When the whole of the fluid, or as much as the pipette will con- tain, is removed, the pinch-cock is again allowed to clip the tube, the pipette is withdrawn, and its contents expelled by com- pressing the ball and opening the pinch-cock. The advantage of this littledevice is that separa- tion can readily be effected at the level of the eye, and arrested at the desired moment with the greatest nicety. The lower end of the pipette is turned side wise, so as not to draw up the fluid beneath. To separate alkaloids in aqueous solution, when more than one is present, Dragendorff devised the method of using various solvents in sequence. The principle on which the method is founded is that some solvents take up certain alkaloids to the exclusion - parts of alcohol. It volatilises at a temperature of 150° without residue, and in this way may be distinguished from its combinations (excepting with ammonia), which leave residues. When heated with strong sulphuric acid, it is decomposed without blackening, into water, carbon dioxide and carbon monoxide. Oxalic acid crystallises in the form of slender jn-isms, and on this account has been mistaken for Epsom salts. When swallowed in poisonous doses, oxalic acid produces local effects which resemble those produced by the mineral acids; but, unlike them, it exercises a special influence on the nervous system and upon the action of the heart. Symptoms. — The symptoms vary not only with the amount of acid, but also with concentration of the solution in which it is taken. If half an ounce or more of the acid is dissolved in water so as to form a concentrated solution, the local effects resemble those produced by the mineral acids. Immediately, or soon after the solution is swallowed, pain is felt in the mouth and throat, which extends to the stomach and radiates over the abdomen ; vomiting usually quickly follows and HI OXALIC ACID. 417 persists, the vomited matter chiefly consisting of altered blood. If the acid is swallowed in more dilute solution, the above-named symptoms are delayed and are less violent, General indications of collapse are manifest, the respiration is gasping, the pulse small and irregular, and IY the extremities, or even the entire surface, may be cyanosed . Clonic spasms are not unfrequent ; they may alternate with tonic contrac- tions of the muscles, especially of those of the lower jaw, producing trismus. Aphonia may occur, and may persist for some time during convalescence. The efl'ects produced by oxalic acid on the nervous system are exceedingly irregular; sometimes they constitute the chief symptom, and at others they do not exceed those which might be reasonably expected from the reflex of the parts with which the poison comes directly in contact. The nerve symptoms comprise paresthesia? and amesthesia of the limbs or trunk, with aching and shooting pains in the loins ; numbness of the tips of the fingers has been observed and tenderness of the muscles of the legs ; convulsions are common, and sometimes resemble those due to strychnine. In other cases oxalic acid seems to V i act as a na rcotic ; I saw a case of this kind in which the sufferer lay unconscious, breathing stertorously, the surface being cold and clammy as in opium poisoning, without there being any vomiting or other signs of gastric irritation. When the nervous symptoms form the prominent feature of the case, the poison has often been taken well diluted, or the stomach has contained some amount of solid food, the indications of gastritis being slight or entirely absent ; in these cases post-mortem signs of local irritation, although present, are not as Avell marked as is usual. Large crystals of calcium oxalate are frequently present in the urine. Fatal Dose. — The smallest recorded fatal dose is 60 grai ns, which taken in the solid form caused the death of a boy aged sixteen. Recovery has occurred after an ounce and a quarter. Death has occurred in ten minutes ; usually it takes place within two hours, but it may be delayed for several days — seven in one case, and twenty-one in another. Treatment. — Chalk suspended in a small quantity of water or milk may be given, although the consequent liberation of carbonic acid is disadvantageous ; saccharated solution of lime has been recommended by Husemann. Plaster chipped from the walls, or egg-shells, powdered, and suspended in a little water are good ; calcined magnesia may be y J given. The alkalies or their carbonates should not be given, as the resulting compounds are both soluble and poisonous. All antidotes should be given in as little water as possible in order to limit diffusion of the poison, its action not being solely local. After the acid is 27 418 FORENSIC MEDICINE. neutralised the bowels should be relieved by an enema or castor oil. Post-mortem Appearances. — These vary in accordance with the amount of the poison and the concentration of the solution ; if the poison is taken in concentrated solution, or in the solid form, the local effects will probably be well marked. There may be c orrosion of t he mucous membrane of the mouth, oesophagus, and stomach, or it may be white, softened and easily detached from its bed. The inner surface of the oesophagus may be longitudinally corrugated, displaying numer- ous small erosions. The degree of inflammation of both oesophagus and stomach varies from a slight redness to an almost gangrenous condition ; the inflammation may reach the duodenum. In a specimen in the Museum of Owens College, the interior of the stomach is black- ened, resembling the condition met with in poisoning by sulphuric acid. Perforation of the stomach is exceptional, although the walls are often considerably softened; the mucous membrane not unfre- quently presents cloudy spots, which are due to deposition of calcium oxalate; they often occur near hemorrhagic infarcts. The kidney s may show a whitish zone between the cortical and the medullary portions, due to the deposit of crystals of calcium oxalate chiefly in the convoluted, and to a lesser extent in the straight tubules; the glomeruli are free from deposit. 1 Examined microscopically the deposit is seen to consist of rhombic prisms, or of octahedral crystals. Chemical Analysis— Tests. — Oxalic acid forms a precipitate of calcium- oxalate on the addition of a solution of calcium chloride or calcium sulphate. Calcium oxalate is insoluble in acetic acid, and is soluble in hydrochloric acid. Silver nitrate give s a white precipitate of silver oxa late, which is ea sily soluble in nitric acid, and also in ammonia. Lead acetate gives a white precipitate, which is soluble in nitric acid. Organic admixtures may be evaporated down at a gentle heat and exhausted with hot alcohol, to which a little hydrochloric acid has been added ; after filtration, the alcoholic solution is evaporated to dryness, and the residue dissolved in water. Quantitative Estimation. — To a measured quantity of the aqueous solution calcium acetate is added in slight excess, and the deposit of calcium oxalate is separated, washed with acetic acid and then with water, and dried. By careful ignition at a moderate temperature the calcium oxalate is converted into carbonate : 100 parts equal 126 parts of crystallised oxalic acid. Potassium Binoxalate [KHCo0 4 2H 2 0] or salt of sorrel, or, as it is also called, salts of lemon, is an acid salt soluble in 40 parts of cold and in G parts of boiling water. It is used in the household for 1 Robert and Kiissner, Virehow's Arch., Bd. 78. POTASSIUM. 419 removing iron stains from underclothing. Tt is nearly, if not equally, as poisonous as oxalic acid, like symptoms being produced. Half an ounce has proved fatal. The chemical tests are the same as for oxalic acid, from which it may be distinguished by its leaving a deposit of potassium carbonate when ignited on a slip of platinum foil. POTASSIUM. Potassium Hydrate [KOH] is met with as a poison'in the impure condition in which it is used in the arts and manufactures. It has a strongly caustic action on the tissues, and on account of its affinity for water the effects produced by it tend to radiate to a considerable distance from the spot to which it is applied. It combines with fatty matters and decomposes the soft structures, leaving a greasy mass which keeps soft and moist; the local damage thus differing from that produced by the mineral acids. In the form of a basic carbonate— as pearl ash— it acts much in the same way. Symptoms. — -When a strong solution of potash is swallowed an immediate burning sensation is experienced in the mouth and throat, which extends to the stomach, and radiates over the abdomen. Vomiting usually occurs; the v omited matter has a strong al kaline reaction , is slimy and may be coloured by blood which escapes from the inner surface of the stomach and oesophagus; shreds of mucous membrane are generally present in the vomit. Purging is not un- frequent. Collapse quickly occurs ; the pulse is thin and feeble, and the surface is cold and clammy. The lips, tongue, and inside of the mouth are red and swollen. Convulsions may occur as in sulphuric acid poisoning. Stricture of the oesophagus is very liable to follow in cases in which the immediate symptoms are recovered from. Fatal Dose. — The smallest recorded fatal dose is 40 g rains; usually a much larger dose would be required, p robably 3 or 4 drachms . Death has occurred within a few hours; more frequently it results after weeks or months from secondary symptoms. Treatment. — Vegetable acids, as acetic (vinegar), or citric (lemon juice) in a dilute form, should be given, with olive oil, demulcents, and opium. The stomach tube must not be used. Post-mortem Appearances.— The lips and, possibly, the surrounding skin on the face may show traces of the caustic action of the poison. Within the mouth the mucous membrane will be softened and of a brown colour, in parts it will probably be detached. In recent cases the tongue will be swollen and inflamed, the mucous membrane of the pharynx and oesophagus presenting more or less the same ap- pearance. The mucous coat of the stomach is inflamed and softened ; 420 FORENSIC MEDICINE. the colour is not constant, sometimes it is bright red and at others dark; it may be completely or merely superficially eroded in parts. If, as is frequently the case, the patient survives some weeks, strict ure is usually found at the lower end of the oesophagus or at the pylorus. Chemical Analysis. — The organic substance containing potash may be evaporated to dryness and incinerated to burn off the organic matter. The residue is then dissolved in a small quantity of water, slightly acidulated with hydrochloric acid, and precipitated with platinic chloride; precipitation maybe aided by the addition of alcohol. The precipitate is dried and then washed with alcohol in small quan- tities until it comes away colourless ; and again dried aud weighed : 100 parts equal 19-272 parts of potash. Tests. — If there is much potash present in the original solution it maybe directly precipitated as a double salt with platinic chloride. A saturated solution of tartaric acid also precipitates potash. Before the suspected substance is submitted to analysis, its alkaline reaction should be ascertained. The spectroscopic reaction of potash is too delicate to be of much use; it demonstrates the presence of the alkali in the tissues and in articles of food that may accidentally be present. SODIUM. Sodium Hydrate [ISTaOH], or caustic soda, is commonly met with as washing soda, which is a mixture of the hydrate and the basic carbonate. The symptoms, lethal dose, treatment, and post-mortem appear- ances are precisely the same as in poisoning with potash. Chemical Analysis. — For toxicological purposes there is no satisfactory chemical test for soda; it is best identified by exclusion. If there is a solid residuum after evaporation and incineration of the suspected substance, and both it and the original substance yield a marked alkaline reaction, and no precipitate is formed on the addition of platinic chloride to a concentrated solution of the incinerated product, the alkali which is proved to be present will be soda. Absence of the alkaline earths must be ascertained. The spectroscopic reaction of sodium is useless in toxicological investigations on account of the ubiquitous presence of its salts. AMMONIA. Ammonia Water [NH 4 OH], also known as spirits of hartshorn, consists of a solution of gaseous ammonia in water. When freshly AMMONIA. 421 prepared the gas is freely given off, and serious results have followed its inhalation when large bottles containing the solution have been broken. The gas attacks the structures of the larynx and the mucous lining of the lower air-passages, often producing alarming dyspnoea; it is to this characteristic that the special features of ammonia poisoning, as compared with the effects produced by the fixed alkalies, are due. Symptoms. — -Immediately after swallowing strong ammonia water a violent, burning sensation is experienced from the mouth down to the stomach, which is fullowed by vomiting ; the ejected matter may con- tain blood. The epithelial layer of mucous membrane is at once stripped off and the mouth feels as though it was filled with " skins." Some of the vapour is sure to be drawn into the larynx, producing a sensation of suffocation, which is followed by a real difficulty of respiration from tumefaction of the glottis ; the breathing is noisy and stridulous, and the greatest distress is manifested from fear of i m pending suffocation. The voice is at once rendered feeble and hoarse, or it may be entirely gone. The patient is continuously occupied in attempts to rid himself of the detached membrane and viscid mucus which accumulate in the mouth. He sits up in bed with an extremely anxious expression, pointing towards the throat and intimating an earnest desire for relief. He suffers from intense thirst, which his condition disables him from alleviating. The symptoms of collapse are present: small pulse, cold, clammy surface, sunken features, and visually great restlessness. If the case goes on to a fatal issue coma usually supervenes, the breathing becoming more and more difficult, partly from swelling of the mucous lining of the air-passages, and partly from excessive secretion of mucus. Even when the symp- toms are at their worst and death appears imminent, recovery may take place so far as the immediate condition is concerned ; the breathing improves, the patient becomes able to swallow and to dislodge the mucus, and in a comparatively short time is out of danger. In one case of this kind, which was under my care in the Salford Koyal Hospital, the patient (a woman) who had swallowed more than an ounce of commercial ammonia water, became gradually more and more col- lapsed, dyspnceic, and cyanosed. until tracheotomy was contemplated. She recovered from the acute stage, but, later on, developed stricture of the oesophagus at its lower part. Pregna nt women frequently abort in consequence o f ammonia poisoning. When recovery takes place from the acute stage, apepsia — from destruction of some of the gastric glands — and stricture of the oeso- phagus or of the pylorus are to be feared. Fatal Dose. — This is difficult to estimate as the amount of gas present in a given quantity of the solution is subject to great varia- 422 FORENSIC MEDICINE. tion. Two drachms have proved fatal, and recovery has taken place, as in the above-mentioned case, from more than an ounce. Death has taken place in a few minutes. The usual period for acute cases is twenty-four to forty-eight hours ; when death is due to secondary effects, life may be prolonged for months. Treatment is the same as in the case of the fixed alkalies, special attention being paid to the respiratory symptoms, such as placing the patient in a tent, the air of which is rendered moist with steam. Post-mortem Appearances. — If death takes place in the acute stage the lips are swollen, the mucous membrane of the mouth is softened and more or less detached, a similar condition existing along the oeso- phagus and, possibly, in the stomach. Immediately after the poison is taken the mucous membrane presents a white appearance, but it quickly changes to an angry-looking red ; the whole thickness or the epithelial layer only of the membrane may be detached. In severe cases the muscular coat of the oesophagus or of the stomach is also softened and completely disintegrated ; actual perforation is of excep- tional occurrence. The effects of the poison rarely pass beyond the stomach. The laryngeal mucous membrane is infiltrated and thickened ; it has been observed to be eroded and, in some cases, to be covered with exudation, forming a kind of false membrane. The smaller bronchi have been found to contain tubular casts. The kidneys may be inflamed. The chronic cases show corresponding post-mortem indications to those met with under similar conditions in poisoning with the fixed alkalies. Chemical Analysis. — Ammonia is recognised by its odour ; it may be separated from organic admixture by distillation ; if the solution con- taining the ammonia is not alkaline, it may be neutralised with calcined magnesia before distilling. The gas is received into water acidulated with hydrochloric acid, and the ammonia is afterwards precipitated with platinic chloride in excess, the precipitate being washed with alcohol to remove the excess, dried and weighed: 100 parts equal 15-68 parts of NH 4 OH. The ammonia separated by distillation may be estimated volumetrically, if preferred. If de- composition of the tissues is in progress it is of little use to examine them for ammonia as a poison, since it is evolved from nitrogenous organic matter. Tests. — Ammonia responds like potash to platinic chloride, and to tartaric acid ; it gives a brown precipitate with Nessler's reagent, and white fumes in the presence of gaseous hydrochloric acid. Ammonium Carbonate [(NH 4 ), CO.,] when swallowed in large doses produces symptoms and organic changes resembling those produced by uncombined ammonia. IRRITANTS. CHAPTER XXVII. SALTS OF THE ALKALIES AND OF THE ALKALINE EARTHS. SALTS OF POTASSIUM. Potassium Nitrate- [KN0 3 ], saltpetre, or sal prunella, when swal- lowed in doses of one ounce or more, produces violent pain in the stomach and abdomen, with vomiting ami purging, the ejected matter sometimes containing blood. Collapse occurs and is evinced by cold surface bedewed with sweat, and small, rapid, irregular pulse, which may subsequently become slow. Occasionally laboured respiration, unconsciousness and convulsions, pains in the loins, cramps in the calves of the legs, muscular twitchings, parsesthesite, paralysis of the limbs and aphonia have been observed. Death is usually preceded by coma ; it may take place suddenly from heart paralysis. Gastric derangement may persist for a considerable time after the acute symptoms have subsided. Fatal Dose. — The smallest recorded fatal dose is two drachms , which caused the death of a man aged forty. Recovery has taken place after one ounce. Death has occurred in from five to sixty hours. Treatment. — Empty and wash out the stomach; give ice and opium to allay the sickness and pain, and alcohol, if necessary. Mustard may be applied over the region of the stomach. Warmth and the recumbent posture are to be maintained. Chemical Analysis. — If fluid, the suspected substance is filtered ; if pultaceous, it is extracted with water and then filtered. The filtrate is evaporated to a small volume and the salt allowed to crystallise out. The crystals are tested for nitric acid and for potash. Potassium Chlorate [KC10 3 ] possesses peculiar toxic properties. When taken in large doses, the red blood corpuscles are broken up by it, and the haemoglobin is converted into methg e moglobin . The mode in which the effects are produced is still sub judice; some observers hold that 424 FORENSIC MEDICINE. the salt is not decomposed within the organism, and therefore that the toxic effects are due to its specific action ; others have demonstrated by experiments that when mixed with certain organic substances, such as pus and fibrin, the salt gives off oxygen. Binz 1 states that after prolonged action of these substances on potassium chlorate, the presence of chloric acid cannot be demonstrated. If blood is mixed with potas- sium or sodium chlorate to the amount of four per cent., it becomes syrupy, and on spectroscopic examination shows the bands of methse- moglobin, either alone or in combination with those of oxyhemoglobin. The stroma of the red corpuscles parts with the haemoglobin, which is subsequently changed into methsemoglobin, and the debris of the cor- puscles produces certain pathological conditions, which will be described among the post-mortem appearances. Symptoms. — When large doses are taken the first symptoms are those of gastro-intestinal irritation: vomiting, pain in the stomach and bowels, with more or less collapse. Shortly after, pain is felt in the lumbar region ; the urine; which may contain albumen, is diminished, or suppressed ; haemoglobin and haematin have been found in it, but not methaemoglobin. The skin becomes cyanosed, and subsequently it is frequently jaundiced. Landerer 2 considers the jaundice to be partly polycholic and partly haeinotogenous. The patient is delirious, or apathetic and somnolent. At this stage the blood is brownish in colour and somewhat viscid ; examined microscopically, colourless erythrocytes (the stroma of the red corpuscles) are seen along with normal corpuscles, interspersed with granular particles of free haemoglobin, or of methsemoglobin. The white corpuscles are increased in number. The combined spectra of haemoglobin and methaemoglobin will be present. Eecovery may take place even when the symptoms have arrived at a very critical stage ; when death occurs, an interval of several days usually elapses after the reception of the poison. Fatal Dose is uncertain ; one ounce and a half has caused death. The fatal period ranges from six hours to as many days. Treatment. — The stomach should be emptied and washed out. The after treatment will be symptomatic. Diuretics and vapour baths, with fomentations or dry-cupping of the lumbar region may be indicated. Post-mortem Appearances. — The mucous membrane of the stomach has been found swollen, softened, and easily separated from its bed ; it may exhibit small ecchymoses. The mucous membrane of the duodenum may present a similar swollen and softened appearance. The blood is chocolate-coloured . The kidneys are also chocolate- coloured, and on section show the most intense colour in the medullary 1 Arch.f. exp. Pathol, 1879. - Deut. Arch. f. Bin. Med., 1891. BARIUM. 425 portion ; the glomeruli are visible as points to the unaided eye. Examined microscopically, the straight and convoluted tubules are tilled with reddish-brown deposit formed of the debris of the red blood corpuscles ; the epithelium is swollen and cloudy. The spleen has been found enlarged and of a peculiar reddish-brown colour ; besides normal red corpuscles the pulp may contain colourless ery- throcyte s. Chemical Analysis— Tests.— The presence of potassium chlorate may be ascertained by adding a few drops of sulphuric acid to a solution containing the salt, and sufficient indigo sulphate as to produce a moderately deep blue colour ; two or three drops of sulphurous acid added to the mixture cause the colour to disappear. If in organic admixture, some of the potassium chlorate may be separated by dialysis and examined as above. Several other salts of potassium and sodium — as the chlorides, sulphates, and carbonates— act as irritants when swallowed in large doses. BARIUM. Barium Chloride [BaCL,2H.,0] has been taken in mistake for Epsom salts and other saline purgatives. It has been taken for suicidal purposes in the form of rat poison, into the composition of some varieties of which it enters. Symptoms. — In poisonous doses it acts locally as an irritan t, and centrally as a nerve poison . In from a few minutes up to an hour or more after the poison is swallowed, violent pain is felt in the stomach and abdomen, accompanied by extreme nausea, which is followed by severe vomiting and purging. The action of the heart is depressi and pain may be experienced in the cardiac region. The implication of the nervous system is shown by ringing in the ears and diplopia ; pains in the limbs, convulsions, and, in some instances, paralysis. Barium is eliminated by the kidneys and bowels; some of the amount taken is deposited in the bones. Fatal Dose. — One teaspoo nful of the powder has caused death. The fatal period has been as short as one hour, and has extended to seven days. Treatment. — The stomach-pump should be used, or an emetic given, unless vomiting has spontaneously occurred. .Sodium sulphate, or magnesium sulphate, should be given in large doses— half an ounce to an ounce or more. Hypodermic injections of morphine and ex- ternal warmth are useful. Post-mortem Appearances.— The mucous membrane of the stomach, and of the duodenum may be swollen and diffusely injected, or spotted 426 FORENSIC MEDICINE. with ecchymoses ; in one instance the stomach was perforated. Par- ticles of the poison have been found in the stomach in a case in which it was taken in the form of barium carbonate. Chemical Analysis — Tests. — The presence of a salt of barium in organic admixture can be readily ascertained by rolling up the end of a piece of thin platinum wire into a small ball, dipping it into the mixture, and transferring it to a Bunsen flame ; a minute quantity of barium reveals itself by colouring the flame green ; the experiment is best conducted in a darkened room. If the green flame is examined with the spectroscope, the flame-spectrum of barium will be seen. After taking up and drying some of the suspected fluid on the ball, the reaction will be rendered more distinct by dipping the wire in strong HC1. A solution of barium in organic admixture may be evaporated to dryness and incinerated ; the product is drenched with HN0 3 , and the excess of acid volatilised. The nitrate, dissolved in water, may then be tested by adding dilute H 2 S0 4 , or an alkaline sulphate, either of which produces a white precipitate insoluble in HN0 3 ; it is also pre- cipitated by a solution of KOH. If the barium is present as phosphate, or sulphate, it must be boiled with a concentrated solution of potassium carbonate for some time, and filtered ; the filtrate is precipitated with dilute H S0 4 , and the insoluble substance on the filter is dissolved in HC1, diluted with water, and also precipitated with H 2 S0 4 . The com- bined precipitates, after washing and ignition, are weighed ; this gives the amount of barium present as sulphate. The absence of strontium and calcium should be ascertained by means of the spectroscope. Other salts of barium — the carbonate, nitrate, and acetate — have acted as poisons. Strontium salts cannot be regarded as poisonous ; the bromide, lactate, and nitrate have recently been administered medicinally in large doses; as much as 200 grains of the nitrate have been given in one day. MAGNESIUM. Magnesium Sulphate [MgS0 4 7H o 0J, or Epsom salts, is usually re- garded as a harmless purgative, but in large doses it has caused death. In experiments on animals it has been found to paralyse the respiratory movements, and also those of the heart. The former of these effects is well illustrated by the following case reported by Sang 1 : — A woman, aged thirty-live, dissolved four ounces of Epsom salts in some warm water and drank the solution. When seen shortly after she complained of a burning pain in the stomach and bowels, and a choking feeling, with 1 The Lancet, 1891. ARSENIC. 4l'7 a sensation as though she was losing power of her legs and arms ; there was neither vomiting noir purging ; the pulse was 96 per minute An emetic of zinc sulj)hate was administered, but did not act, and before the stomach-pump could be obtained profound collapse occurred. The pupils were dilated ; the muscles of the face twitched, and there was complete paralysis ; she then became comatose, and died in one hour and twenty minutes after swallowing the salts. Tlie radial pulse was felt two or three minutes after the respirations had ceased. Christison relates the case of a boy, aged ten, who after swallowing two ounces of Epsom salts was observed to stagger and appear very ill. Half an hour after, the pulse was scarcely perceptible, and the respira- tions were slow and laboured; in ten minutes more he died without vomiting having taken place. METALS. ARSENIC. Metallic Arsenic is probably not poisonous ; but, as it easily under- goes oxidation in the digestive tract, it may produce the usual symptoms of arsenical poisoning. A preparation known as fly-powder, Avhich consists chiefly of finely-divided metallic arsenic, probably along with some arsenious acid, is strongly poisonous. Arsenious Acid [As.,0 3 ], or white arsenic, is the form in which arsenic is chiefly used as a poison. When fresh, it is a glassy-looking substance, with smooth vitreous fracture ; after being kept some time it becomes white and opaque, resembling porcelain. In the form of powder it looks like flour, for which on several occasions it has been mistaken with fatal results. It has little taste, and having no colour, is easily administered for homicidal purposes ; it has one compensating property — that of slight solubility in water. The solubility of arsenious acid varies according to its molecular state which is not constant, its density slightly diminishing with age ; consequently, not only do the transparent and opaque varieties vary in respective solubility, but each individual specimen tends to differ from the rest. When the opaque variety is boiled with water for some time, 11*5 parts are dissolved per LOO parts of water ; on cooling, from 2'5 to 3 parts of arsenious acid per 100 of water are retained in solution; crystalline arsenious acid is slightly less soluble. Cold water dissolves about i grain to 1 grain of arsenious acid per ounce. The solution slightly reddens litmus paper. In acids and in alkaline solutions arsenic is much more soluble. The law requires that when arsenic is sold in quantities of less than 10 lbs., it shall lie mixed either with soot or 428 FORENSIC MEDICINE. with indigo, at the rate of H ounces respectively to the pound of arsenic. When powdered arsenious acid is added to water, or to liquid food, some of the finer particles float on the surface, forming a kind of white scum which cannot be got rid of by stirring; the appearance produced is very significant, and should be remembered when examining fluids which are suspected to have had arsenic added to them. "When combined with potash or soda, arsenious acid is relatively much more soluble, and in this form it is used for domestic and other purposes, as well as in medicine. Some kinds of " fly-papers " are saturated with sodium or potassium arsenite, and much stronger solu- tions of arsenic can be obtained by soaking such papers in small quantities of water than by dissolving arsenious acid itself; this fact has been utilised for criminal purposes. Arsenic Acid [As o 5 ] is used in the manufacture of aniline colours ; and, in combination with sodium, as a fly poison. It is slightly less poisonous than arsenious acid. Arsenious Sulphide [As 2 S 3 ], or orpiment, is almost insoluble in water, and when pure is said not to be poisonous ; the commercial variety usually contains uncombined arsenious acid. Copper Arsenite [CuAsO„], or Scheele's green, and a mixture of copper arsenite and copper acetate, known as Schweinfurt green, though insolnble in water, are partially dissolved by the gastric juice. These pigments have produced toxic effects by their presence in the atmosphere in a state of minute division, the particles being derived from wall-paper or fabrics coloured with them. Arsenetted Hydrogen [AsH 3 ] is extremely toxic; it has produced poisonous effects in workmen who have been subjected to its influence when using hydrochloric acid contaminated with arsenic, to prepare iron for " galvanising," and also in the separation of silver from zinc. Serious results have followed its accidental inhalation in the laboratory. Eczematous eruptions on the legs have been caused by wearing stock- ings coloured with aniline dyes prepared with arsenic. Acute Arsenical Poisoning. Symptoms. — The interval between the reception of the poison and the first appearance of the symptoms is determined by several condi- tions. In a state of solution the same dose acts more quickly than when administered in the solid form ; the presence of food in the stomach tends to retard, and the absence of it to accelerate, the onset of the symptoms. The interval ranges from ten minutes, or even less, when a strong solution is swallowed on an empty stomach, to twelve ACUTE ARSENICAL POISONING. 429 or eighteen hours under converse conditions. If a poisonous dose of undissolved arsenious acid is taken into a full stomach, and the recipient immediately after retires to bed and sleeps, an unusually long period of quiescence may follow. The usual period is from ha lf an hour t o an hou r. In a typical case a s ensation of h eat, rapidly developing into a vi olent burning pain, is felt in the throat and stomach ; then follows nausea, with uncontrollable vomiting and sensation of con- striction in the gullet. The vomited matters at first consist of food that may be present in the stomach ; and, if the poison has been administered as powdered arsenious acid only partially dissolved, opaque white masses of mucus may be mixed with it. After the contents of the stomach have been ejected, the vomit may consist of slimy mucus, or of fluid resembling rice water, which may contain . blood, or it may be bile-stained. If commercial arsenic mixed with I soot or indigo-blue has been taken, the early vomit will probably be 1 tinged accordingly. Soon after the commencement of the vomiting, purging sets in, accompanied by distressing t ene smus, and, frequently, by a burning sensation in the rectum ; after the evacuation of any faeces contained by the bowels, the dejections tend to tak e o n the r ice-water appearance, and they may con tain blood. The pain in the stomach is usually, but not always, increased on pressure. The patient suffers from i ntense thir st, attempts to relieve it being immediately followed by rejection of the swallowed fluid. The feeling of sinking, or depression, which precedes the primary V I vomiting develops into one of extreme prostration an d collapse. The face presents an appearance of great anxiety, the features are sunkeD, the surface is cold, moist, and cyanosed — especially the limbs — tin- pulse is small and thready, respiration is laboured, and the voice is hoarse. As a rule, the tongue is at first thickly coated with a white fur ; subsequently it often becomes red at the tip and round the edges ; sometimes it is unnaturally red over its entire surface. Owing to the profuse vomiting and purging the urine is scanty, and it may contain >v. albumen or blood ; attempts to urinate are painful. Cramps, especially in the calves, torment the sufferer, who tosses about to obtain relief. Death may be preceded by coma which is not unfrequently accom- panied by clonic or tonic spasms, or consciousness may be maintained to the end. It will be observed that in many respects the symptoms strongly resemble those of cholera ; when that disease is epidemic, errors in diagnosis may easily be made. If doubts arise in the medical attend- ant's mind, he should examine the excretions for arsenic. The above description of the symptoms of acute arsenical poisoning embraces the principal features of a typical case ; it is not to be 430 FORENSIC MEDICINE. inferred, however, that all these symptoms invariably occur in every case, nor that their progress is precisely the same. In exceptional instances the poison seems to spend its force on the nerve centres, the gastro-enteric symptoms being less pronounced, or they may be entirely absent. In such cases from the very first extreme collapse occurs with superficial and deep anaesthesia of the limbs, faintness, extremely small, feeble pulse, and coma, which quickly comes on, and terminates in death within six or eight up to twenty-four hours. Complete general paralysis may be present some hours before death. It is not unusual in cases of criminal poisoning for repea ted dose s of the poison to be given. With arsenic, as with other poisons, such a mode of administration considerably modifies the course of the symptoms. The early doses produce gastro-enteric disturbance shown by vomiting, purging, pain in the stomach, foul tongue, loss of appetite, and a feeling of depression and languor ; as the symptoms are passing off, but probably before they have quite sub- sided, another dose of the poison is given and the acute symptoms are renewed. In these cases, some of the symptoms of chronic arsenical - poisoning are also present ; there may be itching and smarting of the eyeballs and the margins of the lids, the conjunctivae being reddened and granular ; a similar hypersemic condition of the mucous membrane of the fauces and throat causes constant hawking apart from actual vomiting, the patient having a sensation as though a hair was in his throat. The tongue and mouth are dry, the former being either thickly coated or red and irritable-looking. The skin has an un- healthy, half jaundiced hue, and may display erythematous or ecze- matous eruptions. More pronounced symptoms of neuritis than occur in the acute form of poisoning are present : — creeping and tingling, especially in the fingers ; numbness of the hands and feet ; severe cramps, not limited to the calves ; dropping of the ankles when the patient is lying on his back in bed, and extreme tenderness of the muscles on pressure. The patient is very restless, and cannot sleep. The temperature at first will probably be slightly elevated. The acute and chronic symptoms may be combined in variable proportion not necessarily corresponding to the length of time the patient has been under the influence of the poison. In some cases in which life has been prolonged for several days after the first inception of the poison, there may be almost entire absence of the chronic features, while in others several may appear within the first twelve hours. Diarrhoea, instead of coming on at once, may be delayed for one or more days, the abdomen being either tender or free from tenderness in the interval. In the case of Reg. v. Maybrick (Liver- ACUTE ARSENICAL POISONING. 431 pool Ass., 1889), in which the accused was found guilty of having caused the death of her husband by the administration of arsenic, purging did not occur until the third or fourth day, the abdominal pain being less violent than is usually the case; there was also absence of cramps in the calves, which, however, is a less constant symptom than diarrhoea. In the case of the Due de Praslin, 1 the abdomen was painful and distended during the first four days after taking a fatal dose of arsenic, but there was only one evacuation of the bowels. The combinations of arsenic with copper produce the usual symptoms of arsenical poisoning. In one case related by Seidel, 2 a girl aged 19 swallowed a tablespoonful of mixed paint, the basis of which was Schweinfurt green; she died in sixteen hours. Indications of the presence of the pigment were visible in various parts of the digestive tract. Huber 3 relates the case of a man who took about 4 grammes of Schweinfurt green; he recovered from the immediate effects, but suffered severely from arsenical paralysis. Death has resulted from the application of arsenical paste to destroy morbid growths , and in infants from the use of nursery-powder adulterated with powdered arsenious acid. Arsenic has been used as a cosmetic; in the case of female poisoners with arsenic, any of the substance traced to their possession is generally accounted for on this ground. Applied as a solution for a limited time to the unbroken skin of an adult, it would not be absorbed to any dangerous extent, if at all. Very exceptionally arsenic has been surreptitiously introduced into the vagina and has caused death; this mode of administration is of ancient origin. A tract printed in 1598 gives an account of the trial and condemnation of one Henry Robson, a fisherman of Ryl, for thus poisoning his wife, who died five days afterwards. Ohabinat 4 records a case of fatal poisoning by arsenic from the application to the breast of an ointment composed of arsenious sulphide and bu arsenic was found in the internal organs. If the orpiment was pur • the case proves that, although insoluble, it is not so inactive as is generally supposed. Fatal Dose. — Two grains of arsenious acid have proved fatal. Recovery has taken place after much larger doses. When a fatal dose is tab the symptoms, usually persist continuously until death takes place, which occurs in from twelve to forty-eight hours. Life is notunfrequently prolonged beyond the limit here stated ; in such cases there are usually remissions in the course of the symptoms. The Due de Praslin lived until the sixth day; Maybrick lived until the eighth day; and in exceptional cases death has not occurred until the fourteenth or even 1 Annah s d'ffygigne, 1847. a Maschka's Handbuch, Bd. 2. :! Zeitschr.f. Uin. Med., 18SS. 4 Annates d'JIygiene, 1S90. 432 FORENSIC MEDICINE. the sixteenth day. In one case, after a large dose, death took place in twenty minutes ; it has not unfrequently occurred in two and three hours. Treatment. — Evacuate the stomach with tube, or emetic, and then give freshly-precipitated ferric oxide. This can be prepared by adding ammonia water, or a solution of potassium carbonate, to the tincture of iron perchloride ; the precipitate is strained off and administered suspended in water. Calcined magnesia may be substituted if ferric oxide cannot be obtained. Demulcents and subsequently morphine should be given. External warmth will be required. Post-mortem Appearances. — Externally the body may present a somewhat shrunken appearance, the eyeballs being sunk, and the surface may be slightly cyanosed ; these appearances are by no means invariable. Rigor-mortis sometimes lasts unusually long. The im- portant internal signs are afforded by the stomach and intestines. On opening the stomach indications of intense inflammation present themselves; the whole of the mucous membrane may have a reddened -velvety look, or the appearance may be limited to the greater curva- ture and the posterior part, or it may exist in two or more separate spots; the colour may be dark red or bright vermilion. Usually small dots or streaks of a darker colour are more or less numerously dis- tributed over the inner surface of the stomach, which is frequently corrugated ; this appearance is not invariable ; it has been found absent in cases in which arsenic in a soluble form was administered. In some parts larger-sized submucous haemorrhages may be seen. The surface of the mucous membrane is occasionally eroded, and particles of un- dissolved arsenious acid are not unfrequently found embedded at or •near the spots so attacked. Yery rarely, the inflammatory condition has gone on to gangrene, or to perforation ; softening of the mucous membrane, so that it can be easily separated from its bed, is less rare. The wall of the stomach is sometimes thinned. The more profound lesions of the stomach wall are caused by the local action of the poison present in the solid form, in addition to the changes which are due to I absorption. When a fatal dose of arsenic has entered the system by /some other channel than the mouth, the post-mortem evidence of gastritis is nevertheless present; like some other poisons arsenic is partially eliminated through the stomach, irrespective of the mode of its administration. The duodenum generally participates in the appear- ance presented by the stomach; the signs of inflammation may be limited to a few inches below the pylorus, or they may extend the whole length of the duodenum. The jejunum has also been found inflamed, and the rectum frequently so. Along with signs of diffuse inflammation in the intestines, small submucous haemorrhages may sometimes be seen ; CHRONIC ARSENICAL POISON I M.. -}"■"» the solitary glands and Peyer's patches arc often swollen. The oesophagus, as a rule, is not inflamed. The liver and kidneys may yield microscopic evidence of granular or fatty degeneration, hut such a condition is not usually distinguishable in rapidly fatal cases. None of the other organs show any characteristic changes. In those exceptional cases in which paralysis of the nerve centres is substituted for the usual gastro-enteritis, the appearance presented by the stomach maybe relatively trivial. Milford 1 describes the post- mortem appearance of the stomach in a case of this kind, in which no vomiting had occurred, although after death the stomach contained not less than 200 grains of arsenic. Only about a quarter of the surface of the mucous membrane near the pylorus presented a bright scarlet colour, the remainder was normal; the duodenum presented a similar, but less marked discoloration ; the rest of the digestive tract was unchanged. Chronic Arsenical Poisoning. Arsenic may be received into the system in small quantities for a prolonged period, and thus produce symptoms differing from the acute form of poisoning. The sources from which the poison is derived comprise wall-papers, fabrics, artificial flowers, toys, and fancy papers which have been used to envelope confectionery. Trade risks consti- tute another source. Copper arsenite, either alone or in admixture with copper acetate, is the usual form in which the poison is used for colouring purposes. In the case of wall-papers and fabrics the pigment is usually so loosely attached that particles are freely given off, and, floating in the atmosphere, are inhaled and swallowed. Some years ago many cases of arsenical poisoning were thus caused, and public attention being drawn to the subject, manufacturers ceased to employ the dangerous pigment. The evil, however, is not altogether a thing of the past; Harding 2 records an example which occurred quite recently in an asylum. A number of cases of chronic arsenical poison- ing took place one after the other among the nurses; the symptoms were eventually traced to the use of some green baize curtains, which were found to contain a large amount of arsenic. Symptoms. — The eaidy indications consist of gastric disorders, loss of appetite, headache, general feeling of malaise, and constipation or diarrhoea; then follow colicky pains, irritation of the eyelids, cachectic hue of the skin, and eczematous eruptions, especially in the folds of the axilla, or between the scrotum and thighs. Sooner or later pro- nounced indications of peripheral neuritis develop, the characteristic i Australasian Med. Gaz., 1S90. - The Lancet, 1S92. 28 4o4 FORENSIC MEDICINE. features of which are sensory disturbances, motor paralysis, and ataxia; the effects of arsenic on the nerves resemble those of alcohol, and differ from those produced by lead, in the prominence of the sensory disorders. The symptoms come on at variable intervals, from a week to three or four weeks, after the initial effects of the poison have manifested themselves ; the affected muscles rapidly atrophy, the knee-jerk is usually lost, and the reactions of degeneration are present; in the arms the paralysis has the same distribution as in lead paralysis. The sensory disturbances usually commence with tingling, numbness, formication, and, in some cases, cutaneous anaesthesia. After death Erlicki and Rybalkin ' found pigmentary changes in the ganglion cells of the anterior cornua in the cervical and lumbar enlargements, as well as degeneration in the peripheral nerves. When the action of the poison is continued the cachexia becomes mox-e pronounced : anaemia, falling off of the hair, defective nutrition of the finger nails causing their detachment, pigmentation (bronzing) of the skin, and other trophic disturbances develop. In relation to the chronic ingestion of arsenic, mention must be made of the tolerance to the poison that may be acquired by its habitual use. The peasants in Styria, by progressively augmenting the dose, acquire the capacity of swallowing with impunity four or five grains of arsenious acid at a time. The object is to enable the " arsenic-eater " to endure greater fatigue in mountain-climbing than he otherwise could do. It is said that arsenic is sometimes given to horses in order to improve their coats and general appearance. The elimination of arsenic takes place by the kidneys, the bowels, and, to some extent, by the skin. It commences very rapidly after ingestion; the poison can readily be detected in the urine half an hour after a single dose of five drops of liquor arsenicalis — equal to about J-r grain of arsenious acid — has been taken. After a like dosfi it may be detected in the faeces. Arsenic is not accumu- lative, although a certain amount may remain in the organism for some time ; it has been detected in the urine forty days after its administration ceased. That which has been absorbed is found after death in largest amount in the liver, as much as one to two grains may be present; the kidneys and the other soft organs contain lesser amounts. Arsenic has been found in the bones and in the hair. In prolonged poisoning the spongy bones, as the cranium and bodies of the vertebrae, and in rapid poisoning the compact bones, as the femur, are the most likely to contain it. Arsenic is not a physi- ological component of the body, therefore, if detected, its presence has to be accounted for. When arsenic is found in disinterred bodies 1 Neurologisches Centralbl., 1892. CHRONIC ARSENICAL POISONING. 135 it lias been suggested that its presence may be due to transudation of the poison from the soil which surrounded the coffin. Arsenic lias been found in the soil of certain graveyards, usually, however, in combination with iron and in an insoluble form; it is therefore in the highest degree improbable that a body free from arsenic when buried, should become contaminated from the soil of a cemetery or churchyard : but to avoid possibility of error in this respect, a sample of the soil which surrounds the coffin should be collected and examined. The body of a person who has died from arsenical poisoning is accredited with the power of resisting putrefaction. If at the time of death the tissues contain much arsenic, it will exercise a preserva- tive influence, but it is not to be assumed that decomposition is retarded in every case of arsenical poisoning. Much of the poison would not be present in the body after a minimum lethal dose, and in such a case putrefaction would follow the ordinary course. Instances of delayed putrefaction in the bodies of those who have died from arsenic have frequently been observed. In the case of Reg. v. Gross (Munster, Ass. L887), for the murder of his wife by poisoning her with arsenic. Pearson x states that when the body was exhumed, seven weeks- after death, all the organs were in an excellent state of preservation, the stomach and the intestines appearing as fresh as though the deceased had died but twenty-four hours previously. In this case the fatal illness lasted about three weeks, during which time repeated doses of arsenic had probably been given ; chemical analysis showed that the body contained a large amount. Brouardel and Pouchet 2 examined the body of a woman who died from arsenical poisoning in May. The body was exhumed on the thirtieth of October following, and was found to be in a remarkable state of preservation, not a trace of the gases of putrefaction being present. The woman suffered from the effects of arsenic for six weeks before her death, and a considerable amount of the poison was found in the body. Chemical Analysis. — If arsenious acid has been administered in the solid form, it is probable that undissolved particles may be found lying on, or embedded in, the mucous membrane of the stomach. If any such particles are found, they should be picked out or scraped off, dried, and tested. Attention should be paid to the presence of any particles of colouring matter — as soot or indigo — with which the arsenic may have been mixed. If the body has been interred, it is possible that the particles of arsenic may be changed into the sulphide. Tests.— In the first instance Reinsch's method of testing for arsenic may be adopted. Trine should be evaporated down to one-fourth or one-sixth its volume before being tested; solid sub- 1 Dublin Journ. Med. Science, 18SS. - Annates d' Hygiene, 1SS9. 436 FORENSIC MEDICINE. stances should be pulpified and mixed with sufficient water as to render them fluid. Previous to testing the suspected substance, the reagents themselves should invariably be tested for arsenic ; pure copper is easily obtained, but hydrochloric acid absolutely free from arsenic is the exception. To some water in a flask, one-sixth its volume of strong hydrochloric acid is added, together with two or three small pieces of copper foil ; the flask is placed on a support covered with wire gauze over a Bunsen flame, and the acidulated water is allowed to boil gently for a quarter of an hour. The copper is then examined : if it retains its primitive brightness and colour, absence of arsenic in the reagents may be assumed. The acidulated water is now replaced by some of the suspected substance, to which one-sixth its volume of strong hydrochloric acid is added from the same bottle as that from which the previous supply was taken, one or more of the same pieces of copper being dropped into the flask. After gently boiling for four or five minutes, the foil is again examined : if the amount of arsenic in the fluid was very small, the foil will only exhibit a purple tint; if a little more arsenic was present, the foil will ipresent a steel-grey appearance ; if a large amount was present, it may be covered with a black amorphous coat which is easily detached. The presence of sulphur-yielding bodies in organic mixtures may cause the copper to be stained. The foil is washed in distilled water, carefully dried on filter paper, and then introduced into a small dry reduction- tube ; the form shown in the illustration is convenient for subsequent microscopical examination, the flattened walls producing less distortion ±han those of a cylindrical tube. Fig. 22. — Reduction tube. The closed end of the tube, on which the foil rests, is brought into the margin of a Bunsen flame and there retained until the film of arsenic is volatilised. When the arsenic leaves the copper, it combines with some of the oxygen of the air, and is deposited, as a ring — a centimetre or more up the tube, in accordance with the heat brought to bear — of octahedral or tetrahedral crystals of arsenious acid. On microscopical examination the largest crystals will be found nearest the foil, where (unless the amount of arsenic is very small) the ring is sharply defined ; the crystals, unlike those deposited from aqueous solutions, are always separate and distinct. A crystalline deposit, ob- tained as described, is very chai'acteristic of arsenic. Having shaken the pieces of copper out of the tube, a couple of drops of water are CHRONIC ARSENICAL POISONING 437 •2:].— Crystals A introduced and, with the aid of heat, the crystals are dissolved ; this takes a few minutes to accomplish on account of the feeble solubility of arsenic, especially when in the crystalline form. When all the deposit is dissolved, the solution is shaken out on to a colour- slab, so as to form two separate drops ; to one a drop of a solution of silver nitrate is added, and to the other a drop of a not too strong solution of copper sulphate. A glass rod that has been dipped in ammonia water is then held horizontally over the drops, close to (so as to allow the gaseous ammonia to act upon them), but without touching them. The one to which silver nitrate was added turns yellow, and the other becomes first blue and subsequently green ; the salts formed are respectively silver arsenite and copper arsenite or Scheele's green. Reinsch's test is inapplicable in the presence of chlorates and nitrates. In addition to arsenic — antimony, mercury , silver, bismuth, plati- num, palladium, tin, and gold are deposited on copper when boiled with it in acid solution ; of these only three — ar senic, antimony, and mercury — yield sublimates in the red uction tube. Marsh's test is founded on the power possessed by nascent hydrogen of reducing arsenious and arsenic acids, and of combining with the metallic arsenic they set free, forming arsenetted hydrogen, from which the arsenic can afterwards be disassociated by heat, and by chemical reagents. The necessary apparatus consists of a bottle or flask, through the stopper of which a long thistle-funnel and an exit-tube pass ; between the flask and the free end of the. exit-tube a chloride of calcium tube is interposed to dry the gas as it escapes. The accompanying figure is taken from a convenient model which T had constructed entirely of glass, in order to avoid the possibility of contamination from the accidental introduction of arsenic by the use of rubber stopjiers 1 . Metallic zinc free fromarsenic is placed in the flask, and some dilute sulphuric acid, also free from arsenic, is added. The purer the zinc, the less freely is it attacked by the acid; with some specimens it is necessary to promote action by the addition of a single drop of a solution of platinic chloride to the contents of the flask ; rapid evolution of hydrogen, however, is disadvantageous ; it is therefore best to allow the acid to act unaided if it will do so. When sufficient hydrogen has been evolved as to render it probable that all the air is expelled from the flask, a sample of the gas should be taken in an inverted test-tube 1 May be obtained from Messrs. Jackson & Co., Half Moon St., Manchester. 438 FOHENSIC MEDICINE. and tested by applying a light to the open end. A sharp shrill report reveals the presence of an explosive mixture of gases ; a slight pop indi- cates that the hydrogen is sufficiently pure to allow of ignition without danger of explosion. As soon as this is the case a lighted Bunsen burner is placed under the exit-tube and allowed to remain ; the tube being supported on both sides of, and near to, the flame. The flame is allowed to play on the tube for thirty minutes before any of the suspected substance is introduced into the flask ; this is necessary in order to prove the absence of arsenic in the acid and the zinc. If the tube remains free from deposit, the purity of the reagents is established. The gas which escapes from the exit-tube may be ignited and allowed to play on a surface of cold porcelain, such as a Fig. 24. — Marsh's apparatus. crucible lid ; the porcelain also remains unstained if the materials used are pure. Having determined the absence of arsenic in the gas that is escaping, some of the suspected fluid is poured down the thistle-funnel. If arsenic is present, a deposit of gradually increasing density makes its appearance in the tube an inch or more away from the Bunsen flame in the direction of the free end of the tube. The hydrogen flame burning at the end of the exit-tube, from being almost invisible, becomes of a whitish-lilac colon )-, and if a large amount of arsenic is present it gives off fumes of arsenious acid. On the approach of a cold porcelain surface to the flame a deposit is obtained which varies in density with the amount of arsenic present, and the length of exposure. Unless a long length of tube is heated by a row of Bunsen's burners a considerable portion of CHRONIC ARSENICAL POISONING. arsenetted hydrogen escapes disassociation during its passage through the heated portion, especially if the hydrogen is rapidly generated. Instead of burning the gas as it escapes, the exit-tube may be turned downwards. into a small vessel containing a solution of silver nitrate, so that the gas bubbles up through it ; in doing so it causes the silver nitrate solution to turn brown or black. Arsenetted hydrogen has a disagreeable garlic-like odour when it escapes into the air. Marsh's test may be used with organic matter containing arsenic, but with many organic lluids it is extremely difficult to avoid the formation of froth on the surface of the liquid, which is liable to mount up to the exit-tube and spoil the results. Marsh's test is not applicable to lluids containing nitrates, nitrites, chlorides, or free chlorine. Examination of the Deposits. — The colour of the deposits on the porcelain varies from light-brown to black ; the heaviest deposits show a brown tinge at their margins, although the bulk of the deposit is black. A drop of a solution of bleaching powder allowed to fall on one of the deposits immediately dissolves the portion on which it falls, leaving a white circle of porcelain visible. Ammonium sulphide applied in the same way merely detaches the film from the porcelain, and breaks it up ; it dissolves but a limited amount. If a deposit is treated with a few drops of nitric acid and heated, it is dissolved and converted into arsenic acid. The free nitric acid being evaporated, a drop of a solution of silver nitrate added gives the brick-red colour of silver arseniate. It will be remembered that silver arsenite is yellow. t Fig. 25. — Deposit of arsenic on exit-tube of Marsh's appar The deposit in the exit-tube also has a brown hue, especially at the less dense parts; when very dense it is black. If heat is applied to the tube after it is detached from the flask, the film is volatilised, and combining with oxygen is deposited away from the source of heat as crystals of arsenious acid. If, whilst the heat is being applied, a current of dried hydrogen is passed through the tube, the deposit will be volatilised, and re-deposited as metallic arsenic. When dealing with minute amounts of arsenic, it is well to have the end of the exit-tube drawn out for a couple of inches into capillary dimensions, and after a deposit is obtained in the wider part to drive it by the aid of heat into the capillary portion whilst hydrogen is still passing through it, before detaching the tube from the apparatus. If, when 440 FORENSIC MEDICINE. tilled with hydrogen, the tube, or the stained portion of it, is hermeti- cally sealed at both ends, it can be preserved as corpus delicti. The solution of silver nitrate through which the arsenetted hydrogen passed will be partially converted into a solution of arsenious acid with deposition of metallic silver from which it can be separated by filtration. If ammonia water is added to the filtrate, the arsenious acid combines with some of the remaining undecomposed silver nitrate and produces a precipitate of yellow silver arsenite. Copper arsenite may be tested by dissolving a little in ammonia water : the colour changes from green to blue, which is evidence of the presence of copper. If to a drop or two of the ammoniacal solu- tion placed on a colour-slab, a crystal of silver nitrate is added, yellow silver arsenite forms round the crystal. The other tests for arsenic and copper respectively may also be applied. The best way of separating arsenic from organic admixture is to take advantage of the volatility of arsenious chloride [AsCL] ; this method is especially convenient as regards the viscera. Before being submitted to it, the substance under examination should be finely divided, and thoroughly dried in a hot-water oven. When sufficiently dry, it should be powdered in a mortar and then placed in a flask connected with a condenser, the lower end of which dips into a receiver containing either water alone or a solution of potassium or sodium hydrate ; both condenser and receiver should be kept cold with a stream of cold water. The powdered material is then well covered over with pure strong hydrochloric acid, and the heat of a water bath is applied to the flask until about three-fourths of the hydrochloric acid has passed over. The heat is temporarily withdrawn, and more hydrochloric acid is added to the flask, a fresh receiver being substituted for the one already used ; distillation is then resumed. The whole of the arsenic usually comes over by the time the second distillation is complete ; if not, the process must be repeated. The combined distillates are then dealt with as will presently be described. In order to secure free volatility of the arsenic as chloride, it is essential that the liquid under distillation should be saturated with gaseous hydrochloric acid. If, therefore, the organic matter cannot be dried, or in the case of liquid organic substances containing arsenic, the plan recommended by Hufschmidt, x which is a modification of Sonnenschein's " 2 method, excellently fulfils its purpose. After the hydrochloric acid is added to the organic matter in the flask, a stream of hydrochloric acid gas is passed into it to complete saturation ; heat is then applied, and distillation carried on Avhilst a stream of hydro- 1 Berichte tier deutsch. che.m. Gesellsch., 1884. - Hantlbuch tier gerichtlichen Chemie. CHRONIC ARSENICAL POISONING. 441 chloric acid gas is being passed through the liquid undergoing dis- tillation. The result of securing complete saturation of the acid is that the arsenic is rendered so volatile, that the whole of it readily passes over in the. first distillate ; less heat is required, and, conse- quent^, the product obtained is not so much contaminated with organic products. Care must be taken to have all the joints in the apparatus free from leakage, as the gaseous As< '1.. is extremely volatile. Filter paper dipped in a solution of AgXO . blackens if held to a leaky joint. \\ hen ga seous arsenious chloride is dissolved in water it is decom- posed into arsenious and hydrochloric acids. 1 f the amounl of arsenic that comes over is small, it will all be dissolved by the water in tin- receiver as arsenious acid ; if it is in excess, the water will be rendered tui'bid by undissolved particles ; the addition of a little potassium or sodium hydrate to the water, before distillation, ensures the solution of the whole of the arsenicas potassium or sodium arsenite. Quantitative estimation may be effected by passing sulphuretted hydrogen, to complete saturation, through the distillate obtained from the arsenious chloride. When all the arsenic is precipitated as sul- phide, removal of the excess of H.,8 can be accomplished by passing a stream of C0 2 through the liquid. The precipitate is then thrown on to a tared filter, washed, dried at 100°, and then weighed : 100 parts equal 60 "9 S of metallic arsenic. If, as is probable, some sulphur has fa llen, it may be rem oved by dissolving the arsenious sulphide in ammonia, with the aid of gentle heat ; separating from any deposit, and reprecipitating as sulphide by the addition of hydrochloric acid. After weighing, the sulphide may be reduced to the metallic state- by mixing it with potassium cyanide and sodium carbonate, and placing the mixture in a piece of hard glass-tubing drawn narrow for a couple of inches at the end. Dry C0 2 is passed through the tube from the thick end, and gentle heat applied until the tube and its contents are free from moisture; the heat is then increased so as to reduce the sulphide to metallic arsenic, which is deposited on the narrow part. of the tube, which should be kept cool. The part of the tube con- taining the deposit may be sealed off from the rest, and preserved as proof of the presence of the poison. When a portion only of an organ — the liver, for example — is used for quantitative estimation, in order to avoid the objection raised at the Maybrick trial, it is advisable to reduce the entire organ to a pulp, and to take a portion of the pulp for analysis. The objection raised was that the poison is not equally distributed throughout the organ, and therefore that a reliable estimation of the total amount of poison contained cannot be made from proportional calculations founded on 442 FORENSIC MEDICINE. the amount obtained from isolated fragments. Whatever value the objection may or may not have, it is important to meet it in the way indicated. ANTIMONY. The preparations of antimony, which are met with in toxicological enquiries, are antimony and potassium tartrate, and antimony chloride, chiefly the former. Antimony and Potassium Tartrate [KSbC 4 H 4 ; ,H 2 0], or tartar emetic, is a well-known medicinal preparation, which contains about 35 per cent, of metallic antimony. It is very soluble in water. Symptoms of Acute Poisoning. — When a poisonous dose is taken into the stomach an astringent metallic taste is usually experienced almost immediately, which is usually followed in a few minutes by violent pain from the mouth down to the stomach. The pain is hot and burning, and is accompanied by a sensation of constriction in the throat. Immediately after, profuse vomiting comes on, and a little later diarrhoea ; blood may be present in the. vomit, but is more usually absent. The depressing effects of the poison quickly show themselves in the form of a small, frequent pulse, diminished arterial tension, cold clammy surface, shivering, and profound collapse ; in this stage the surface may be cyanosed, and the patient unconscious. Clonic spasms may precede death. Respiration is slow and laboured. The urine may be almost entirely suppressed. Anomalous symptoms not unfrequently occur. Vomiting may be delayed as long as an hour after the poison is swallowed, and then it may either be slight or very violent. In some instances the symptoms resemble those produced by a narcotic. Dobie * records a case in which one drachm of tartar emetic was followed by a comatose condition, the patient dying on the sixth day. Respiration is not invariably affected; Carpenter- records a case in which, after 170 grains dissolved in water were swallowed, the respirations remained unaffected, recovery taking place. Fatal Dose. — The smallest recorded is one grain and a half of tartar emetic, following a similar dose taken twenty-four hours previously. No effect was produced by the first dose, but the second caused violent vomiting and purging, death taking place in about thirty-six hours: the patient was a healthy woman of twenty-five years of age. 3 This is an exceptional case. Five to ten grains probably represent a minimum fatal dose for a healthy adult. Children have succumbed to less. On 1 The Lancet, 1SS7. 2 New York Med. Rec, 1883. 3 Bulletin tie Therupeutique, vol. li. ANTIMONY. 4 4-"> the other hand, recover}- in adults lias followed 170 grains (see above) and in one ease even 200 grains. Death may occur in from a few hours to several days. When large doses are quickly rejected, the local effects of the poison are often speedily recovered from; the danger to a great extent appears to lie in its depressing effects, including those due to violenl vomiting and purging. Sub-acute or Chronic Poisoning. — Winn death results from homicida l poisoning with tartar emetic it is usually due to repeated doses, which progressively depress the systemic powers, prevent the retention of food, cause persistent vomiting and purging, and thus eventually lead to a fatal issue. In the case of Beg. v. Pritchard (High Court of Justiciary, Edin., 1865), the prisoner was accused of having poisoned his mother-in-law and his wife by the administration of tartar emetic. The latter was in her usual health up to the end of October, 1864, when she began to suffer from frequent attacks of vomiting : on leaving home she gradually regained her usual health, but after her return she again began vomiting and was attacked with severe cramps. The vomiting occurred within an hour or two after meals, which were always sent to her by her husband ; not only food, but also beverages, such as camomile tea, egg-flip, and port-wine, were rejected. Death took place on March 18th, 1SU5. During the illness of the deceased cramps constituted a prominent symptom ; the wrists were turned in and the thumbs powerfully flexed. Retching, vomiting, and diarrhoea were persistent, the tongue was foul, and there was constant thirst with profound depression. A considerable amount of antimony was found in the viscera after death, especially in the liver and in the contents of the intestines, in which it was present in a soluble form ; it is probable that the last dose of the poison was administered a short time before death. The prisoner was condemned, and, before his execution, confessed having poisoned the deceased. Tartar emetic is not unfrequently administered in dangerous doses to drunkards during a debauch, not with the object of poisoning them, but to produce such vomiting and nausea as to render them incapable of further excess for the time being. In a case of this kind recently seen by me the patient vomited, and was purged excessively; the tongue was foul and the surface was cold, but the pulse and respirai i<>n were not much affected. Cramps of the muscles of tin' limbs were severe and continuous; they lasted more than forty-eight hours, ami pei'sisted in the hands after the other parts originally attacked were free. Antimony was found in the urine. The patient recovered from what in all probability was a single dose, with a celerity that strongly contrasted with the severity of the symptoms. 444 FORENSIC MEDICINE. Antimony Chloride [Sb01 3 ], or butter of antimony, is used in an impure state for certain trade purposes, and, exceptionally, has been administered as a poison. In addition to the toxic effects of antimony. this salt has a powerfully corrosive action on the tissues with which i comes in contact, and produces symptoms and post-mortem signs accordingly. Treatment of Acute Antimonial Poisoning. —The poison usually pro motes its own evacuation; if it has not done so, the stomach mus- be emptied either with the stomach-pump or an emetic, or probabb tickling the throat will be sufficient to excite copious vomiting. When antimony chloride has been taken the stomach-pump should be usoi with great caution, if used at all. Then t annin , or some substance containing it, should be given so as to form an insoluble combination with any of the poison that remains in the stomach. After the poison is evacuated useless vomiting should be checked by ice and opium. External warmth should be applied, and stimulants given if needed It is characteristic of antimony poisoning that after a large dose, either a speedily fatal issue may be expected from exhaustion, or an almost equally speedy recovery ; in this respect it differs from arsenic. Anti- mony is eliminated by the kidneys and the bowels. Post-mortem Appearances. — After acute poisoning by tartar emetic the mucous membrane of the stomach is usually strongly injected ami swollen, and in parts may show indications of loss of superficial portions ; it is covered with a slimy mucus, and is frequently ecchy- mosed. A similar appearance, less intense, will be found in the duodenum. In some instances the mucous membrane of the stomach has been found ulcerated, and detached down to the muscular coat. the mucous membrane of the oesophagus being also ulcerated ; in others there is no appearance of ulceration of the stomach, the mucous membrane being also free from signs of inflammation. In the case 01 Bravo, who was poisoned with tartar emetic in 187G, both stomach and duodenum were pale and yellowish on their inner surfaces ; there were ulcers in the c?ecum, and the large intestines were blood-stained. The liver and kidneys may show fatty changes, usually only whei death has been caused by several doses, with intervals between them. The post-mortem appearances of poisoning by antimony are neither s< characteristic nor so constant as in arsenical poisoning. Antimony Chloride produces post-mortem appearances like those o' a corrosive, such as hydrochloric acid ; exceptionally, corrosive effect may be absent. Cooke 1 records the case of a woman, aged forty, wh swallowed the contents of a four-ounce bottle of butter of antimony in mediately after a meal ; vomiting without blood occurred, and profoun ' The Lance t, 1883. ANTIMONY. 445 collapse. Death took place in less than two hours. On post-mortem examination no corrosion of tongue, mouth, fauces, nor oesophagus was found; the mucous membrane of the stomach was intensely cong< almost black. Chemical Analysis— Tests.— Organic fluids, or solids, when pulpified and mixed with water to a fluid consistency, may be tentatively e-xam- / ined by Reinsch's method, as described in the preceding section. The amount of antimony present, and the length of time the solution is boiled with the copper-foil, and, to some extent, the acidity of the solution determines the appearance presented by the deposit. If it is but slight, the foil merely acquires a purple tint; if thicker, it resembles tarnished sheet zinc; and if very copious, it is covered with an amorphous black coat. When the foil is heated in a re duction tube, the deposit is volatilised, and condenses on a cooler part of the tube as a white amorphous cloud of antimonous oxide, which, when only minute traces of antimony are present, is scarcely visible. Under the microscope no trace of crystalline formatio n can be seen. Sometimes there is an appearance that at first sight might be taken for a crystalline deposit, but careful examination corrects the impression. After shaking out the copper foil the deposit of antimonous oxide maybe dissolved with gentle heat in a couple of drops of a solution of tartaric acid, and tested with J1,S, which gives the orange-coloured sulphide. If preferred, the deposit of antimony on the copper foil may be dissolved off in a weak solution of potassium hydrate, to which a little potassium permanganate has been added. Heat is applied until the deposit is dissolved, and then the fluid is separated by filtration from the precipitate of manganese that forms, is acidulated with HC1, and treated with II. ,S. The suspected fluid may be further tested by Marsh's process, as described in the last section. Antimonetted hydrogen is without odour and burns with a greenish-white flame. Examination of the Deposits.— In thin films the deposit on porcelain obtained from the flame is of a neutral tint, without trace of brown ; where the deposit is heavy, it is amorphous and black — like a smoked surface. The deposit is insoluble in a solution of bleaching-powder, b ut is freely soluble in ammonium sulphide , leaving, when dry, an orange-coloured residue of antimonous sulphide. When a deposit is dissolved in HN0 3 with heat, evaporated, and treated with a solution of silver nitrate, no colour change is produced ; the deposit of arsenic similarly treated yields a brick-red colour. In the exit-tube of the Marsh apparatus the deposit of antimony in the first instance appears immediately over the flame ; it then separates into two portions, the larger one being towards the free end 446 FORENSIC MEDICINE. of the tube, that to the flask-side of the flame being lighter, and some- times scarcely visible. The two deposits are most wide] y separated at the under part of the tube where it is hottest ; they curve over towards each other at the upper and cooler part. When the deposit has taken up its final position, it is much nearer the flame than is the casr with arsenic ; all this is due to antimony having a higher vola- tilising point than arsenic. The deposit of antimony has a bright metallic lustre, like that of mercury ; at the part where it fades away — furthest from the flame — it is smoky, but without trace of brown, as is the case with arsenic. If the deposit is very slight, it may be devoid of metallic lustre, being smoky, or greyish if moisture is pre- sent. On applying heat to the tube, the film of antimony is volatilised with difficulty ; it comes down again, if oxygen is present, as a white amorphous deposit of antimonous oxide. t Fig. 26. — Deposit of antimony on exit-tube of Marsh's apparatus. Antimony may be obtained from organic admixture by acidulating the organic fluid with HC1, and placing it in a platinum capsule, in which a small piece of pure tin or zinc is laid ; where the metals touch each other a black deposit of metallic antimony is formed in a few minutes, or in an hour or two, according to the amount present. After removal of the fluid and of the tin or zinc, the deposit should be washed, and then treated with strong HNO,, with the aid of heat, and the free acid driven off; the residue may be dissolved in strong HC1. If the solution thus obtained is largely diluted with water, the oxychloride is precipitated as a white insoluble salt, which may be dissolved in a solution of tartaric acid, and precipitated with H S as antimonous sulphide, recognised by its orange colour. In some instances antimony may be directly precipitated from organic admixture by passing H 2 S through it to saturation, previously adding a little tartaric acid, and boiling to ensure the metal being in solution. When dealing with the tissues it will be necessary to break them up by the moist process, taking the precaution to adapt a condenser to the flask in which the chlorine is evolved, in order to prevent pos- sible loss from volatilisation of antimonous chloride. There is not much risk, however, as antimonous chloride is not nearly so volatile as arsenious chloride. Quantitative Estimation. — Through a given proportion of the filtrate obtained after breaking up the organic matter, sulphuretted hydrogen is passed to complete saturation, so as to precipitate the antimony as ACUTE MERCURIAL POISONING. !i< sulphide. As antimony sulphide cannot be thoroughly dried at 100% it is necessary to conduct the drying in an atmosphere of CO.,. other- wise at the requisite temperature it would lose sulphur. There will probably be also some free sulphur to get rid of that has fallen from the H.S. The precipitate, after drying in the ordinary way at 100°, should be powdered in an agate mortar, and put into a porcelain boat, which is placed in a hard glass tube through which dried C0 2 is passing. Heat is applied until all moisture and free sulphur are ex- pelled : Hie residue is pure S1>..S.. : 100 parts equal 71 '77 of antimony. If free from uncombined sulphur, the sulphide .. in strong HC1 without leaving any residue. MERCURY. Metallic mercury in bulk has only very exceptionally produced symptoms of poisoning. In a finely-divided state, as in blue pill or blue ointment, or in "a state of vapour, the toxic effects of the metal are readily produced. The principal poisonous salt is mercuric chloride ; much less toxic, and much less frequently encountered in forensic investigations are mercurous chloride, mercuric oxide or red precipi- tate, and mercurammonium chloride or white precipitate. Mercuric nitrate resembles mercuric chloride in its effects. When pure, mercuric sulphide, or cinnabar, excepting in the form of vapour, is inert. The combinations of mercury with the organic radicles. methyl and ethyl, are virulent poisons. Acute Mercurial Poisoning. Mercuric Chloride [HgCl.,], or corrosive sublimate, dissolves in 16 parts of cold water and 3 parts of boiling water. It readily combines with albumen, a property upon which its corrosive action depends. Symptoms. — Immediately after a poisonous dose of mercuric chloride in solution is swallowed an acid metallic taste is perceived, which is accompanied by a sensation of constriction in the throat. A hot, burning sensation quickly develops, which spreads from the mouth, along the oesophagus down to the stomach. Vomiting of white slimy masses, which are frequently mixed with blood, rapidly follows. The pain radiates to the abdomen; there it assumes a colicky character, and is succeeded by co piou s diarrluca accompanied by severe tenesmus : the stools are watery, often blood stained, and they, as well as the vomited matters, contain shreds of mucous membrane. Blood is mor e constantly present in the vomited matters and in the motions than with poisoning by either arsenic or antimony. The mucous membrane -> 448 FORENSIC MEDICINE. of the mouth and pharynx is white and swollen, that of the larynx frequently heing also swollen, making the voice hoarse, and the breathing difficult and noisy. The urine is often completely suppressed for twenty-four hours or more; any that may be passed will probably contain albumen, and it may be tinged with blood. Symptoms of profound collapse are present ; the surface is cold, moist, and cyanosed, the pulse being small and irregular. There may be severe hiccough, or convulsions. If the victim survives the early symptoms, s alivation is likely to appear twenty-four or more hours after the inception of the poison ; this is not always the case, even when a large dose has been Taken and recovery takes place. Other symptoms of stomatitis may be present. The external use of corrosive sublimate has produced fatal poisoning from applications of a strong solution to ulcered surfaces. Absorption may take place through the unbroken skin. The extensive use of corrosive sublimate as an antiseptic has occasionally been the cause •of accidents. Legrand 1 records the case of a woman who received two uterine injections of a solution of corrosive sublimate, 1 in 2000, and in consequence died in three days. In a case related by Huber - a woman accidentally had 150 cc. of a - 5 per cent, solution of corrosive sublimate, diluted with an equal volume of water, administered as an enema ; violent vomiting and purging set in, with subsequent collapse, which ended in death on the fifth day. Fatal Dose. — Three grains of mercuric chloride taken by the mouth have caused death in a child. From 3 to 5 grains would probably prove fatal in an adult. Recovery has followed 90 grains in one case, in which salivation occurred ; and 100 grains in another, in which there was no salivation. Death usually occurs within three or four days ; it may take place in a few hours, or be postponed for seven or eight days. Red Precipitate [HgO] when taken in large doses produces the usual symptoms of irritant poisoning. Ord 3 relates a case in which one tea-spoonful was taken ; vomiting, diarrhoea (without blood) and tenderness of the abdomen were present ; recovery took place without salivation. In another case recovery followed two drachms. White Precipitate [NH.,HgCl]. — About 35 grains, sold in mistake as one of the ingredients of a seidlitz powder, caused the death of an adult. Forty grains taken by a man, aged fifty -two, caused death in five hours. Twenty grains produced violent vomiting and purging, with blood in the stools, in a woman of forty-eight, followed by salivation and stomatitis ; recovery took place. In other cases it has been taken in 1 Ann. de Gynecologic, 1S90. - Zeitsclir.f. Uin. Med., Bd. 14. :i The Lancet, 188S. ACUTE MERCURIAL POISONING. 449 much larger doses — as much as two drachms — without fatal result. This salt has been regarded as non-poisonous; on one occasion a woman indicted for administering it to her husband was acquitted on this ground ! Mercuric Nitrate [Hg(N< > 3 ) 2 H 2 0] on several occasions, when admini stered as a poison, has been in admixture with free nitric acid, in which condition it is used for veterinary purposes ; it is a powerful corrosiv e. Half an ounce of the solution in nitric acid caused the death of an adult in twenty-five minutes. Death has also resulted from its use externally as an escharotic. Metallic mercury in a finely-divided state is absorbed as such, hut is probably partially oxidised, and combined with albumen before being taken up by the blood. Mercuric salts, as before stated, at once combine with albumen, and probably exist in this combination in the systemic fluids, being held in solution by excess of albumen. Mercurous salts are taken up with difficulty on account of their insolu- bility, a large proportion being rejected either by vomiting, or by the bowels. The relative insolubility of mercurous salts does not deprive them of toxic properties, however, as is shown by many instances of fatal poisoning with them. Runeberg 1 relates the case of a woman who received three subcutaneous injections of calomel — l. 1 , grain in each — within one month. Ulcerative stomatitis, with profuse saliva- tion and diarrhcea set in, followed by collapse and death, which took place in a few days. Mercury is eliminated by the urine, faeces, saliva, and skin. When abundantly present in the body it may be found in the serum of blisters, in the milk, and in any other normal or abnormal secretion. Treatment. — In acute poisoning, if emesis has not already occurred, the stomach should be emptied by an emetic followed by plentiful administration of raw white of egg; the albuminate thus formed , though insoluble in water, is soluble in excess of albumen, therefore it should be removed as quickly as possible by producing further vomit- ing. Magnesium carbonate is useful to reduce the mercuric salt to a less active form. Afterwards demulcents and opium will be required. Post-mortem Appearances of Acute Mercurial Poisoning. Taking the appearances of mercuric chloride as a type, the lips and the mucous memb ramc of the mouth, including that of the tongue is usually swollen, softened, and of an ash-grey or white colour ; this appearance may persist along the (esophagus, the affected membrane being some- times corrugated, and sometimes eroded. The mucous lining of the stomac h is swollen and softened; it has been found deeply injected — of a bright scarlet colour — with ecchymoses ; in other cases the indica- 1 Arch.f. Dermatohylr u. Syph., 1SS9. 29 -t50 FORENSIC MEDICINE. tions of inflammation are not nearly so obvious. Eschars have been found in the vicinity of the pylorus. The small intestines are usually much less affected than the caecum, colon, and rectum, which are goncralh deeply injected, the lining membrane being probably ulcerated in pai-ts, with indications of haemorrhage. If death was very rapid, the intestines may present no abnormal appearance. Evidence of i nterstitia l nephritis will probably show itself, unless the case was so very acute as not to allow time for its production. Deposits of lime salts have been found in the tubules of the cortex of the kidneys ; when this is the case, a corresponding diminution of lime salts has been observed in the bones. A case was inves- tigated by Kaufmann, 1 in which a woman of twenty years died in nineteen days after swallowing a solution containing from 8 to 12 grms. (124 to 186 grains) of mercuric chloride. On the fourth day anuria occurred, which lasted two days; on the three following days the urine was plentiful. On section the kidneys were found to be deeply injected and to contain a number of calcareous deposits in the cortices- Microscopical examination showed that the appearances presented by the kidneys did not depend on parenchymatous inflammation, but on a non-inflammatory necrosis of the epithelium, due to coagula- tion- or anaemic - necrosis. The calcareous deposit existed in the epithelial cells and not in the lumen of the tubules. The epithelial layer of the mucous membrane of the stomach also contained numerous minute calcareous deposits. A number of t hromboses due to alter a- tion of the blond, which is regarded by Kaufmann as the essential nature of corrosive sublimate poisoning, were found in the capillaries of the lungs and elsewhere. Whether the blood stasis in the capillaries is caused by changes in the red corpuscles themselves, or to liberation of fibrin-ferment is not certain, possibly to both. Chronic Mercurial Poisoning. "When mercury is taken into the system in repeated small doses, the effects produced are of a special character, differing in their salient features from those met with in acute poisoning. Chronic mercurial poisoning occurs almost exclusively among workers in the metal, or among those who handle substances which contain its salts: looking-glass makers, thermometer and barometer makers, workers in quicksilver mines and in manufactories in which the preparations of cpiicksilver are produced, represent the first division; furriers, bronzers, and others the second. The order varies in which the symptoms of chronic mercurial poison- 1 Virchow's Arch., 18S9. CHRONIC MERCURIAL POISONING. 451 ing occur. The first indications usually are symptoms of dyspepsia, anorexia, colicky pains, loss of flesh and of strength. Increase in the secretion of saliva is observed, accompanied by fa- tor of the breath. tenderness of the gums, and the general symptoms of stomatis . The sufferer looks anaemic ; he is subject to attacks of nausea, vomiting, and diarrhoea. The skin shows erythematous, eczematous, or pustular eruptions. Sooner or later the occurrence of special symptoms indicate that the nervous syst em is implicated ; in some instances the nerve-symptoms are the first to show themselves. The earliest and most characteristic i — ±r is a _fine tremor of the muscles of the tongue and face, at first only manifest under excitement ; the tremor tends to spread to the arms, and later to the legs. Although at first called up by exertion only, its fineness— resembling paralysis agitans — distinguishes it from that of disseminated sclerosis. Subsequently the tremors are continuous, although still accentuated on voluntary movement, rendering co-ordi- nated muscular action difficult; during sleep they may be absent, or simply lessened, in accordance with their intensity when the patient is awake. As is the case in all tremors that affect the muscles of articulation, the patient stammers and hesitates when speaking. The tremors may exist without appreciable loss of muscular power, but, as a rule, more or less paralysis occurs. Letulle 1 found this to be the case with a number of workers in the Almaden Mercury Mines ; the diminution in muscular power, as tested by the dynamometer, was proportional to the duration of the mercurial influence. Muscular weakness may occur without tremors, but complete paralysis is invari- ably preceded by tremors. S ensory disturban ces, such as imperfect tactile sensibility, hyperesthesia, and painful sensations, are, as a rule, localised and not profound. P sychical disturbanc es are frequent, and take the form of mental irritability, loss of power of concentration, with headache and palpitation. The condition called mercurial eiv- thism may be present, the patient being subject to hallucinations, and to attacks of acute mania. In the majority of cases observed by Letulle, the digestive organs were healthy. The teeth may be blackened, and appear as though corroded by an acid; the condition, however, differs from ordinary caries. Chemical Analysis. — The presence of mercury in organic admix- ture, in not too small an amount may be demonstrated by Reinsch's test. The film of mercury on the copper foil is very character- istic, presenting the appearance of polished silver; if the foil after being dried is put into a reduction tube and heated until the mercury is driven oil", minute globules of the metal are deposited 1 Arch, de Phys. Norm, tt Pathol. 1SS7. 452 FORENSIC MEDICINE. <>n tho cooler part of the tube. Under the microscope by transmitted light they appear like black halls ; by reflected light they show a metallic lustre round their margins. When the tube is cool (the copper being shaken out), the vapour given oft' from a scale of iodine introduced into it, soon colours the mercurial deposit yellow, which gradually deepens into scarlet mercuric iodide. The presence of mer- cury in organic fluids may also be ascertained by immersing in the fluid after acidulation with hydrochloric acid, a slip of gold foil in contact with a piece of tin wire ; a white stain (metallic mercury), appears on the foil where it is touched by the tin. On account of the volatility of the metal the moist method should be used in oi'der to separate mercury from organic matter. If the amount of mercury is not very small, the liquid obtained after treatment of the organic matter with potassium chlorate and hydrochloric acid may be satu- rated with H 8, and allowed to stand until a black precipitate of mercui'ous sulphide falls, which, after separation, must be thoroughly washed free from all trace of chlorides. Any silver, lead, or copper sulphides present may be separated by treatment with nitric acid in which they are soluble ; mercurous sulphide is insoluble in nitric acid. After the precipitate is washed and dried, it may be weighed and the amount of mercury calculated — 100 parts equal SG'2 mercury. The sulphide is then treated with niti'o-hydrochloric acid, evaporated to dryness, and dissolved in "water. The solution thus obtained may be tested in various ways for mercury. Tests. — With mercuric salts potassium iodide gives a scarlet pre- cipitate soluble in excess. Potassium hydrate gives a yellow precipi- tate. Stannous chloride gives a white precipitate of mercurous chloride which changes to grey — metallic mercury. With soluble mercurous salts potassium hydrate gives a black precipitate ; potas- sium iodide a green precipitate ; stannous chloride a white precipitate changing to grey ; potassium chromate a brick-dust coloured preci- pitate. A number of methods have been devised for separating mercury present in very small amount along with organic matter. Some modification of the moist method is usually adopted to destroy the organic matter, and much ingenuity has been expended on the sub- sequent separation of the metal. Hofmeister's method as adopted by Winternitz 1 dispenses with destruction of the organic matter when urine is the fluid to be examined. The urine is acidulated with 10 per cent, of HC1, and is left for two days to deposit uric acid ; after filtration it is slowly passed through a system of glass tubes containing rolls of copper gauze. The mercury present is deposited in the metallic 1 Arch./, exp. Pathol v. Pharmal;., 1889. LEAD. 153 state on the gauze, and after washing and drying, is driven off by heat, and is deposited on a cool part of the combustion tube in which the volatilisation is performed, and weighed. Bohni 1 modifies this pro- cess by destroying the organic matter in the moist way, and after freeing the liquid from chlorine, allows it to pass over copper gauze as above described. Ludwig and Zillner- after destroying organic matter with hydrochloric acid and potassium chlorate, precipitate the mercury with zinc dust, from which it is volatilised by heat. The tube containing the deposit is weighed, and again after the mercury is driven off by heat. These recent methods, which for the most part are modifications of older processes, present certain advantages, and enable approximately exact results to be obtained, but after some experience in their use, I prefer the e lectrol ytic method as being easier of application, and of equal accuracy. The organic fluid after treatment with potassium chlorate and hydrochloric acid, is submitted to electrolysis, as described in the following section, a small slip of gold-foil being substituted for platinum as the cathode. After the mercury is deposited, the gold-foil is washed, first with water, then with absolute- alcohol, and lastly with ether, and carefully dried and weighed. It is then introduced into a piece of hard glass tubing through which a current of dry air is passed and sufficient heat is applied to drive off the mercury from the foil on to the tube. The foil is re-weighed, and, for control purposes, the tube is weighed with the deposit, and again after it has been driven off by heat. LEAD. The salts of lead chiefly encountered as toxic agents are the neutral acetate (sugar of lead), the basic acetate (Goulard's lotion), the car- bonate (white lead), the tetroxide (red lead), and the chromate (yellow chrome) ; other salts of lead, as the chloride and nitrate, are poisonous but are not so accessible to the public. Fine particles of metallic lead are poisonous when repeatedly taken into the system. The salts of lead act as mild irritants, some being more powerful poisons than others. The chromate, for example, although insoluble in water, acts more energetically than the acetate, which is soluble. Lead poisoning may be acute or chronic ; an intermediate subacute form is not unfrequently encountered. 1 Zeitzchr. f. phi/a. Chemie, 1891. - Wiener klin. Wochemchr., 1889. 454 FORENSIC MEDICINE. Acute Lead Poisoning. Lead Acetate [Pb(C 2 H 3 0) 2 3H 2 0], the salt of lead most frequently used, has a sweetish taste : it only produces acute poisoning when taken in large doses. Symptoms. — If an ounce or more is swallowed, a strong astringent metallic taste is at once perceived, followed by a feeling of constriction in the oesophagus, and a hot sensation, which spreads to the stomach. Within half an hour after, vomiting comes on, the vomited matter consisting of white opaque masses, which may be tinged with blood. There is great thirst, and violent colicky pains in the abdomen, which come on in paroxysms ; the abdominal muscles are tense, and the patient eases the pain by bending himself forward and compressing the abdomen. The bowels are usually constipated, but exceptionally diarrhoea has occurred ; the motions are dark, almost black, from the presence of lead sulphide. The urine may be partially suppressed. Great prostration, vertigo, and pains in the head and limbs are experienced, with general numbness, or paresthesia?, cramps in the calves, and occasionally paralysis of the limbs. Drowsiness is not unfrequent ; the tongue is coated, and the breath is offensive ; the pulse is small and frequent. In acute lead poisoning, from a single dose the gums do not exhibit the blue line which is characteristic of chronic lead poisoning. The gi'eater number of cases of acute lead poisoning recover. The subacute form occurs after taking repeated doses of a soluble salt of lead, which, though small, are not minute. The patient is troubled with intense thirst and a metallic taste. Colic, with retraction of the abdominal muscles, is a prominent symptom; the bowels are obstinately confined. The urine is lessened in quantity. The blue line round the margin of the gums is usually present ; the pulse is weak, and slow ; the tongue is coated and the breath is offensive. There may be some of the more acute symptoms present, as prostration, numbness, and vertigo. Death rarely occurs, the symptoms passing off in a week or two, after the poison ceases to be administered. Gastric disorder and colic are the symptoms which first indicate the occurrence of the subacute form of lead poisoning, which occasionally happens in consequence of active medicinal treatment by means of lead acetate. Usually lead acetate may be administered in medicinal doses for a considerable time without producing poisonous symptoms, as, for example, when given to check the obstinate diarrhoea which accompanies tubercular ulceration of the bowels ; on rare occa- sions poisonous symptoms follow :i single dose. Fatal Dose. — The exact amount of lead acetate which will cause death is not known. Recovery has followed an ounce. CHRONIC LEAD POISONING. -\:>:, Treatment of Acute Poisoning.— The stomach should be emptied either by the tube or emetics unless there lias been free, spontaneous vomiting. Sodium and ma gnesium sulphates should be given in half ounce doses, dissoh ed in half pints of water; dilute sulphuric acid may be substituted. The lead sulphate thus formed should be got rid of Dv purgatives, as, although an insoluble salt, it is not entirely harm- less. Demulcent drinks, as bailey water, milk, or white of egg are beneficial. Opium may be necessary for the colic and to restrain useless vomiting. Post-mortem Appearances.— On account of the comparative rarity of fatal cases, the post-mortem signs are not well known. In addition to the usual indications of acute gastro-enteritis, the mucous membrane of the stomach has been found to be covered with a whitish-grey deposit. Erosions of the mucous membrane of the stomach and of the bowels have been observed, apparently due to the lead salt remaining in contact with it in parts. The mucous membrane of the stomach, in addition to being inflamed, may be thickened and softened, a condition which sometimes extends to the duodenum. The other organs yield no reliable indications. Chrome Lead Poisoning. The sources from which the lead is derived in chronic poisoning are almost illimitable. They may be divided into those due to OCCupation- risks, and those due, to the accidental presence of lead in fluids and comestibles, and in substances which are repeatedly brought in contact with the surface of the body; in the latter case it is probable that tin poison is accidentally transferred to the mouth by the finger, in hand ling food for examjde. Among the first division are those employed in the manufacture of, and workers in, white and red lead — painters, fitters, plumbers, and others; workers with metallic lead, as smelters, file cutters (who use a thick plate of lead on which to bed the files while they are being cut), compositors, those who melt down old lead, shot manufacturers, and lead pipe makers, together with workers in lead glaze for earthen- ware, and makers of lead glass. Among the accidental causes are : — drinking-water which has been stored in lead cisterns, has passed through lead pipes, or is derived from contaminated sources; food cooked in so-called tinned vessels, the coating in the cheaper kinds sometimes containing lead, or in earthen ware vessels lined with lead glaze, or food preserved in "tins," the solder of which contains a per- centage of lead. Wine bottles that have been cleaned by shaking lead shot within them: confectionery coloured with lead chromate ; 456 FORENSIC MEDICINE. tea, and snuff packed in lead foil ; hair dyes and cosmetics containing load, and soda-water syphons fitted with pewter or lead valves, have all from time to time given rise to chronic lead poisoning. It is doubtful whether metallic lead can be taken into the system through the intact skin; the usual portals are the mouth and nostrils. Workers in metallic lead do not suffer unless they are frequently in the presence of large quantities of the molten metals, or inhale fine particles of solid lead or of its oxide from manipulating old metal. ( >rdinary plumbers, who handle unoxidised metallic lead all day long, comparatively rarely suffer from lead poisoning unless from the use of white or red lead in fitting. Lead, although not usually classed amongst the volatile metals, is capable of volatilisation at a high tem- pei-ature, and in the form of vapour may be taken into the system through the respiratory tract and also into the stomach. One of the worst cases of chronic lead poisoning I ever saw was that of a man who bought the sheet-lead linings of old tea chests, and melted them down into pig-lead. He did the work in a small room without any contri- vance for ventilation, and attended to the whole process himself. File cutters abrade small particles of lead by constant hammering, and in this way the metal gets into the mouth and air-passages. In other trades in which lead is used, the salts of the metal are introduced into the system by want of cleanliness ; a workman is content to wipe his hands on his apron, or other cloth already contaminated with lead, and then to handle food in the act of taking his meals. He will also hold between his teeth brushes or other articles soiled with lead paint. Idiosyncrasy has much to do with chronic lead poisoning; of half a ■dozen persons subjected to the same risks, perhaps one only develops symptoms. The use of alcohol increases the tendency to chronic lead poisoning; Oliver 1 regards it as a most potent factor. Gouty subjects easily succumb to the influence of lead, and in its turn, the metal tends to develop gout. Oliver states that women succumb to the influence of lead more quickly than men and at an earlier age — IS to 23 ; in the ■case of men the usual age is from 41 to 48. Cases have been observed in which symptoms of chronic poisoning appeared years after the indi- vidual had ceased to be exposed to the action of the metal. In pregnant women abortion frequently results from chronic lead poisoning. Symptoms. — The early symptoms are usually referred to indigestion; the patient has pains in the stomach or abdomen, which may or may not be evoked, or increased by taking food ; the appetite is diminished and the bowels are constipated. A disagreeable, sweetish, astringent taste is experienced in the mouth, and the breath is offensive. The skin acquires an unhealthy colour; at first it is yellowish, subsequently 1 Lead poisoning in Us acufe and chronic forms, 1S02. CHRONIC LEAD POISONING. 457 it is anaemic . Round the free margins of the gums a blue line is seen must strongly marked in the upper jaw; where teeth are absent the blue line is also absent. The lead is due to deposition of lead sulphide in the substance of the gums; small quantities of food containing sulphur cling to the teeth, and in consequence of decomposition slowly give off H.,8 which combines with the lead present in the gums. Nutrition is interfered with and the patient consequently emaciates. The pulse is usually slow, and of high tension. Patients in this condition often go on for a long time without much change, although they may continue to be under the influence of the poison; usually, however, one or other of the more pronounced symptoms of chronic lead poisoning is developed. They comprise : — colic, arthralgia (pain in the neighbourhood of the joints), paralysis, and encephalopathy (psychical disturbances). Colic is usually the iirst to appear, although cases of typical lead paralysis occur in which the patients deny ever having had colic; as a rule one or more attacks of colic precede the other symptoms. Colic is usually ushered in by recurrent abdominal pains as mentioned in the general symptomatology, an attack may suddenly occur, however, without any antecedent pain. In most cases the pain radiates round the umbilicus, and is accompanied by tenesmus and retraction of the abdominal muscles; whether the muscles are retracted or not, they are tense and resistant, and the pain is relieved on pressure. Except in rare cases, when there is diarrhoea, the bowels do not act in spite of the tenesmus. During the attacks of colic the pulse becomes still slower, and is full and hard. There is no rise of temperature of any significance. Arthralgia. — The pains to which this name is given probably origi- nate in the sensory nerves of the muscles in the neighbourhood of the joints ; they may be preceded by shooting or flying pains, or they may come on suddenly without warning. They occur most frequently about the knees; less frequently about the elbows and shoulders. The sensation is that of a boring, tearing pain, which seems to affect the bone itself. The flexors suffer most frequently; as a rule, the small joints are not attacked. The pain may extend to the muscles of the trunk, especially to the lumbar muscles. Contraction and twitchings of the muscles have been observed. Paralysis. — The muscles most frequently attacked are the extensors of the hand and fingers. The order in which they succumb is usually — the extensor communis, the extensores digiti minimi, pollicis longus, carpi ulnaris, radialis, pollicis brevis, and (after a longer interval) the ossis metacarpi pollicis. The supinator longus usually escapes, and shows up in contrast to the wasted muscles. The result of the mus- 458 FOEBNSIC MEDICINE cular paralysis is that when the arms are held out horizontally, with the palms of the hands downwards, the hands drop, and cannot be raised, the condition being known as "wrist-drop." Exceptionally, the paralysis begins in the muscles of the upper arm ; the deltoid, biceps, and coraco-brachialis being affected, and in this — the upper arm type — the supinator longus is attacked. Both arms usually suffer, though one may be more affected, or further advanced than the other. The interosseous muscles of the hands and those of the ball of the thumb are sometimes specially attacked, producing the " claw-shaped " hand. The legs may be attacked, but usually not until arms have suffered for some time ; the anterior muscles — the extensors of the foot — are the first to suffer; the tibialis anticus, like the supinator longus, usually escapes. The muscles of the trunk are rarely affected. The characteristics of lead paralysis are : — little if any disturbance of the sensory fibres— probably limited to the early period if present — with profound trophic changes ; the affected muscles undergo extreme atrophy, and yield the reaction of degeneration. Lead paralysis is usually regarded as peripheral, but it does not correspond with the distribution of the peripheral nerve supply ; in the arm, for example, all the muscles supplied by the musculo-spiral are not affected. Changes have been found both in the nerves and in the ganglion cells of the anterior cornua of the cord. Encephalopathy. — Psychical disturbances usually commence by head- ache, dizziness, and sleeplessness; there may also be amaurosis: further development may lead to a condition of drowsiness, or to one of excitability, which may be accompanied by hallucinations or wild delirium. Eclampsia is common, especially in women, and involves an unfavourable prognosis; the convulsions may be repeated at intervals for days, the patient remaining unconscious for some time after each attack. Lead possesses selective properties in relation to the nervous system, which is attacked by it both centrally and peripherally ; it is capable of entering into combination with nerve-substance, and thus of directly interfering with its function. Blyth 1 chemically examined the brain of a man who had succumbed to the influence of lead, and found an amount of the metal in it equal to 117T milligramme of lead sulphate. Treatment of Chronic Lead Poisoning. — Removal of the patient from the influence of the poison is essential; when dyspeptic symptoms, especially if accompanied by pains in the abdomen, are complained of, the margins of the gums should always be examined. Various reme- dies, of which the favourite is potassium iodide, have been used to promote elimination of the metal. From the results of some investi- 1 Ahstraet of Proc. Chum. Soc, 18S7-8S. CHRONIC LEAD POISONINo. 159 gations recently made, 1 I have arrived at the conclusion that potassium i odide d oes not influence the rate of elimination of lead. In two ca of chronic plumbism, it was given in 15 and 10 grain doses respectively three times a day for a week or ten days, and then stopped for a like period, and again resumed ; during the whole period of the experiments the faeces and urine voided in the preceding twenty-four hours were analysed three times a week. The results showed that slow elimination, chiefly through the bowels, was going on the whole time, and that it was not increased when potassium iodide was being taken, in conjunc- tion with which magnesium sulphate was sometimes given. Several other accredited eliminants were also tried with negative results. The only treatment that to a slight degree seemed to increase the amount of lead in the excretions was a combination of hot baths and general massage, with occasional purges. Fresh air, good diet, as much exercise as can be judiciously taken, with hot baths and general mas- sage, are the means chiefly to be relied on to promote cure in cases of chronic lead poisoning. The special symptoms require ajDpropriatr treatment : — Colic will require opium; arthralgia, hot fomentations, and probably opium; paralysis, local massage and electricity. The elimination of lead from the system takes place chiefly by the bowels ; to a much lesser extent by the kidneys. It has been asserted that lead is eliminated by the skin, but I have never succeeded in obtaining any evidence of this ; the instances of blackening of the skin by baths containing potassium sulphide, which are cited in proof, were probably due to the presence of the metal, derived from external sources, in the pores of the skin. ^Vhen a medicinal dose of a soluble salt of lead is administered, about half or two-thirds of it passes in an insoluble form directly through the bowels without being absorbed ; what remains is gradually eliminated in the faeces and urine, a small percentage being probably ^ retained in the tissues for an indefinite period. Two grains of lead acetate were given to a patient three times a-day for five consecutive days ; on the lasl day of administration the fseces (l!27 grins.) yielded 0-1 7G2 grm. of lead, equal to about 5 grains of had acetate ; on the second day after the administration ceased, 290 grms. yielded 0-1411 grm. (about 4 grains) of the acetate; on the fourth day the amount fell to 0-0053 grm.. and on the sixth to 0-0006 grm., after which there was little more than a trace. The largest amount obtained from the urine in any one day was equal to a little over one milligramme of lead : this rapidly fell to less than one half. In a few days after there was a mere trace. In each instance the faeces and urine analysed were i British Med. .1 itr??., IS93. 4G0 FORENSIC MEDICINE. respectively the excretions of twenty-four hours. It is evident that only a small percentage of lead is absorbed when given medicinally ; the instances therefore, in which symptoms of lead poisoning are produced by medicinal doses, demonstrate that it is not essential for much of the poison to be stored tip in the tissues, but that what is stored up exists in a very stable form and probably in intimate com- bination with them. The elimination in cases of chronic poisoning was investigated in a similar way ; the f*ces and urine passed in twenty-four hours were analysed every second or third day, the weight of the faeces and the volume of the urine being noted on each occasion. The results showed that the daily elimination in the fa?ces was from five to ten times greater than that in the urine : the amount in the fieces varied from 3 milligrammes of metallic lead down to a mere trace ; the largest amount obtained from the urine in any one day was 0*9 milligramme. Chemical Analysis. — Any lead that comes away with the excretions, or is contained in the tissues after death, exists in combination with organic matter from which it requires disassociating before it will respond to reagents. If the amount of organic matter with which the lead is combined is small, it may be evaporated to dryness if a fluid, or simply dried if a solid, and then incinerated at as low a temperature as will effect the purpose. The residue is drenched with nitric acid, the acid driven off with a gentle heat and the nitrate thus formed is dissolved in a little water and tested. Tests. — Sulphuretted hydrogen produces a brown or black precipitate in accordance with the amount of lead present. Potassium iodide gives a yellow discoloration, or precipitate; the former when the lead is in very small amount. The precipitate is soluble in boiling water from which it crystallises on cooling in gold-coloured scales. In making use of this test with minute quantities of lead that have been treated with nitric acid, it is essential that all the free acid should be driven off, otherwise the reagent is decomposed and a yellow colour is produced by the liberated iodine. There are grounds for believing that some of the extraordinary results which have been obtained with potassium iodide, in testing urine for lead, were due to this fallacy. Potassium chromate gives a yellow precipitate. Sulphuric acid gives a white precipitate, hastened, when in very dilute solution, by the addition of alcohol ; the precipitate is soluble in ammonium acetate. A lead salt mixed with sodium bicarbonate, and heated on charcoal in the reducing flame of the blowpipe, yields beads of metallic lead incrusted with its yellow oxide. When minute quantities of lead are present in combination with large amounts of organic matter, the dry process is tedious, difficult to CHRONIC LEAD POISONING. 401 carry out, and uncertain in its results. The plan adopted in the investi- gations on the elimination of lead above-mentioned was as follows :— The urine was evaporated down to the consistence of gruel, and the faeces were mixed with distilled water to a like consistence; they were then severally treated with potassium chlorate and hydro- chloric acid, as described on p. 404. The filtrate after cooliu- was placed in ;i glass cell, the bottom of which consisted of a sheel of vegetable parchment. The cell was immersed to such a depth in an outer cell containing distilled water acidulated with a few drops of sulphuric acid, that the liquids in the inner and outer cells stood at the same level. A piece of platinum foil exposing a surface of about 50 cm. square was submerged in the liquid contained in the inner cell. and connected with the cathode of four Grove's elements, a similar piece of platinum foil connected with the anode being immersed in the outer cell ; the pieces of foil were so placed as to be opposite each other, separated by the parchment diaphragm. The circuit was closed from six to eight hours, after which the foil was removed from the inner cell, gently washed and dried. The metallic lead was dissolved off the foil with dilute nitric acid aided with heat, and after driving off most of the free acid, the solution was decomposed with dilute sulphuric acid, and an equal volume of alcohol added ; it was then set aside for twenty-four hours. The precipitate of lead sulphate was washed with water containing 12 per cent, of alcohol, until all the free acid was removed ; it was then separated by decautation, ignited, and weighed. The amount of lead was calculated from the weight of the sulphate : 100 parts of sulphate equal 68-319 parts of metallic lead. Whether the moist or the dry process is used, the residue alter the primary filtration should be tested for lead which may exist as sul- phate, and remain undissolved. If the original substance contains lead, as sulphate, the salt should be dissolved with heat in an aqueous solution of ammonium tartrate, to which a little free ammonia lias been added, and precipitated with sulphuretted hydrogen: 100 parts of lead sulphide equal 86-01 parts of metallic lead.' It is better, how- ever, to convert the sulphide into sulphate, by treating it with nitric, and subsequently with sulphuric, acids. It may be then ignited. weighed, and calculated by the factor for lead sulphate. In place of the electrolytic method, the solution obtained after destruction of the organic matter in the moist way may be precipi- tated with sulphuretted hydrogen, and the precipitate dealt with as above described. When the amount of lead is very small, the electrolytic method is much preferable. vn id* forensic medicine COPPEK. The salts of copper having a distinctive colour and a sti-ongly astringent taste are ill adapted for criminal purposes; still cases have occurred in which the sulphate and the acetate have been administered with homicidal intent; acute copper poisoning, however, is usually- due to accident or to attempted suicide. Metallic copper is slightly if at all poisonous ; many cases have happened of accidental swallowing of copper coins, which in some instances have remained within the digestive tract for a considerable time, but, with one exception, no toxic effects are recorded. When a soluble salt of copper is swallowed, it is probably transformed into an albuminate, and, if in small amounts, produces but slight local changes ; if in greater quantity, it not only combines with any free albuminoid substances in the stomach, but it also attacks the mucous membrane and erodes it. Acute Copper Poisoning. The salts that are usually answerable for acute poisoning are the sulphate [CuS0 4 (H o 0) 5 ] or blue vitriol, and the basic acetate [Cu(C 2 H 3 0„) 2 2CuO] or verdigris. Symptoms. — When a poisonous dose of either of these salts is taken, the usual effects of an irritant poison are produced within five or ten minutes. There is violent vomiting and purging, pain in the stomach and abdomen, a metallic taste, thirst, and the symptoms of collapse. The vomited matter at first is green or blue ; the lips also and the inside of the mouth maybe thus coloured. The vomit maybe dis- tinguished from bile by the addition of ammonia water, which strikes a deep blue with the copper salt, the colour of bile remaining un- changed. Pain in the head is frequent, and sometimes convulsions occur. The urine is diminished in amount, and may contain blood. Jaundice has been observed. In children the nervous system from the first may be seriously disturbed, producing profound depression, irregular respiration, tonic, or clonic spasms of the muscles of the limbs, or complete paralysis, the condition rapidly passing into coma, and death. Fatal Dose. — Is not known exactly. One ounce of th e sulphate, and the same quantity of the acetate, have each proved fatal. Death may occur in a few hours ; it is more usually delayed for several days. Treatment— If vomiting is taking place it may be aided by draughts of warm water, in which the white of egg is beaten up. If necessary, the stomach-pump must be used. Demulcents, such as barley water, CHRONIC COPPEIi POISONING. 403 a arrowroot water, and milk should be given. Morphine may be I sary to relieve pain and subdue useless vomiting Post-mortem Appearances.— Indications of the effects of an irritant will be present probably from the mouth down to the .stomach and bowels; the mucous membrane will be tumefied and softened, and in the stomach it may be erode,! ; the whole tract will show signs of inflam- mation. There may be distinctive indications of the poison, especially with the acetate, in the form of green-coloured particles adhering to the gastric, or intestinal mucous membrane; with the sulphate (if the discoloration exists) the appearance will be that of a bluish stain : the staining may be distinguished from that due to bile by the addi- tion of ammonia Mater. The liver may show fatty changes. Chronic Copper Poisoning. Chronic poisoning with copper is not nearly so frequent as the cor- responding form of lead poisoning; whether this is due to feebler toxic action, or to non-accumulation of the poison in the system, is a dis- puted point. Roger 1 maintains that copper salts are barely toxic when taken into the stomach, owing to their reduction by glucose and their removal from the circulation by the liver; but when injected directly into the blood-current they are distinctly toxic. As proof of the iu- nocuousness of copper in small doses, it has been asserted that workers ^ in the metal never suffer from its effects ; it is probable, however, that the continuous introduction of small amounts of copper into the system produces s ymptoms which, though longer delayed, closely resemble tho se due to lead. In brass workers Suckling 2 observed wrist-drop and other symptoms attributable to peripher al neuritis ; a green line was present on the margins of the gums, and the lower parts of the teeth were stained green. In other cases metallic taste, dyspepsia , attacks of vomit ing, and diarrhoea, with colic, have been observed. It is stated that the colic differs from lead colic in not being arcom- panied by retraction of the abdominal muscles; the tendency to > diarrho-a is also a distinguishin g feature from chronic lead poisoning . Some observers who have noticed the line on the margin of the - describe it as being of a reddish-purple, others as indistinguishable from the blue line of lead, others again as in the eases instanced above. Copper may find its way into the system along with food, with which it has been accidentally, or purposely, mixed. Accidental ad- mixture occurs from the use of brass cooking utensils, the risk bein^ increased by want of cleanliness. Certain foods, or condiments, are more liable to act on metallic utensils than others ; fats easily dccom- 1 Bevut de Mid., 1SS7. 2 Brit. Med. Journ., 18SS. 4GI FORENSIC MEDICINE. pose, and their acids, and also the vegetable acids contained in some fruits quickly attack copper. In large establishments it is some- times customary to substitute copper hot-water pipes for those of lead, as being ultimately more economical; if water conveyed by these pipes is examined, copper in small amount may be detected. The copper boiler and hot-water cylinder, in use in many households, may be a source of contamination, especially when supplied with some kinds of water. Copper is purposely added to certain articles of diet in order to improve their appearance ; this is frequently done in the case of pre- served green peas, and some kinds of pickles, as gherkins. The chlorophyll, to which the bright green colour of the vegetables is due, is partially decomposed with corresponding loss of colour during the process of conservation, and a soluble copper salt (usually the sulphate) is added in order to restore the colour and make them attractive to the eye. The amount of copper varies in different specimens from one grain per pound of peas upwards. In one case 1 the enormous amount of copper, equal to twenty-six grains of crystallised copper sulphate per pound of peas, was detected. The possible toxic effects that may accrue from the consumption of vegetables thus adulterated is repeatedly discussed before the law courts, with varying results — a certain percentage of copper is pronounced inj urious on one occasion, and not on another. Except in the case of those, who from idiosyn- crasy are unusually susceptible to the influence of copper, it is very unlikely that poisonous symptoms would manifest themselves after a single meal, of which preserved peas containing a small amount of copper formed a part. Hence it is difficult to do other than admit that the occasional use of vegetables thus adulterated would not be attended by symptoms of poisoning. At the same time it is to be regretted that the door is left open for the introduction of a substance which might be productive of harm. Any mischief that resulted would be clue to the copper absorbed, and to its local action on the gastric mucous membrane, the vegetables themselves do not appear to be affected so far as their digestibility is concerned. Experiments by Ogier 2 and by Oharteris and Snodgrass 3 on the artificial digestion of greened vegetables show that the presence in small amount of a salt of copper exercises no advei'se influence in this respect. In greened vegetables copper probably exists as an insoluble leguminate from which the metal is liberated and rendered soluble by the action of the gastric and pancreatic digestion. In Erance where the system of greening vegetables is largely carried ^Sanitary Ilecord, 1S77. " Laboratoire de Toxicologic, 1S91. 3 The Lancet, 1802. CHRONIC COPPKR POISONING. 4G5 out, the law which formerly prohibited the use of copper salts for this purpose has been repealed. The New York Board of Health allow canned peas to be sold that contain not more than three-quarters of a grain of metallic copper — equal to three grains of the crystallised sulphate — per pound, provided that the label on each tin contains a statement to that effect. In relation to this subject the question of the natural occurrence of copper in certain vegetables has to be considered ; minute quantities have been found in wheat, coffee, and a number of other articles of every day consumption. This, to a certain extent, accounts for the fact that copper is almost invariably present in the human body, of which it has been erroneously assumed to be a physiological con- stituent. It is probable that copper is being continuously introduced into the system from the source just mentioned, or from the use of copper or brass cooking utensils, and hot-water apparatus. When making the investigations on the elimination of lead men- tioned in the preceding section, although the patients were not taking any substance known to contain copper, I rarely failed to obtain evi- dence of its presence in the faeces. The amount varied; it was some- times considerable, as much as two milligrammes of metallic copper being eliminated in the twenty-four hours. Copper was not detected in the urine in these cases. The freces from a number of individuals were subsequently examined for copper, with the result that traces at least, and often much more, were invariably obtained. These analyses show that copper is almost constantly present in the system, and they also prove that the metal is chiefly eliminated by the bowels; corroborative of the latter statement is the fact that when a soluble salt of copper is therapeutically administered, so that one or more grains are taken daily, although minute quantities may be found in the urine, the bulk is eliminated in the faeces. It is probable that, like lead, copper is partially retained in the system, but the accumulation takes place more slowly. Chemical Analysis.— Organic matter may be got rid of either by the dry or the moist way. If the former is adopted the residue, after evaporation of the nitric acid, will betray the presence of copper by a greenish or bluish tinge. Tests. — The clear solution may be tested with potassium ferroeyanide which gives a chocolate-brown precipitate ; by ammonia water, which gives an azure blue ; by potassium sulphocyanide, which, in dilute solution, gives an emerald green, and in stronger solution an olive green, in either case, on the addition of ammonia water, the ordinary blue reaction of that reagent with copper is obtained. If a drop of a solution of a copper salt, having a slightly acid reaction, is allowed 30 46G FORENSIC MEDICINE. to remain for a minute or two on the bright blade of a knife it leaves a deposit of metallic copper. Another method is to place in the liquid a bright steel needle, or piece of iron wire ; the resulting film of copper may be dissolved in a few drops of ammonia water, to which it imparts a blue tint; this test may be used in the presence of organic matter — tinned peas, for example. Quantitative estimation may be made by precipitating the copper as sulphide, and then dissolving it in strong nitric acid ; the acid is evaporated and the residue gradually heated to a full red heat until all the combined nitric acid is driven off. The result is cupric oxide : 100 parts equal 79-85 parts of metallic copper. If the quantity of copper is very small in proportion to the organic matter present, the latter may be destroyed by the moist method, and the resulting fluid dealt with by electrolysis, as described in the last section. The deposit of copper is dissolved off the platinum with dilute nitric acid, aided by heat, and, if the amount is very small, estimated volumetrically ; if larger, it may be treated with H,,S, converted into oxide and directly weighed. SILVER. Acute poisoning by a salt of silver is exceptionally rare, and usually results from the accidental swallowing of a piece of " lunar caustic " which is being used to cautei'ise the throat. Symptoms of Acute Poisoning by Silver Nitrate [AgNO.]. — When swallowed in the solid it acts as a violent irritant and corrosive on the mucous membrane of the stomach. Pain is felt in the stomach and abdomen, followed almost immediately by vomiting and probably purging; the early vomited matter consists of cheesy masses of coagulated mucus, which darken on exposure to light ; blood may be present both in the vomit and in the dejections. Collapse, cardiac depression, and cramps may occur. Silver is eliminated to some extent by the kidneys, but most of that which is received into the system is deposited in the metallic state in the tissues. Fatal Dose. — Not determined. Scattergood x reports a case occurring in an infant, in which a piece of lunar caustic, three-quarters of an inch long, accidentally slipped down the throat; although antidotal treat- ment was at once resorted to, the child died in six hours. A similar and fatal case happened some years ago to an adult in Manchester. Treatment. — Common salt and water, followed by an emetic or the stomach-pump ; afterwards, white of egg and ice. If the solid lunar caustic has been swallowed, an emetic is preferable to the stomach- pump. 1 Brit. Med. Journ., 1S71. ( IIUONIC POISONING BY SILVER. 467 Chronic Poisoning by Silver. This usually results from the prolonged internal use of a silver salt medicinally. Instances have occurred in which absorjition, resulting in chronic poisoning, has taken place from long-continued application of the nitrate to granulations ; workers in metallic silver have also suffered from local symptoms affecting the skin. A common result of chronic poisoning by silver is discoloration of the skin — argyria — due to deposition of particles of the reduced metal in the papillary layer of the corium, not in the rete mucosum, as is the case in physiological skin-pigmentation ; on account of the nature of the pigment and its position, the discoloration is very permanent. A dark line is also formed on the margins of the gums ; the mesentery, kidneys, and other glandular organs have been found stained. In animals staining does not take place, but disturbances of nutrition, paralysis and fatty degeneration of the liver and kidneys occur. Gowers 1 relates the case of a man who, after taking silver medicinally for years, suffered from paralysis of the long extensor of the fingers, and of the extensors of the phalanges of the thumb, on both sides ; on the right, the radial extensors of the wrist were also paralysed ; argyria and the black line on the gums were present. Post-mortem Appearances. —In acute poisoning indications of the caustic effect of the poison may be present, as streaks or patches of a greyish white colour on the parts with which it came in contact. When solid lunar caustic is swallowed, the stomach suffers most severely at the lower part where the caustic lay. In addition there will be inflammation of the stomach, and probably of the duodenum. In chronic poisoning the tissues will be found stained as above described. Chemical Analysis. — Destruction of organic matter by the moist method is not feasible as the silver chloride which would be formed is insoluble. Incineration may be adopted, in the course of which, if the poison is present in not too small amount, a coating of metallic- silver will be deposited on the bottom and sides of the capsule due to the reducing action of the organic matter. Tests. — On adding dilute hydrochloric acid a white curdy precipitate is produced, which is insoluble in nitric acid, but is soluble in ammonia water. A solution of caustic potash gives a brownish precipitate in- soluble in excess, but soluble in ammonia and in nitric acid. Potassium iodide gives a yellow precipitate, and potassium chromate a red pre- cipitate. The quantity of silver may be estimated by precipitating it 1 Diseases of the Nervous System. 468 FORENSIC MEDICINE. from a solution of the nitrate by means of sodium chloride, filtering on a tared filter, drying and weighing the precipitate : 100 parts of silver chloride equal 75-28 parts of metallic silver. The operation should be conducted by gas light. ZINC. Acute poisoning by zinc is limited to two of its salts — the sulphate, 1 and the chloride. The action of the two salts is different — the sulphate when taken in poisonous doses is simply an irritant; the chloride is a corrosive. Acute Poisoning by Zinc. Zinc Sulphate [ZnS0 4 7H 2 0], or white vitriol, very closely resembles Epsom salts in naked-eye appearance, for which it has been accidentally administered. The symptoms produced by a poisonous dose are violent vomiting, pain in the stomach and abdomen, metallic, astringent taste, which quickly follow the act of swallowing the poison; to these purging usually succeeds. The immediate emesis, together with the compara- tively feeble toxic action of zinc sulphate render a fatal issue excep- tional; when death takes place it is in consequence of exhaustion. Fatal Dose. — Not known. Recovery has followed one ounce. Zinc Chloride [ZnCl.,,H 2 0], known in commerce in the form of Burnett's fluid, and also as soldering fluid, is a violent corrosive. Symptoms. — Severe burning sensation in mouth, throat, stomach, and abdomen, followed by immediate vomiting and diarrhea, with severe tenesmus, and distension of the abdomen; the ejected matters contain traces of mucous membrane and of blood. Profound collapse is shown by cold surface, clammy sweat, thin pulse, great prostration, and, in immediately fatal cases, coma, with irregular breathing. It is not uncommon for the acute symptoms to mitigate for a time, and then to recur after an interval of days, or even weeks, which is due to pro- gressive disorganisation of the tissues of the digestive tract. Ward x records an instance where several men on board ship were attacked with symptoms resembling those of cholera, caused by drinking water in which zinc plates were placed, to prevent corrosion of the boiler, from whence it was obtained. Death has resulted from the application of chloride of zinc paste as an escharotic. The elimination of zinc takes place by the bowels and to a lesser extent by the kidneys. Fatal Dose. — Six grains have proved fatal, but recovery has followed 3 or 4 drachms of the solid salt. Treatment. — Poisoning by the sulphate will probably require little 1 The Lancet, 1SS6. A( UTE POISOXIXG BY ZINC. 1G9 more than attention to the symptoms; usually the stomach spon- taneously relieves itself of the poison, if not the tube should be used; then warmth should be applied, and stimulants and opium given if required. In poisoning by the chloride, potassium or sodium carbonate, tannic acid, white of egg, milk, and demulcents should be administered, followed by opium if necessary. Post-mortem Appearances. -The sulphate only gives rise to the ap- pearances usually observed in acute; gastro-e ntcritis ; as previously stated the poison is purely an irritant and therefore causes no destruc- tion of tissue. With the c hloride the case is different. If the patient dies shortly after swallowing the poison, the digestive tract, from the mouth down to the stomach, possibly as far as the duodenum, will show more or less i ndications of corrosion . There will be patches of softened membrane having a white appearance, which in parts may be detached, together with the usual signs of acute inflammation. If the patient survives the reception of the poison for some weeks, the gastric mucous membrane will probably be completely disorganised and in parts replaced by cicatricial tissue. Jalland 1 records the case of a man who committed suicide by swallowing an unknown quantity of a satu- rated solution of zinc chloride; he died on the seventy-ninth day. At the necropsy the stomach was found to be completely destroyed; the remains consisted of a sausage-like mass of inflammatory adhesions without any trace of mucous membrane; the cavity — four inches long and three-quarters of an inch in diameter — resembled that of a chronic abscess. Chronic poisoning by zinc has been observed, chiefly in smelters of the metal. The symptoms to some extent resemble those produced by lead : derangement of the digestive organs, colic with constipation, or, more frequently, diarrhoea ; indications of peripheral neuritis have been observed. Gastric symptoms have resulted from drinking water or milk stored in zinc-lined vessels. The zinc used for "galvanising"' iron vessels is impure, and fluids containing chlorides will act on it. Chemical Analysis. — In neutral or alkaline solution zinc may be precipitated from organic admixture by sulphuretted hydrogen. The precipitated sulphide will probably carry down with it some organic matter, and therefore, if weighed, would indicate an amount in excess of that which was really present. For this reason it is better to convert the sulphide into nitrate or sulphate, and then to precipitate it as carbonate by boiling with sodium carbonate in excess. After being well washed with hot water, the precipitate is strongly ignited so as to convert it into oxide, and is weighed : 100 parts of zinc oxide equal 80 - 26 of metallic zinc. ' Brit. Med. Journ., 1SS7. 470 FORENSIC MEDICINE. Tests. — A white sulphide is formed in neuti-al or alkaline solutions dn the addition of ammonium sulphide, or of sulphuretted hydrogen ; the precipitate is insoluble in a solution of potassium hydrate. A solution of potassium hydrate added to a solution of a salt of zinc pro- duces an opalescent, gelatinous precipitate, which has a tendency to adhere to the sides of the test-tube ; it is soluble in excess. The same result is produced by ammonia water, unless free acid or ammonium salts are present, when no precipitate is formed. Potassium ferrocyanide gives a pale gelatinous precipitate, and potassium ferri- cyanide a fawn-coloured precipitate. Ammonium carbonate gives a white precipitate soluble in excess. If zinc oxide is strongly heated it turns yellow, becoming white again on cooling ; when moistened with cobalt nitrate and heated with the blowpipe flame, zinc oxide forms a green pigment — Rin man's green. The salts of Cadmium when swallowed act much the same way as zinc, but more powerfully. TIN. Poisoning by the salts of tin is exceptionally rare, and has only resulted from accident, for the most part from the use of tinned meat and fruit. In Belgium and France it has been found that some confectioners put stannous chloride into gingerbread in order to obtain with inferior materials an appearance like that legitimately due to fine flour. In some instances as much as 5 kilogrammes per 200 kilos, of bread were present. After making a series of experiments, Pouchet and Riche 1 have recommended legal prohibition of the practice on the ground of its being injurious to health. No fatal case of poisoning by tin has yet been recorded. A case 2 that has more than once been cited as one of fatal poisoning by the chloride, was really one of hydrochloric acid poisoning, and is so stated by the original reporter. Half a tea-cupful of hydrochloric acid, having some tin in solution, was swallowed, and ultimately caused death. Symptoms. — Metallic taste, vomiting and diarrhoea, with pain in the stomach ; pain in the head has also been observed. In some cases the poison has depressed the action of the heart ; Luff 3 records the rases of four adults who suffered from severe symptoms of poisoning after having eaten some tinned cherries; in all four the pulse was feeble, rapid, and irregular, and the surface was cyanotic. Luff found 1-9 grain of stannic oxide, derived from solder used in the construc- tion of the tins, per ounce of the cherry juice. The doses of tin 1 Annates d' Hygiene, 1S92. - Med. Times, 1841. 3 Brit. Med. Joum., 1890. BISMUTH. 471 nialate respectively received by the sufferers were calculated to range from four to ten grains. All the cases recovered. Sedgwick 1 relates how nine persons, after eating pears which had been stewed in a newly tinned pan, were simultaneously attacked with diarrhoea, vomiting, and abdominal pains. The juice of the fruit was found laden with tin salts. Tin is eliminated by the kidneys and bowels. Treatment. — -Empty the stomach, and then give demulcents, white of egg, milk, and ice, with opium if necessary. Chemical Analysis. — Organic matter may be destroyed by the moist method and the resulting solution precipitated with H.,S. The sulphide may then be ignited and converted into stannic oxide, 100 part-; of which equal 78*38 parts of metallic tin. Tests. — With mercuric chloride and a little hydrochloric acid. stannous chloride gives a white precipitate of mercurous chloride. which turns grey and subsequently black (hastened by boiling) from the formation of finely-divided metallic mercury. With gold chloride it gives a purple precipitate. If a little brucine is dissolved in a few drops of strong nitric acid and then diluted with about fifty times its volume of water, boiled, and allowed to cool, a reddish fluid is obtained. A few drops of this added to a solution of a tin salt pro- duces a lilac colour. Stannic salts give a yellow precipitate with H.-.S ; stannous salts a dark brown. BISMUTH. Exceptional cases of poisoning by the subnitrate [Bi0N0 3 ,H o 0] have occurred both from internal and external use. Symptoms. — Salivation, metallic taste, pain in stomach, vomiting and purging, the dejections having a greyish-black colour, and collapse. The gums may be inflamed and even gangrenous ; the breath is very foul. A disagreeable garlic-like odour has been observed from pro- longed medicinal use of bismuth, which it is stated is due to impurities, in the form of tellurium or arsenic. In toxic doses the usual symp- toms of gastro-enteritis occur. Bismuth is eliminated in the faces, urine, and saliva ; like lead much passes directly through the bowels without being absorbed. Fatal Dose. — In one case two drachms caused death in nine days. Treatment. — Evacuate the poison, and then give ice and opium if necessary. Post-mortem Appearances.— Those due to acute gastritis. Chemical Analysis. — Organic matter may be destroyed by the moist method, the bismuth precipitated as sulphide, and afterwards dissolved 1 The Lancet, 1888. 472 FORENSIC MEDICINE. in concentrated nitric acid ; the solution of the nitrate thus obtained is evaporated to dryness and the residue is dissolved in water with the aid of a little nitric acid. Tests. — Potassium hydrate produces a white precipitate, insoluble in excess, which becomes yellow on boiling. Dilution with water pro- duces a precipitate, which may be distinguished from the precipitate similarly produced with antimony by its insolubility in solution of tartaric acid. Potassium chromate produces a yellow precipitate which is soluble in nitric acid and insoluble in potassium hydrate. Quantitative analysis may be conducted by diluting the solution of the nitrate and then addino; ammonium carbonate and boiling for some time. The precipitate, after ignition, is weighed : 100 parts of the oxide equal 89*65 of metallic bismuth. IRON. The salts of iron which come under the observation of the toxi- cologist are the sulphate [FeS0 4 ,7H.,0], copperas, or green vitriol, and the chloride [Fe.,Cl ,6H 2 O] in alcoholic solution known as tincture of ii-on. Symptoms. — Large doses of the sulphate give rise to a metallic taste, pain in the stomach, vomiting, and purging, the dejected matters being black from the formation of ferrous sulphide. The chloride is a more active irritant ; in large doses it has been found to act somewhat like hydrochloric acid. Both these salts, but especially the chloride, are not unfrequently administered in poisonous doses for the purpose of pro- curing abortion • the inefficacy of the proceeding has been already discussed in the section on criminal abortion. Iron is eliminated by the bowels and kidneys. Fatal Dose. — That of the sulphate is unknown. An ounce and a half of the tincture of the chloride has caused death in about five weeks. Treatment. — Evacuate the poison, then give demulcents, ice, and, if necessary, opium. Post-mortem Appearances. — If death takes place in the early stage there will be the usual signs of gastritis, with probably some special discoloration of the membrane due to the action of the metal. In the fatal case from the chloride above-mentioned, Christison found a thickened, inflamed condition of the stomach towards the pyloric end. Chemical Analysis. — Examination of the vomited matter or of the contents of the stomach only is required ; on account of the physio- logical presence of iron, the tissues yield no satisfactory evidence. CHROMIUM. 473 Tests. — Potassium sulphocyanide produces a bright red with a ferric salt, no change with ferrous salts. Potassium ferricyanide gives a brown coloration with ferric salts, and a blue precipitate with ferrous salts. Potassium ferrocyanide with ferrous salts produces a whitish pre- cipitate which becomes blue on exposure; with ferric salts a deep blue precipitate of Prussian blue. Potash gives a red brown precipitate ..vith ferric salts, and a whitish precipitate with ferrous salts. The amount of iron present in vomited matter may be estimated by converting the metal into a ferric salt, if it is not originally in that form, and then precipitating the oxide with ammonia, ignitin^ and weighing : 100 parts of ferric oxide equal 70 parts metallic iron. CHROMIUM. The compounds of chromium which are of interest to the toxicolo^ist are chromic acid, potassium dichromate, and lead chromate. Chromic Acid [ GyCgytezat, Buda] est, 1SS9. 486 FORENSIC MEDICINE. surfaces and the eyelids are swollen, and the skin is not unfrequently covered with an eruption. There is a tendency to heart-paralysis, which sometimes occurs a day or more after the acute symptoms have subsided. Formerly many deaths occurred from the treatment of ovarian tumours, chronic abscesses, and empyema by the injection of solutions of iodine ; the proceeding is not without considerable risk when the iodine is exposed to a large absorptive surface. Iodine is freely eliminated by the kidneys. Huber 1 found 0-278 oramme of iodine in 300 cc. of urine, obtained from a woman who swallowed about four grammes of the tincture. It is also eliminated in the saliva, milk, and in the secretions of mucous membranes. Fatal Dose. — Not precisely known, as the tincture which has usually been taken is of no definite strength. One drachm of the tincture has caused death, and recovery has taken place after one ounce, calculated to contain half a drachm of solid iodine. Only eight or nine fatal cases are recorded. Death has occurred in twenty-four hours. Iodoform. — The use of iodoform in dressing wounds, and its injection in solution into chronic abscesses, have caused death ; grave symptoms followed by recovery not unfrequently occur. A variety of symptoms have been observed — as elevation of temperature, rapid pulse, gastro- intestinal irritation, skin-eruptions, cerebral disturbance, with delirium or coma. Iodoform is most likely to produce dangerous effects when injected in the form of ethereal solution. Gaillard 2 records a case in which the injection into an abscess of about eighty grains, dissolved in ether, produced cessation of breathing and apparent death ; artificial respiration was resorted to, and the patient recovered. Barois 3 records a case in which the patient died in a comatose condition on the ninth day after injection of an ethereal solution containing forty-five grains of iodoform. Death has resulted from the free use of iodoform to dress open wounds, such as those produced by amputation of the breast or of the leg. Ozerny 4 relates the case of a woman, aged fifty-eight, in whom the wound produced by removal of a breast and the axillary glands was dressed with a drachm and a half of iodoform ; three days later symptoms resembling those of meningitis set in, decubitus followed, and death occurred on the twenty-third day. Potassium Iodide, when administered medicinally, occasionally pro- duces a number of toxic symptoms, which are of therapeutical rather than toxicological interest; iodism, with its accompanying skin erup- tions and glandular affections, is a well recognised condition, but as it results from medicinal treatment, and is rarely fatal, medico-legal i Zeitschr. f. Urn. Med., 1SS8. 2 Bull, de Chirurg., 1889. 3 Arch, de Med. el de Pkarm. Milit, 1S90. 1 Wiener med. Wochenschr., 1882. BROMINE. 487 investigation is not required. Death is stated to have occurred in one or two instances from the use of potassium iodide. Wolf 1 records the case of a woman who took four six-grain doses, at intervals of four hours, which produced swelling of the face and a pemphygoid eruption, involving the mucous membrane of the nose, mouth, throat, and larynx ; on the fourth day diarrhoea with blood-stained stools occurred, the woman dying on the eighth day. Treatment. — Acute poisoning by free iodine demands evacuation of the stomach with tube, or emetic, followed by farinaceous mixtures, as starch, arrowroot, flour, and the like, which have been cooked so as to rupture the starch-granules. Morphine and stimulants may be required. Post-mortem Appearances. — Not well known. Yellow staining and softening of the mucous membrane of the mouth, oesophagus, and stomach have been observed ; a kind of exudation product, resembling false membrane, has been found in the larynx. Gastritis may be pre- sent, and the inflammation may advance as far as the duodenum. Chemical Analysis— Tests.— If free iodine is present with organic matter, some of it may be extracted by shaking with carbon bisulphide, which acquires a rose, or violet-red colour, in accordance with the amount of iodine taken up. If the iodine is in simple combination, it may be liberated by nitric acid, and then extracted as above. If in combination in organic admixture, potassium hydrate should be added, and, after desiccation, the organic matter should be destroyed by heat; when cold the iodide is dissolved out in alcohol, evaporated to dryness, and treated with sulphuric acid, so as to set free the iodine, which is recognised by its reaction with starch. BROMINE. Only three fatal cases of poisoning by bromine in the liquid state arc recorded. In one reported by Snell, 2 a man swallowed one ounce of bromine on an empty stomach ; half an hour after he was found suffering from intense burning pain and eructations ; there was neither vomiting, purging, nor thirst, but the patient experienced a frequent dcsiiv to evacuate the bowels. In two and a half hours symptoms of collapse occurred, and death took place seven and a half hours after the poison was swallowed. On section, the mucous membrane of the oesophagus was inflamed; the external surface of the stomach was much injected, and displayed several ecchymosed spots ; internally its surface appeared like tanned leather, hard, and black in colour, and 1 Berliner Uin. Wochemehr., 1886. . "New TorkJourn. of Med., 1S50. -J88 FORENSIC MEDICINE. could easily be peeled oft'; the duodenum presented the same appear- ance, the mucous membrane between the valvuhe conniventes was softened ; the peritoneum and omentum were stained a reddish-yellow. In a case reported by Schmalfuss, 1 the dead body of a man was found, the lips and tongue being dry, hard, and dark-brown in colour. On opening the abdomen the odour of bromine was perceived ; the posterior wall of the stomach was altogether wanting, a portion of its anterior wall, which was grey-green in colour, being all that remained ; the appearance was as though it had been burnt, a similar condition existing in the duodenum. About fifty grammes of a yellowish sub- stance were found free in the abdominal cavity. The intestines, liver, and spleen were softened ; some of the contents of the caecum yielded bromine by simple distillation. The quantity swallowed was about ninety grammes. A third case is recorded by Herwig. 2 A girl, aged ten, was given by a quack a mixture containing potassium bromide, to be taken with chlorine-water. In four hours after the third dose collapse set in, followed by death in twelve hours; at the necropsy hemorrhagic inflammation of the stomach was found. It was after- wards ascertained that each dose of the mixture, on the addition of chlorine, yielded '0-44 gramme of free bromine. When inhaled the dense fumes given off by bromine are very irritating to the respiratory mucous membrane. Duftield 3 relates the case of a laboratory assistant who accidentally inhaled the fumes from about three pounds of bromine, which produced spasm of the glottis and impending death from asphyxia ; by the use of steam to the throat the spasm was relaxed, and the man recovered. Kornfeld 4 relates a case in which a child, aged one year and three-quarters, inhaled bromine vapour, and died from respiratory and gastric disturbances on the sixth day ; after death the skin of the face and neck, where the vapour came in contact with it, was parchment-like ; bromine was detected in the skin and the clothing. Potassium Bromide. — The evil effects of prolonged treatment with potassium bromide are not unfrequently seen, but death resulting from its use is rare. Eigner 5 records the case of a woman who suffered from epilepsy, for which she took potassium bromide in increasing doses until they amounted to two teaspoonfuls daily, which was con- tinued for several weeks. She became salivated, with fcetor of the breath, and inflammation of the gums ; delirium supervened, and she died in five days. Treatment. — In the exceptional cases in which bromine is swallowed, 1 Vierteljahrsschr. f. ger. Med. (Supplement), 1889. - Zeit&chr. f. Medicincdbeamte, 1889. 3 American Joum. Pharm., 1SG7. 4 Friedreich's Blatter f. ger. Med., IS 3. . s Wiener med. Fresse., 1886. CHLOEINE, 189 treatment would probably be of little avail; after evacuation of tin- contents of the stomach, albumen or starch might be given. Poisoning with the vapour is best treated with steam inhalations. Chemical Analysis. — Uncombined bromine may be separated from organic admixture by distillation ; if it is in combination, it may be set free by saturating the solution with potassium dichromate, and acidulating with dilute sulphuric acid before distilling. Solid m of organic matter may be pulpified, mixed with a saturated solution of potassium hydrate, evaporated to dryness, and the organic matter burnt off ; the residue is treated with potassium dichromate and sul- phuric acid, and distilled. Tests. — Bromine may be recognised by its smell, by colouring starch- paste yellow, and by giving a yellowish-white precipitate with silver nitrate. A solution of bromine in water, added to a solution of phenol, gives a white precipitate of tri-bromophenol. CHLORINE. Fatal poisoning by chlorine is rare, the opportunities for its occur- rence being limited to chemical works and bleach-works. In the latter a form of chronic poisoning is met with, in which the patient acquires an amende or chlorotic look, loses flesh, and sutlers from dyspeptic troubles associated with gastric catarrh ; the sense of smell is blunted, and the bronchial mucous membrane may be affected. The following fatal case of acute chlorine poisoning is recorded by Sury-Bienz, 1 A man, aged forty-eight, who worked in a chemical manu- factory, accidentally took one or two breaths of pure chlorine : he at once experienced irritating cough, dyspnoea, and stabbing pain in the breast. On the following day the cough persisted and the dyspnoea was urgent, but there was very little expectoration; the respirations were accelerated to 48, and the pulse retarded to 48 per minute. There was no albumen in the urine. The breathing became worse, the expirations being very short, and the patient died in less than forty- eight hours. On section the lungs were found to be emphysematous and (edematous : they were not consolidated, hut the air-passages con- tained a reddish, frothy fluid ; the epiglottis was pale and free from tumefaction, as was also the mucous membrane of the larvnx ; that of the trachea and bronchi was diffusely reddened; no fatty changes were observable in the heart and other organs. Death appeared to be due to heart-paralysis, which is in accord with the results of physio- logical, experiments. Cameron- relates the case of a man who was 1 Vit rfrfjahrsschr. /. 1. SULPHURETTED HYDROGEN. 491 heart-paralysis. Three fatal cases from washing out the stomach with a solution of boric acid are recorded by Hogner. 1 The symptoms produced were: — General depression, erysipelatous eruption on face and purpuric spots on the body, elevated temperature, vomiting, diarrhoea, frequent desire to urinate, blood in the urine, stupor, and death, in one case on the third day. Welch - records a case of poison- ing from the use of a vaginal tampon of boric acid : — Formication of hands and feet, swelling of the skin of the face, hands, and feet, with pronounced depression of the nervous system, dysuria, prostration, and collapse ensued. Recovery took place, the skin undergoing general desquamation. The affection of the skin is one of the most constant of the signs of boric poisoning. Lemoine 3 reports four non- fatal cases from surgical practice : — Erythema and urticaria were present in all ; among the other symptoms were vomiting, delirium, hallucinations, and in one case diplopia. As a food preservative boric acid is usualty employed in combina- tion, in the form of borax. Although it may be difficult to trace any ill-effects to the swallowing of small closes of borax, there are good grounds for assuming its noxiousness, especially when added to milk which constitutes the chief food of young children; in the law-courts it has been held to be injurious, convictions having been obtained against those who had thus adulterated milk. Chemical Analysis. — Organic fluids containing boric acid or borax, may be evaporated down, treated with sulphuric acid, and extracted with alcohol. Tests. — The alcoholic extract of boric acid burns with a green-coloured flame. Boric acid partially reddens blue litmus-paper and browns turmeric paper ; the reaction with turmeric is distinguished from that due to alkalies by not disappearing under the influence of acids. CHAPTER XXIX. GASEOUS COMPOUNDS. SULPHURETTED HYDROGEN. Poisoning with pure sulphuretted hydrogen [H.,S], excepting in chemical works, is rare; in those cases in which mischief results from 1 Eira, 1884. 2 New York Med. R?r ., 1888. *Gaz. de Paris, 1890. 492 FORENSIC MEDICINE. its inhalation, the mixed gas known as sewer gas is the combination in which it usually exists. Sewer gas is composed of a variable mixture of sulphuretted hydrogen with free hydrogen, carburetted hydrogen, ammonia, carbon dioxide, and atmospheric air deprived of part of its oxygen. Although several of these gases are poisonous, the toxic effects of sewer gas are chiefly due to the sulphuretted hydrogen it contains; one description of the symptoms and post-mortem appear- ances, therefore, will serve for both sulphuretted hydrogen and for sewer gas. Symptoms. — When a small dose only of the gas is received into the system the respirations are rendered difficult, the pulse becomes small, there is a feeling of oppression in the head, accompanied by sickness, dizziness, and probably diarrhoea; at the same time great muscular I prostration is experienced. If the dose is larger, urgent symptoms of i asphyxia and heart failure, with profound collapse, cyanosis, dilated pupils, unconsciousness, delirium, and convulsions may occur. Secondary effects are very rare. Wiglesworth 1 records the case of aman employed in a chemical works who became maniacal, and continued so for two or three weeks, after having accidentally inhaled sulphuretted hydrogen. He began to improve at the end of a month, but did not recover his mental vigour for five months after his admission into the asylum, which took place about a week after the onset of the symptoms. Asphyxia, due to the action of the gas on the haemoglobin, and pro- bably also on the tissues, by which they are respectively rendered incapable of yielding up and of receiving oxygen, is believed by some to be the cause of death; ot hers attribute dea th to certain disturbances of the nervous system by which the pulmonary and the cardiac inner- vation is deranged. Kaufmann and Rosenthal 2 demonstrated experi- mentally that inhalation of sulphuretted hydrogen lowers the blood- pressure, and lessens cardiac action by stimulation of the vagus-centre. Brouardel and Loye 3 found that in animals which are made to respire sulphuretted hydrogen the pupils are dilated, the heart-beats slowed, and the respirations are gradually diminished in amplitude; in some cases the heart continued beating for two minutes after respiration had ceased. Pohl 4 believes that the presence of sulphuretted hydrogen in the blood determines the formation of sodium sulphide which causes paralysis of the central nervous system. Lehmann 5 thinks that in animals death is not solely due to changes in the blood and to paralysis of the central nervous system, but also to oedema of the lungs. Uschinsky infers from experiments on animals that the toxic action of H..S cannot i Brit. Med. Journ., 1892. - Arch. f. Anat. u. Physiol, 1865. :i La France Medlcale, 1885. 4 Arch. f. expo: Path., 1S87. 5 Arch. f. Hygiene, 1892. B Zcitschr. f. pJiysiol. C/iemie, 1S92. SULPHURETTED HYDROGEN. 49:"> depend on the formation of sulphur-methaemoglobin since large quan- tities of blood charged with the gas can be injected into the circulation without causing the least harm, although sulphur-methaemoglobin can readily be distinguished in blood subsequently withdrawn from the animal; and further that in animals which have been poisoned with H. 2 S sulphur-methaemoglobin cannot always be detected. 1 [e considers death to be solely due to paralysis of the central nervous system. It has always been taught that H.,S is freely eliminated by tin- lungs, but recent investigations are against tin's view; Laborde* found that a residuum of the gas remained in the blood after it had passed through the lungs ; Uschinsky states that H 2 H is only feebly eliminated by the lungs. Treatment. — In order to combat the tendency to death, and at the same time promote elimination, artificial respiration should be vigor- ously carried out. Cold effusion has been recommended, but if the surface is already cold it would lie worse than useless; the application of external warmth would rather be indicated. Cautious inhalation of chlorine diluted with air has been suggested on the ground that it combines with the hydrogen of the H 2 S and precipitates the sulphur ; it might be very carefully tried along with artificial respiration. Post-mortem Appearances. — Putrefactive changes quickly follow death. In some cases cadaveric rigidity is reported to have been well marked, which is contrary to what might be expected, as after poison- ing by sulphuretted hydrogen the molecular vitality of the muscles disappears with the occurrence of somatic death. The blood is fluid and dark in colour, and in consequence the organs which are rich in blood — as the liver, lungs, and spleen — are also darker than usual. The brain has been found of a peculiar dirty greyish-green owing to the colour of the blood; the muscles are dark, including those of the heart; they sometimes present a bluish tint. The remaining appear- ances are common to other forms of death from asphyxia. The blood of human beings poisoned by H.,S has been examined spectroscopically by many observers with negative results. Laborde, Uschinsky, and others, in experimental poisoning of animals with sulphuretted hydrogen, obtained the characteristic spectrum of Diet- haemoglobin in combination with sulphur. Chemical Analysis — Tests. — The odour is sufficiently distinctive to indicate the presence of even minute amounts of sulphuretted hydro- gen. A piece of white filtering paper, dipped in a solution of lead acetate, is rapidly discoloured when suspended near tissues or other substances impregnated with the gas. 1 Comptes rendus de la Soci€i6 de Biologie, 1S8G. 494" FORENSIC MEDICINE. CARBON DIOXIDE. Poisoning with carbon dioxide [C0 2 ] occurs in coal-mines (from the gas generated by explosions, to which the name "choke damp" is applied), in deep wells and excavations, in brewer's vats, and in the neighbourhood of lime-kilns and brick-kilns, which are in operation. The percentage of carbon dioxide in atmospheric air that will cause fatal results to human beings who respire it, is not accurately known; under ordinary conditions probably 20 per cent, and even much less, would soon prove fatal. Human beings can breathe air mixed with 20 per cent, of pure CO., for some time without life being endangered; but a much lower percentage of the gas as it is exhaled from the lungs is lethal. Within limits, both men and animals may acquire a certain tolerance for the gas, and breathe air contaminated with it that would be noxious to the untrained organism. The test usually used to as- certain whether air charged with CO., is respirable or not, is to lower a lighted candle into the mixed gases ; if it goes out the atmosphere is poisonous. To this extent the test is trustworthy, but the converse is not to be assumed, namely, that if the candle burns the air is harm- less : a candle will burn in a percentage of C0 2 that is dangerous to life. Symptoms. — When a poisonous but not concentrated mixture of carbon dioxide and air is respired, heaviness in the head with giddi- ness, noises in the ears, a sensation of tightness across the chest, and an inclination to sleep are experienced ; shortly after, the muscles lose power, so that if the individual is standing at the time, he falls to the ground. The subsequent symptoms are those of .asphyxia: coma, stertorous breathing, cyanosis, and possibly convulsions; sometimes delirium occurs. When an individual is plunged into a concentrated atmosphere of carbon dioxide, as occasionally occurs to workmen who are lowered by a rope into a well or vat which is filled with the gas, immediate loss of consciousness and of muscular power takes place, death rapidly ensuing unless the victim is at once rescued. When carbon dioxide diluted with air is respired, it acts both as a poison and also — when the partial pressure of the gas in the atmo- sphere is greater than that in lungs — as a preventive to excretion of the physiologically-formed C0 2 . The ultimate effects on the organism, allowing for the degree of concentration in which CO., is respired, are the same as those of asphyxia resulting from the cutting off of oxygen and the consequent accumulation of carbon dioxide in the tissues, but the respiratory movements more quickly cease than when the respired air is simply deficient in oxygen ; in the latter case the excretion of CO., is but little affected. CARBON MONOXIDE. 495 The treatment is that for asphyxia— artificial respiratidn, external warmth, and stimulants. Post-mortem Appearances. — They are simply those of death from asphyxia: dark-coloured, fluid blood, fulness of the right heart and veins, with usually hypersemia of the lungs, and frothy mucus in the air-passages. Chemical Analysis. — The analysis thai may be required is that of the atmosphere in which the poisoning took place. A sample may be obtained by displacing the air in a dry flask or bottle of five or more litres capacity when immersed in the suspected atmosphere; this may be done with a pair of bellows; or if the gas is contained in a well or other excavation, the flask may be filled with fine dry sand, attached to a cord and let down to the required depth; by means of a second cord fastened to the lower part of the flask it is inverte 1. so that the sand Hows out and is replaced by gas; the flask is withdrawn mouth upwards and immediately stoppered. The amount of C< >., in the flask is ascertained by adding 20 to 50 cc. of a titrated solution of barium hydrate, replacing the stopper and shaking well for some minutes. The loss of hydrate by conversion into carbonate, which falls as a white precipitate, is estimated by titrating the solution with oxalic acid. CARBON MONOXIDE. The chief combinations in which carbon monoxide [CO] is met with in medico-legal practice are — emanations from slow combustion stoves, or fire-places to which a restricted amount of air is admitted, and mixtures of atmospheric air with coal-gas or water-gas; death has resulted from sleeping in a closed room, in the open fire-place of which coke instead of coal was burnt. Poisoning by CO not unfrequently causes the death of those who are unable to escape from a building which is on fire. In all these instances other gases besides CO and air are present; but the toxic effects are chiefly, if not entirely, due to the CO. It is impossible to determine the minimum percentage of CO in air that will cause death to human beings; one per c ent, is usually accepted as a fatal admixture . Coal-gas co ntains a variable amount, from 4 t o 7 or 8 per cent, of CO along with varying amounts of hydrogen, carburetted hydrogens, watery vapour, nitrogen, and carbon dioxide. Watj which is sometimes used as a substitute for coal-gas, contains as much as 40 per cent, of CO , its dangerous properties being accentuated by the absence of any characteristic odour, by which its presence might be revealed. In some gas-works coal-gas is adulterated with water-gas; the consumers being thus supplied with an unnecessarily dangerous 495 FORENSIC MEDICINE. illuminant, and at the same time cheated out of the candle-power they have a right to expect. The absence of odour, together with the lethal potency of water-gas, has led to its prohibition in some countries; the former difficulty has been met, but not very successfully, by causing the gas to pass through some volatile substance, in order to impart an odour to it. The use of gas burners on the Bunsen-principle to heat lai*ge bodies of cold water, as is done in some bath-rooms, is attended with con- i siderable risk. The flame is rapidly cooled by contact with the surface of the water reservoir, and combustion is consequently rendered im- perfect, the oxides of carbon, with acetylene being given off"; when water is heated in this way, provision for abundant ventilation should be made, (lasoline stoves, if used in small rooms, are not free from danger. M'Cormick 1 relates a case in which a man and his wife were found dead in a bedroom heated by a gasoline stove, the gas given off being principally carbon monoxide. Carbon monoxide poisoning occurs in two forms — acute and chronic. Acute Poisoning by Carbon Monoxide. Symptoms. — There maybe a preliminary period of excitation, which is quickly followed by a sensation of heaviness in the head, dizziness, noise in the ears, accelerated cardiac and respiratory movements, oppression on the chest, and occasionally nausea and vomiting. Along with these symptoms muscular weakness occurs, with drowsiness, loss of sensation and of the reflexes, to which coma succeeds ; in fatal cases convulsions frequently precede death. The pulse is small and becomes more so as the gravity of the case increases, so that not unfrequently, when the patient is first discovered, the radial pulse is imperceptible. In the state of coma the conjunctivae are strongly hypenemic, the eyes having a staring appearance, with partially dilated and insensible pupils. The whole of the skeletal muscles, including the sphincters, are relaxed, the surface is cold and cyanotic, and the lips are often covered with froth. It has been frequently stated that sugar is almost invariably present in the urine of those suffering from poisoning by carbon monoxide ; its occurrence, however, is only occasional. Maschka " 2 in two out of twelve cases found a trace only of sugar in the urine. Iloppe-Seyler 3 constantly found a substance present in the urine which reduced copper salts, but never any glucose. Garofalo i examined the urine 1 Med. News Phil. , 1891. - Prager med. Wochenschr., 1S80. 3 Phijxiolor/. Chemie, 1881. 4 CUcosuriaper Ossido di Carbonio, 1891. ACUTE POISONING BY CARBON MONOXIDE. [27 from a number of dogs poisoned with carbon monoxide, and failed to find a trace of sugar. in medico-legai practice the symptoms observed in poisoning by carbon monoxide are not always exactly the same; this arises from the admixture of other gases. Poisoning by pure CO can only be procured experimentally, but the salient features of CO poisoning are present in all cases in which that gas is the principal toxic I component. The p owerful toxic action of carbon monoxide is due to its affinity for haemoglobin. When CO is inhaled it displaces the oxygen of the haemoglobin, with which it combines, forming carbon monoxide haemo- globin— a much more stable compound than oxyhemoglobin. The combination is sufficiently intimate to resist the action of reducing agents, but it gradually yields to the action of oxygen ; if air or oxygen is passed for a long time through a solution of COHb the CO is gradually separated from the haemoglobin, taking its place. In the living body carbon monoxide haemoglobin neither takes up nor gives off oxygen, and therefore is incapable of acting as an oxygen carrier to the tissues, death usually occurring before the whole of the hemoglobin is saturated with CO; upon the degree of saturation depends the possibility of recovery. If such an amount of haemoglobin remains free as to enable internal respiration to be carried on so as to maintain life until the combined CO is gradually got rid of, recovery is possible ; if not, death takes place from asphyxia. Dreser, 1 when experimenting with rabbits, found that death occurs when the capacity of the blood to take up O is reduced 30 per cent, below the normal. In carbon monoxide poisoning the blood presents a very different appearance to that which is met with when death from asphyxia results in the usual way. In ordinary asphyxia the blood is dark, in CO poisoning it is b right-red. This is due to COHb being irreducible ; it retains its colour under circumstances that would deprive 2 Hb of its oxygen and cause it to assume the dark appear- ance of reduced hemoglobin. It is stated that carbon monoxide possesses an intrinsic toxic action in addition to its power of depriving the tissues of oxygen ; from experiments Linossier - deduces that CO does possess such an action, but that it is very feeble. Heineke 3 states that coal-gas, along with other poisons, produces ferment-intoxication in the blood, and in consequence the white corpuscles develop a tendency to adhere to each other and to form thrombi. Treatment. — Artificial respiration should be perseveringly kept up, 1 Arch.f. exp. Pathol., 1801. -Lyon Medical, 18S9. *T)eutsches Arch.f. kiln. Med., 1SS7-S. 32 498 FORENSIC MEDICINE. and warmth applied externally. Oxygen may be administered by inhalation from time to time. Stimulants are useful ; if the patient cannot swallow they may be administered by the rectum, or ether may be injected under the skin. Two cases are recorded in which subcutaneous injections of nitro-glycerine were followed by recovery ; in one, the pulse improved, and the respirations deepened forthwith. Venisection with transfusion has been tried : out of twenty-three cases in eight only was the treatment attended with success. Stocker 1 records a very encouraging case in which transfusion was used. A man slept in a room heated by a stove, and was found next morning insensible and apparently dying. Ether injections, artificial respira- tion, and electrical stimulation of the phrenics were tried for forty-eight hours without effect ; at last 800 grms. of blood were withdrawn from the median vein, and replaced by 110 grms. of defibrinated human blood ; in two hours gradual improvement set in, but the pulse, respiration, and temperature did not become normal until the third day ; the ultimate recovery was prolonged over many weeks. When transfusion is resorted to, it should be preceded by withdrawal of blood, and the transfused fluid should be human blood — in other words, an appropriate oxygen-carrier — saline solutions are useless. The views of Heineke are opposed to transfusion, as defibrinated blood, injected into the circulation, would tend by the introduction of a certain amount of fibrin ferment to increase the evil. Post-mortem Appearances. — The external appearance is very charac- teristic, on account of the bright pink colour of the post-mortem stains ; cadaveric rigidity is usually well marked, and passes off slowly. Internally, the colour of the tissues is equally striking : — The blood is cherry-red in colour, and is for the most part fluid ; the blood-vessels are dilated, and, being filled with the bright-red blood, impart a very characteristic appearance to many of the viscera ; microscopically ex- amined, the red corpuscles show no change. The brain and membranes may be hypersemic, but they often contain no excess of blood ; serous effusion is not unfrequently found in the cerebral ventricles. The lungs may be hypersemic ; they have been found cedematous. The mucous membrane of the trachea and bronchi often presents a normal appearance, but it may be coated with froth. Another characteristic feature has been frequently observed to follow death from poisoning by carbon monoxide — the organs and the blood strongly resist putrefactive changes. Stevenson 2 states that portions of the liver from a case of poisoning by water-gas showed an unchanged aspect, and retained the odour of the fresh organ two months after they were removed from the 1 Correspondenz-Blatt f. schweizer Aerzte, 1S88. 2 Guy's Hosp. Repts., 1890. ACUTE POISONING BY CARBON MONOXIDE. 499 body although no preservative was used ; the stomach and duodenum in parts were also unchanged in appearance. Spectroscopic Examination of the Blood.— When blood is fully satu- rated with CO (all the haemoglobin being converted into < 'OHb), the i absorption spectrum yielded by it consists of two bands resembling those of 0.,Hb, but they are slightly nearer the violet end of the spec- trum ; the change of position, however, is only appreciable by direct comparison of the two spectra side by side. If this constituted all the difference, it would be insufficient to afford convincing evidence for medico-legal purposes; but a further and more decided difference is manifested on the addition of a reducing agent, such as ammonium sulphide — the bands of COHb are unaltered, which is in marked contrast with the change that takes place in O.Hb when similarly treated. As previously stated, death \isually occurs before the whole of the Hb has been converted into COHb ; when this is the case, a mixture of COHb and o Hb is present in the blood, and con- sequently the addition of a reducing reagent does not affect the Hb which is in combination with CO, but it reduces that which is in combination with O. Thus the spectrum yielded by the blood of a person who has died from CO poisoning does not necessarily remain unchanged on the addition of a reducing agent : the Hb which is combined with O is reduced, and shows the broad band of reduced Hb, on which are superimposed the two persistent bands of that por- tion of the Hb which is combined with CO \_vide Diagram of Blood- Specti*aJ. Hoppe-Seyler's test of adding a solution of sodium hydrate to CO blood yields a cinna bar red ; normal blood is converted into a dirty brownish-green mass. Salkowski l has modified this test by diluting the blood with distilled water to twenty times its volume, placing the solution in a test-tube, and adding an equal volume of a solution of sodium hydrate (S.G. 1-34) : the solution containing carbon monoxide blood, after a momentary turbidity, becomes bright, and light-red in colour ; that containing ordinary blood changes to dirty brown. Quantitative Estimation. — A convenient method of ascertaining the quantity of CO contained in the blood is that adopted by Grehant. 2 The blood to be examined is placed in a flask connected with an apparatus for the extraction of gases, some glacial acetic acid is added, and the flask is placed in boiling water : the result is that the haemo- globin is converted into hsematin, with liberation of the carbon mon- oxide. The carbon dioxide that is given off is absorbed by potassium hydrate, and the oxygen by pyrogallol, the remainder consists of a l Zeitschr.f.phyaiol. Chcmic, 1SSS. - Comptes rendu* tie la SocUti de Biolo>' internal respiration on the hypothesis that hydrocyanic acid deprives the tissues of their power to take up oxygen. According to this view the oxygen of the blood is neglected by the tissues and it therefore accumu- lates until the whole of the blood — venous as well as arterial — assumes a bright red colour; asphyxia thus takes place in the presence of excess of oxygen. Another explanation attributes the arrest of internal res- piration to the condition of the blood. Robert "' states that HON forms a definite compound with metlnemoglobin ; if a few drops of the dilute acid are added to a 2 per cent, solution of methsemoglobin, its- brown hue is changed to bright red, and its spectrum to one resem- bling that of reduced lnemoglobin. Cyanmethamioglobin possesses considerable stability and resists the reducing influence of the tissues so as to be capable of recognition eight days after death in the blood of an individual poisoned with hydrocyanic acid ; ammonium sulphide also produces no effect, and a current of air may be passed through it without disassociating- t lie IU.'X. According to Kobert's views hydrocyanic acid, when taken into the living organism, kills the protoplasm of the red corpuscles, rendering them functionless as oxygen carriers, and by combination with methsemoglobin causes the blood to assume a bright red which determines the peculiar tint of the post-mortem stains and also that of the mucous membrane of the stomach. 1 Guy's Hosp. ltepts., 1869. - l>h /Jlausuure, lS(iS-70. 8 Hoppe-Seyler, Med. chem. Untersuch. l Zeitschr. f. klin. Med., 1889. * Weber Cyanmethamofflobin und 1 1 the teeth were tightly clenched ; the face was Hushed, but the surface was cold ; the respirations were shallow and slow ; the pulse was only just detectable at the wrist ; the pupils were small, and acted feebly to light. The breath had an odour resembling amy] nitrite, or essence of pears; later on the breathing ceased, necessitating artificial respira- tion several times, the pulse continuing in the meanwhile. The urine contained both amyl and ethyl alcohols. Recovery took place. Swain ' records a fatal case of poisoning by "faints,"' a refuse after distillation of spirit from potatoes, consisting of a mixture of amyl, propyl, and other alcohols. The mucous membrane of the stomach was soft and thick, and the organ contained a grumous fluid tinged with blood. The odour of amyl nitrite, but sweeter, was perceived on opening the body ; there was fluid in the ventricles of the brain which also was odorous. No cirrhotic changes were found in the liver nor kid- neys, although the patient had frequently indulged in raw amy] alcohol. Test. — By distillation with potassium acetate and sulphuric acid, amyl acetate is produced, which is known commercially as essence of jargonelle pears ; it may be recognised by its odour. Amyl Nitrite [C 6 H n N0 2 ]. — A case, interesting in more than one respect, is recorded by Eosen.' 2 A student, aged twenty-two. who was subject to epileptic seizures, had some amyl nitrite given to him for treatment by inhalation. On one occasion, feeling an attack imminent, he got the bottle of amyl nitrite in order to inhale some ; he had a tit, and on recovering consciousness, experienced sensations which con- vinced him that he had drunk some of the fluid during a state of epi- leptic automatism. Eructations and vomiting occurred. When seen the face was pale, the lips were bloodless, the respirations quiet, and the pulse 110 per minute : he had pain in the head, was much depressed, felt a burning sensation in the throat, and oppression in the region of the stomach. The mucous membrane, touched by the poison, was slightly eroded ; gastric catarrh followed, with ultimate recovery. The amount swallowed was from twelve to fifteen grammes. NITROGLYCERINE. Nitroglycerine [0 ; ,H 5 (NO.,). ; O..] is an oily liquid which detonates violently on percussion ; it is slightly soluble in water, and freely soluble in alcohol and ether. It produces the physiological effects of a nitrite in a powerful degree: — The arteries relax, causing a sensation of fulness and throbbing in the head, frequently accompanied by violent pain ; the action of the heart is quickened, and the blood tension lowered ; paralysis, both motor and sensory, occurs, and death from 1 Brit. Med. Journ., 1S91. - Centralis, f. Jdin. Med., 1888. 512 FORENSIC MEDICINE. respiratory paralysis. Nitroglycerine lessens the capacity of haemo- globin to take up oxygen ; the blood is sometimes chocolate-coloured, and yields the spectrum of methsemoglobin. Symptoms. — A burning sensation in the throat, nausea, vomiting, giddiness, excessively violent pain in the head, Hushing of the face, tumultuous action of the heart, pulsation felt all over the body, pros- tration, unconsciousness, muscular twitchings, perspiration, stertorous, dyspnoeal breathing, and cyanosis, with complete paralysis, have been observed. The fatal dose is not known. About one ounce caused death in four hours. A man recovered, after extremely violent and dangerous symptoms, who swallowed a tablespoonful of dynamite (a mixture of nitroglycerine with about one-third of its weight of silicious earthy matter), to which a few extra drops of nitroglycerine were added. A man committed suicide by eating two "bobbins'' of dynamite four inches long by three-quarters of an inch thick. CHLOROFORM. Chloroform [CHC1.,]. — Poisoning with liquid chloroform is not common and is almost invariably the result of accident or of attempts at suicide ; its pungent taste and powerful odour render it unfitted for homicidal purposes, although in one case at least it was strongly suspected to have been administered by the mouth with homicidal intent. Symptoms.- — The effects produced by chloroform swallowed in the liquid form resemble those caused by its inhalation plus the local action of the liquid on the mucous membrane of the stomach and bowels, on which it acts as an irritant, producing symptoms of gastro- enteritis. After a poisonous dose is swallowed, vomiting usually occurs, the romited matters not always yielding the odour of chloro- form ; in a short time the p atient becomes unconscious and presents the appearance of a person deeply under the influence of chloroform administered by inhalation: — The face is pale and cyanotic; the features are sunken ; the pupils are insensitive to light, and are frequently dilated but they may be normal ; and the entire surface is cold and bedewed with sweat. Unless the tongue is drawn forward the breathing is stertorous and gradually becomes feebler and slower ; the pulse is small and slow, the blood-pressure falling considerably. Death may result from paralysis of the respiratory centres or from heart-paralysis. [f the patient recovers consciousness, he complains of a hot, burning pain in the stomach and bowels ; he may have diarrhoea, and the CHLOROFORM. 513 motions may bo tinged with blood. Tho liver may be enlarged and tender, and the skin icteric. Death lias occurred from In art-paralysis after the patient lias recovered consciousness. A case is recorded by TJrasch 1 of a man who drank seventy grammes (a fluid ounce and a half) of chloroform which produced profound unconsciousness lasting for ten hours; he then came to himself and complained of pain in the region of the liver, which was enlarged; sixty-seven hours after the poison was taken he died of heart-failure. Fatal Dose. — The smallest recorded fatal dose swallowed by an adult was about seven fluid drachm s; one third the amount caused the death of a boy four years old. Recovery has taken place after two ounces in one case, and after three in another, in which the odour of chloroform was present in the breath for two days ; in both cases profound narcosis was produced. Death has taken place in three hours ; more commonly in twelve or more. Treatment. — Evacuate the stomach with the tube, and wash it well out ; follow up with artificial respiration and faradisation of the phrenics ; if the breathing fails, administer inhalations of amyl nitrite at frequent intervals ; keep the patient in the horizontal posture and apply external warmth. To diminish the risk of heart-failure the patient should be kept in bed for several hours after recovery of con- sciousness. Chloroform is principally eliminated by the lungs. Post-mortem Appearances.— Unless the presence of chloroform in the body can be ascertained, there is no characteristic indication of the cause of death. The mucous membrane of the stomach and bowels may be injected, softened, and even eroded ; incipient fatty changes in the liver, kidneys, and heart have been observed ; the blood is frequently fluid, and dark in colour. Chemical Analysis— Tests.— The most delicate test is that afforded by splitting up chloroform vapour into chlorine and hydrochloric acid. The substance containing chloroform is placed in a flask furnished with a piece of hard glass tubing, bent at a right angle just above the stopper of the flask, and again, twelve or fourteen inches away from the flask, at a right angle, downwards; at a point midway between the two bends a Bunsen flame is allowed to play until the tube is red hot. A second tube, through which air is gently forced, perforates the stopper and dips below the level of the contents of the flask, which are heated so as to volatilise the chloroform. When the vapour arrives at the incandescent spot it is split up into chlorine and hydrochloric acid : the former may be recognised by holding to the end of the tube a piece of starch-paper moistened with a solution of potassium iodide, which becomes blue from the action of the liberated iodine on the starch ; 1 Deutsche vv I. Zcitung, 1890. 33 514 FORENSIC MEDICINE. the latter by substituting a piece of moist blue litmus-paper which is reddened, showing the presence of an acid. If the end of the tube is plunged into a solution of silver nitrate, silver chloride is formed, which may be recognised by being insoluble in nitric acid, and soluble in ammonia. This test is so delicate that by finely mincing the lungs, adding sodium carbonate to slight alkalinity, and treating as above described, chloroform has been detected several weeks after death from its inhalation. Chloroform may be separated by distillation from organic admixture, such as the contents of the stomach, if present in sufficient amount to be recognised by its odour, otherwise it is better to adopt the process just described. After separation chloroform may be tested thus : — A little alcoholic solution of potassium hydrate is put into a test-tube along with ten or twelve drops of aniline, and a little of the chloroform-containing fluid, and is well shaken up. On gently warming the mixture for a short time, the suffocating and disagreeable odour of phenyl-isocyanide or isonitril is developed. The reaction is thus expressed — C H Cl 3 + 3 K H + C 6 H 5 N H 2 = C 6 H 5 X C + 3 K CI + 3 H 2 0. Aniline. Phenyl-i>ocyanide. Another test is to dissolve a little /3-naphthol in an aqueous solution of potassium hydrate, to which a few drops of the suspected fluid is added, and the solution gently warmed ; if chloroform is present the liquid turns blue. Chloroform reduces Fehling's solution. Quantitative estimation may be made by introducing the organic admixture into a flask as before described and passing the vapour through an incandescent combustion-tube containing small fragments of pure caustic lime, with which the chlorine combines. The lime is afterwards dissolved in dilute nitric acid and the chlorine precipitated with silver nitrate — 100 parts of silver chloride equal L>7-7- r >8 parts of chloroform. CHLORAL HYDRATE. Chloral Hydrate [CoH 3 Cl 3 2 ] in poisonous doses produces profound coma and abolishes the reflex irritability of the spinal cord. It lowers the blood-pressure partly by paralysing the vasomotor centre and partly by its action on the cardiac ganglia. Symptoms. — Shortly after the reception of a poisonous dose of chloral hvdrate the patient becomes drowsy and gradually passes into a state of coma, from which be cannot be roused. Inspiration is slow and laboured, long intervals sometimes occurring between the breaths ; the pulse is thready, and in the later stage slow. The pupils are generally contracted ; the face is sunken and cyanotic, or it is pallid CHLORAL HYDRATE. 515 and ghastly; the surface of the whole body, but especially of the limbs, is remarkably cold, and is bedewed with perspiration. The reflexes are abolished, and there is absence of sensibility. In fatal cases the temperature is further lowered, and death takes place from heart-paralysi s. It is charact eristic of pois oning by chloral hydrate for the toxic symptoms to come on very suddenly , sometimes directly after the poison is swallowed; in these cases the rapidity with which the fatal symptoms appear points to immediate paralysis of the heart, which causes death before the usual effects of the poison have time to manifest themselves. In cases of impeded circulation through the Lungs, or of fatty heart, small duses produce toxic effects. In the case oi Reg. v. Parton (Man- chester Ass., 1889), the prisoner was convicted of having caused the death of an elderly man by the administration of chloral hydr. beer, with the object of robbing him whilst insensible ; the man was found in a cab in a state of unconsciousness, and he died shortly after. Post-mortem examination revealed nothing characteristic; the heart was covered and infiltrated with fat, and death probably resulted from heart-paralysis. In the course of the day the deceased had drunk alcohol freely, but there Avere no indications of death from acute alcoholism. Traces of chloral hydrate were found in the contents of the stomach ; the dose taken was probably small, but it was sufficient to paralyse a feeble heart. Fatal Dose. — -The toxic action of chloral hydrate is extremely ir- regular. Twenty grains caused the death of a patient (who took it for neuralgia) in half an hour ; in another case thirty grains were fatal. Kane 1 states that ten grains rendered a woman of thirty-four pro- foundly comatose, with contracted pupils ; she recovered. An old lady of seventy died in nine and a half hours after taking ten grains. Three grains caused the death of a child one year old. On the other hand, recoveries are numerous after enormous doses of several hundred grains ; in one case recovery took place after four hundred and twenty grains taken in one dose. Death has occurred in uinutes; it may be delayed for six or more hours. Chloral hydrate to a great extent is decomposed in the organism, one product — urochloral acid — is found in the urine, in which also small amounts of unchanged chloral hydrate may sometimes be detected. Treatment. — The stomach should be emptied by the tube or by an emetic. Warmth is of the utmost importance ; it should be maintained by hot bottles, and the body should be surrounded by blankets, under- neath which friction may be applied. Persistent attempts at rousing the patient should be made by means of the faradic current and other 1 New York Med. Rec, 1SS0. 51G FORENSIC MEDICINE. usual methods. If the breathing fails, artificial respiration should he performed. Hypodermic injections of strychnine („ 1 - grain) have been nvommended, but strychnine is not so good an antidote to chloral hydrate as chloral hydrate is to strychnine. Stimulants will probably be required : ether hypodermically, or alcohol by mouth or rectum. Hot coffee is useful. Post-mortem Appearances. — There is no characteristic appearance. The heart and lungs have been found to correspond with the usual conditions of these organs when death has resulted from cardiac or respiratory failure. In a few instances, the mucous membrane of the stomach has been found softened, reddened, and easily detached. The blood is usually fluid, but not invariably so. It has been stated that putrefactive changes are retarded in chloral poisoning, but this effect is not constant. Chemical Analysis. — The contents of the stomach should be digested for twenty-four hours with about three times their volume of absolute alcohol acidulated with a few drops of sulphuric acid, the mixture being repeatedly agitated ; the alcoholic extract is then separated, and the alcohol evaporated. The residue is first extracted with petroleum ether, to remove fats, &c. (chloral hydrate is insoluble in petroleum ether), and is then shaken out with ethylic ether, which dissolves the chloral hydrate and deposits it on evaporation. On account of chloral hydrate being decomposed in the living organism, it may escape detection on analysis of the viscera and their contents after death. Urine also may be first treated with petroleum ether and then with ethylic ether in order to extract chloral hydrate. Tests. — The most delicate test for chloral hydrate, as such, is ammonium sulphide. A drop or two added to a weak solution of chloral hydrate produces no immediate change, but in a short time the mixture becomes opalescent and gradually acquires a yellowish or reddish milky appearance, very suggestive of urine overloaded with urates and charged with pigment. Unless chloral hydrate is present in very small amount its presence may be demonstrated by adding a few drops of a solution of potassium hydrate, which decomposes the chloral into chloroform and potassium formate : — C 2 H, CL O, + K H = K C H 2 +H.0 + C H Cl 3 , the chloroform is recognised by its odour, and subsequently by the production of phenyl-isocyanicle (see under Chloroform), and the potassium formate by boiling it in solution with silver nitrate, which it reduces to the metallic state. Trichloracetic acid also yields chloro- form when treated with alkalies. The /3-naphthol test (see under Chloroform) may also be used for chloral hydrate from which chloro- SULPIIOXAL. 517 form is liberated by the potassium hydrate used to dissolve the naphthol. "When chloral hydrate is present in very small amount, the best plan is to place the organic admixture in a flask, render it alkaline with sodium hydrate, and then cany out the method described in the chemical analysis of mixtures containing chloroform. Wynter Blyth. 1 recommends the addition of tartaric or phosphoric acid in the first instance; any chloroform obtained by distillation of the acid fluid must have existed as such in the organic matter. If the fluid in the flask is then alkalised and distillation resumed, all the chloroform-vapour that subsequently comes over is derived from chloral hydrate. TJrochloral acid may be obtained from the urine by evaporating it down, acidulating with hydrochloric acid, and shaking out with ether. On evaporation of the ether, needle-shaped crystals arranged in stars are deposited; an aqueous solution of these crystals reduces Fehlim/s solution, and turns the polarised ray to the leit. SULPHONAL. Disulphonethyl-dimethylmethane, or sulphonal, is used to procure sleep. It is a crystalline substance, produced by oxidation of a mixture of ethyl-mercaptan and dimethylketone (acetone). It is sparingly soluble in water and ether, and is more freely so in alcohol. As is the case with all hypnotics, sulphonal is used by the public on their own responsibility, and in this way has given rise to serious results. In a fatal case recorded by Knaggs, 2 a man took rather more than an ounce of sulphonal. He became comatose, with slow respiration, slow pulse, sometimes increasing to 90 beats per minute, and elevated temperature — ranging from 100 J to 103° F. ; the pupils were of normal si/.e and reacted to light. There was profuse perspiration, and total suppression of urine. He remained in the same condition for three days, when the breathing became short and jerky, ami Anally ceased. In a case recorded by Eeinfnss 3 a woman, aged forty-seven, took sul- phonal in doses of fifteen to twenty-two grains almost daily until the total amount reached between two and three ounces. She began to vomit and complained of pain in the stomach and abdomen. She then lost power over the legs, and had two attacks of clonic spasms; the pupils were contracted and equal, and reacted to light. Thirst, diminution in temperature, profuse perspiration, and during the last twenty- four hours muscular tremors and unconsciousness ended in death on the thirteenth day after the commencement of the vomiting. A i Poisons, 1SS4. " Brit. Med. Journ., 1S90. 3 Wiener med. Blatter, 1892. 518 FORENSIC MEDICINE. peculiar appearance was observed in the urine, which from the first was dark, and reddish-brown in colour, due to the presence of hamia- toporphyrin; albumen and renal epithelium were present. Kober 1 relates the case of a man, aged fifty, who for four or five weeks took doses of from 7 to 22 grains of sulphonal. As in the last case, the urine varied in colour from burgundy-red to reddish-black ; it con- tained albumen and casts, but no red corpuscles ; later on suppression of urine occurred, and the patient died. In addition to hsernatopor- phyrin and albumen, Jolles 2 found unchanged sulphonal, and increase of the combined sulphuric acid in the urine. In the case of a man, aged thirty-four, who took sulphonal in very large doses — a teaspoonful at once — Ullmann 3 observed reeling gait, stammering speech, and erratic gesticulations, which lasted four or five days. In another case there wei-e ataxic symptoms, which prevented locomotion and impeded speech. On the other hand, enormous doses have been taken without any permanent ill effects. Neisser 4 records a case in which a youth, aged fifteen, for the purpose of committing suicide, took 50 grammes of pow- dered sulphonal, and shortly after another 50 grammes, amounting together to more than 3 ounces. In three-quarters of an hour he became unconscious, and was found about six hours after, when he was taken to the hospital ; emetics were administered, and the stomach was washed out. He slept until the sixth day, and on the ninth day was perfectly well. The urine contained neither albumen nor sugar, but unchanged sulphonal was obtained from it. In another case a man, after taking over an ounce, slept for five days and then recovered. Tests. — If a little dry sulphonal is heated in a test-tube with char- coal or iron in powder, the odour of mercaptan is given off; if iron is used, the subsequent addition of hydrochloric acid to the residue liberates sulphuretted hydrogen. If a little dry sulphonal is melted and the heat is continued until the clear liquid boils, the addition of pvrogallol produces a brown colour with evolution of mercaptan. CARBON BISULPHIDE. _ Carbon Bisulphide [CS 2 ] has only exceptionally caused acute poison- ing ; chronic poisoning, by its vapour, is more common in consequence of its wide-spread use in india-rubber and gutta-percha works. Symptoms of Acute Poisoning. — In a case recorded by Davidson "' a man swallowed about two ounces of carbon bisulphide. "When seen 1 Centralbl.f. klin. Med., 1892. 3 Internal. Bin. Rundschau, 1891. 3 Corresp. Blattf. schweiz. Aerzle, 1889. 4 Deutsche med. Wochenschr., 1S91. 5 Med. Thins and Gaz., 187S. CARBON BISULPHIDE. 519 the patient was in a state of collapse; the muscles were relaxed and the pupils dilated and insensible to light ; the pulse was quick and feeble, the breathing laboured, the odour of the poison being perceptible in the breath ; the lips were blue, and the surface was cold ; occasional convulsive tremors or shiverings occurred. The odour of carbon bisulphide could be perceived both in the urine and the fseces. Recovery took place, the patient being well on the fifth day. A fatal ca.se is recorded by Foreman. 1 A man swallowed about half an ounce of carbon bisulphide and became comatose in half an hour. The respirations were slow and laboured; the pulse 150 to 1G0 in the minute ; the surface was cold and clammy: the pupils were normal. Death occurred two and a quarter hours after the poison was swal- lowed. At the necropsy the odour of the poison was perceptible ; the posterior wall of the stomach was congested for about the size of a crown-piece ; hemorrhagic points were visible in the gastric mucous brane. The veins were gorged with black blood, the blood throughout being fluid. The urine yielded the odour of carbon bi- sulphide. Treatment. — The stomach-pump should be used, and the drowsiness then combatted as is customary with other narcotics. "Warmth should be applied to the body, and stimulants administered internally. In case of need, artificial respiration is to be resorted to. If there is no diarrhoea, purgatives should be given. Carbon bisulphide is eliminated by the lungs, kidneys, and bowels. Death is apparently due to paralysis of the respiratory centres, which is also the cause of death in animals experimentally poisoned with carbon bisulphide. Chemical Analysis. — From organic admixture carbon bisulphide may be separated by distillation. It is recognised by its odour, and by giving a black precipitate of lead sulphide when heated with lead acetate and potash. Chronic Poisoning.— Like many other volatile poisons carbon bisul- phide, when long inhaled, produces peripheral neur itis, iu addition to disorders of the digestive tract . In the early stage of chronic poison- ing as it occurs amongst workmen in certain departments in rubber factories, the appetite fails, and the patient is always conscious of the odour of the bisulphide, even when away from his work. Sometimes a state of mental exaltation or of depression occurs, with sleeplessness, headache, nausea, vomiting, and colicky pains. These symptoms are followed by those of neuritis. In some cases investigated by Ross, 2 the earliest of the neural symptoms was a burning sensation iu the hands, alternating with numbness; then followed tingling and nuinb- 1 The Lancet, 1SS6. - Med. Chron., 1SS7. 520 FORENSIC MEDICINE. ness in the feet, with weakness. In one case the immediate narcotic effects of the vapour were demonstrated by the patient's desire to return to his work, because when he inhaled the vapour he felt some relief from the symptoms. The extensor muscles of the forearm and those of the leg were atrophied and partially paralysed, producing wrist-drop and ankle-drop respectively. There were numbness and tingling in the toes and feet, and in the tips of the fingers. The field of vision was restricted for all colours. Another patient was disturbed by horrible dreams, fancying himself surrounded by animals; sometimes, when at his work, he found himself talking nonsense. When the vapour of carbon bisulphide is present in considerable amount, the workmen not unfrequently develop symptoms resembling those of delirium tremens. PETROLEUM AND PARAFFIN OIL. Petroleum is a natural oil, consisting of a mixture of the higher, but not the highest, paraffins or hydrocarbons of the series C„ H 2n + „, of which marsh-gas is a type. The commercial oil varies in S.G. from •7 to -825, and in boiling point from 150° to 300° C. If well refined, it is a transparent, slightly fluorescent liquid, free from colour, but it usually presents a slight yellowish tinge when examined in bulk ; it has a peculiar penetrating odour. It is largely used as an illuminant. An early product of distillation of the crude oil is known as petroleum ether, which has a S.G. of ~6G to *G7, and a much lower boiling point [50° to G0° C] than the ordinary variety. Petroleum ether is used for extracting fats from organic fluids, and as a solvent. Paraffin Oil is a mixture of paraffins obtained by distillation of shale ; from the toxicological standpoint it does not differ from petroleum. In retail trade petroleum and paraffin oil are sold indifferently, the one for the other. The toxic properties of petroleum depend greatly upon the kind of oil taken, but in any case it is not an active poison. Lewin, 1 basing his conclusions on a number of experiments on animals, and observa- tions on the human subject, does not regard petroleum as a poison in the ordinary sense of the word, the dose necessary to produce toxic effects being so large. M'Culloch 2 saw a man, aged forty-three, one hour after he had swallowed nearly half a pint of paraffin oil ; he was pale, and his breath had the odour of the oil ; he complained of his throat being hot and dry, and he had a feeling of warmth in the epi- gastric region, but no pain ; the pupils were normal ; the pulse was full, but this probably resulted from excitement. After an emetic he Virchow's Arch., 1SS8. 2 The Lancet, 18S5. PETROLEUM AND PARAFFIN OIL. 521 vomited a little food and about eight ounces of paraffin oil. The oil was in his stomach an hour, along with very little food, hut it did nol cause the least indication of gastric irritation; the man was quite well the next morning. Vincent 1 saw a girl, aged Bfteen and a half, who swallowed about half a pint of paraffin oil. Fifteen <>r twenty minutes after she vomited, and was cold, with pale anxious facej feeble pulse — L32 in the minute — and sighing respiration. She had pain in the throat, epigastrium, and left hypochondrium. Recovery took place. Unusually severe symptoms occurred in the case of a woman, aged thirty-six, who was seen by Carruthers. 2 During a debauch she swallowed half a cupful of paraffin oil; in half an hour she had violent pain, and vomited, the. vomit was stated to contain blood. \\ hen seen she complained of pain in the epigastrium, and afterwards of pain in the left lumbar region. The motions contained blood, and also paraffin oil. A considerable quantity of oil floated on the surface ol the urine after it had stood a while ; on distillation 6 cc. of pure oil were obtained ; subsequently the urine contained albumen and blood. The odour of the oil was present in the breath for twenty-four hours. The patient was not seen for three or four hours after she swallowed the oil, and although she vomited in the interval, a considerable quan- tity had remained in the stomach, as was shown by the matter subse- quently vomited. She was well in a week. On more than one occasion a pint of petroleum has been swallowed without causing more than temporary disorder. Some writers doubt the possibility of petroleum being present in bulk in the urine. Lewin in his experiments on animals found that it did not appear as such in the urine, and disputes its occurrence in the human subject. Several cases are recorded, however, besides the one just related, in which unaltered oil was found floating on the urine after the individual had swallowed it in large amount. Biller y records a fatal case, in which an infant, eighteen months old, drank some "gasoline." It became unconscious, powerless, livid in the face, tympanitic in the abdomen, and cold on the surface ; death occurred in thirty minutes. Vaseline, which is a mixed intermediate product between the liquid and solid members of the paraffin series of hydrocarbons, is usually regarded .as a harmless substance. One instance is recorded by Robin- son, 4 in which half a teaspoonful Mas respectively given to three children for sore throat; it produced vomiting, pains in the knees, and cramps in the legs, with partial collapse ; all the children recovered. 1 Brit. Med. Jonrn., 1S8G. : The Lanrct, 1890. 3 New York Med. Journ., 1SS9. 4 Brit. Med. Journ., 1SSG. 522 FORENSIC MEDICINE. CHAPTER XXXI. BENZENE AND ITS DERIVATIVES. Benzene [0 C H C ], or benzole, is one of the principal ingredients in coal-tar, from which it is obtained by fractional distillation ; commercial benzene contains small quantities of some of the other light hydi-o- carbons. It is a colourless, volatile liquid, having an odour which recalls that of coal gas ; it is exceedingly inflammable, and gives off a vapour which is explosive when mixed with air ; it is insoluble in water, on which it floats. It is used in the manufacture of aniline, and also in cleaning gloves and wearing apparel. Symptoms of acute poisoning much resemble those of alcohol : a stage of excitement, which is quickly followed by heaviness in the head, and a tendency to stupor or coma. Foulerton 1 records the case of a man who, in the pursuit of his avocation, entered a large and almost empty tank used to store benzene ; when found, he was insensible, and could not stand ; he could answer questions in an indistinct way, moaning and laughing hysterically. The face was flushed, and the surface of the body cold; there were muscular twitchings ; the pupils were dilated, and reacted to light ; the pulse was 88 fall and soft ; the respirations, reduced to 8 or 9 in the minute, were deep, stertorous, and irregular, as much as fifteen seconds sometimes intervening between the breaths. The patient vomited, the ejected matter smelling of benzene. Re- covery took place. Averill 2 met with a case, in which a man accident- ally swallowed three or four drachms of benzene. He became pale and unconscious, with small, weak, rapid pulse, and slow breathing ; the pupils did not react to light. The stomach was evacuated, and the vomited matter contained oily-looking globules, which took fire on applying a light. Recovery occurred, the odour of benzene being perceptible in the breath sixty-two hours after the poison was swallowed. Palk 3 records a fatal case in a child two years old, death taking place ten minutes after a mouthful of benzene was swallowed ; the post- mortem appearances, beyond a faint odour of benzene on opening the abdomen, were negative. A fatal case of poisoning by benzene-vapour is recorded by Sury- Bienz. 4 It occurred to a workman in a chemical manufactory, who had to attend to a process, in the course of which a great deal of benzene 1 The Lancet, 1S86. "Brit. Med. Journ., 1889. :; Viertdjahrsschr. f. ger. Med., 1892. i Ibid., 1S8S. NITROBENZENE. 523 was volatilised. He was heard to call out that he was ou fire; he then reeled, fell to the ground, and died forthwith ; a fellow-workman who ran to his help perceived a powerful odour of benzene, but there was no fire. At the necropsy the veins were found tilled with fluid blood, and there was some oedema of the lungs, bu1 nothing else of moment. NITRO-DERIVATIVES OF BENZENE. Nitrobenzene [0 6 H 5 N"0 2 ], or nitrobenzole, is the product yielded by the action of nitric acid on benzene, ft is a light yellow liquid having an odour resembling that of oil of bitter almonds, and is known in commerce as artificial oil of bitter almonds or oil of niirbane ; it is largely used in the preparation of aniline and also to scent toilet soaps. Dinitrobenzene [C H 5 (NO 2 ) 2 ]. — The compound used commercially is the meta-dinitrobenzene which forms long rhombic prisms of a light yellow tint when pure; the commercial variety is yellowish-brown. It i< soluble in alcohol and ether, and when impure, to ;i slight extent in water. It is produced in aniline works and enters into the com- position of the explosive "roburite'' now largely used in coal mines for the purpose of blasting. Roburite consists of a mixture of dinitro- benzene, or chloro-clinitrobenzene and ammonium nitrate. Nitrobenzene. Symptoms of acute poisoning with nitrobenzene. The most charac- teristic symptom is the occurrence of a livid or cyanotic appearance of ace, the lips especially acquiring a dull lead colour; the fingers and toes, and even the whole body may be intensely blue. If the patient is able to walk, his gait is unsteady, and his muscular power feeble; vomiting may occur, the vomited matters probably having the odour of the poison, which also pervades the breath; drowsiness develops and rapidly passes into stupor or coma. The pulse is usually feeble and quickened, and may be intermit tent ; the breathing is often shallow and irregular with quickened expiration; the temperature is reduced and the surface is clammy. The pupils have been observed to be contracted in some cases and dilated mothers; dilatation is common in the comatose stage. Blood withdrawn during life has been found darker than usual. Filehne ' found that in d< gs poisoned with nitrobenzene the blood was chocolate-brown in colour: on spectroscopic examination it yielded a band in the red near the hsematin band, which he regards as directly 1 Arrh.f. exp. Pathol, 1878. 521: FORENSIC MEDICINE. due to the action of nitrobenzene. In no case did he find that the nitrobenzene was converted in the system into aniline. Filehne ex- plains the dyspnoea as being due to incapacity of the haemoglobin to carry oxygen to the tissues ; animals poisoned with nitrobenzene exhale more C0 2 and take up less O than in the normal. Lewin 1 found the band in the red to be identical with that of hiernatin. Fatal Dose. — Twenty drops have proved fatal. Recovery has occurred after very nearly an ounce, but the patient received prompt and efficient treatment. Dodd 2 records the case of a man, aged forty-seven, who swallowed two drachms of nitrobenzene and then eat his dinner, after which he walked three-quarters of a mile. One hour and a half after the poison was swallowed extreme cyanosis developed; the skin was clammy, the pulse feeble, and the respirations were shallow, irregular, and sighing; among other symptoms was trismus. The breath had the odour of nitrobenzene. The stomach was well washed out, and the patient recovered. In fatal cases death takes place in from one to ( \venty-four hours. Treatment. — Evacuate and thoroughly wash out the stomach ; apply external warmth and friction, and if necessary use artificial respiration and faradism. Stimulants may be required; they should not, however, be given by the mouth unless the stomach has been thoroughly washed out, as alcohol is a solvent of nitrobenzene. In severe cases, transfusion of defibrinated human blood may be resorted to after removal of an equal amount of blood from the patient. Dinitrobenzene. Poisoning with dinitrobenzene usually occurs in manufactories where this substance is used ; it is received into the system either in the form of vapour or of finely-divided particles floating in the air, or from handling it in bulk. It is customary in many works to provide the men with rubber gloves as otherwise their hands become contaminated with the poison which is thus transferred to food ; it is probable that prolonged handling of dinitrobenzene may lead to its introduction through the skin. The symptoms of acute poisoning resemble those produced by nitro- benzene : — Headache, giddiness, loss of power in the limbs, blue color- ation of the lips, cold and livid surface, quickened feeble pulse, dyspnoea, shallow irregular respiration, with long intervals between the breaths, and coma. The cyanotic appearance may be limited to the face or it may spread to the limbs; usually the trunk is not much affected; the 1 Yirchow's Arch., 1S79. - Brit. Med. Journ., 1891. DINITROBENZENE. • >_'•> blood is dark, and sometimes chocolate-coloured. Vomiting frequi occurs spontaneously. Chronic poisoning with dinitrobenzene, which also occurs amongst those who prepare or purify it, produces a different class of symptoms. Schroder and Strassmann 3 investigated several cases and describe the chief symptoms as follows: headache, pain in the stomach with irregular action of the bowels, loss of appetite, sleeplessness and general feeling of lassitude. The lips are blue and the skin acquires a dirty yellow tint, the sclera being yellow; in some cases the mucous membrane of the mouth especially of the uvula and pharynx, looks as though it was covered with a yellow bloom which, however, can not be wiped off. The gastric and hepatic regions arc very tender on pressure, the liver usually being enlarged. The urine is dark brown, but quite clear; dinitrobenzene was proved to be present in it. The symptoms present very much the appearance of those due to catarrhal jaundice, but the urine yields no trace of bile, the motions retain their colour, and the prostration and blue colour of the Lips are different from anything observed in cases of jaundice. Rbhl - describes certain effects produced on the nervous system by chronic dinitroben- zene poisoning resembling those of peripheral neuritis: — Numbness, a sensation of cold in the feet, with various paresthesia? and cramps. From experimental researches by Huber 3 it appears that dinitroben- zene combines with haemoglobin which then yields a spectrum identical with that of acid hsematin, but it does not respond like lnematin to reducing agents. On the addition of ammonium sulphide the band in the red, between C and D, persists, but it is slightly displaced; the oilier two bands remain unchanged. The spectrum is probably the same as that described by Filehne in his investigations on nitrobenzene ; it is not always obtained with the blood of animals poisoned with dini- trobenzene, nor has it. been observed in the human subject. The urine as before stated contains dinitrobenzene, which exists as such; no derivatives have so far been detected. By means of treat- ment with zinc and hydrochloric acid, the dinitrobenzene present in the urine may be converted into phenylenediamine ; if the urine is then alkalised with soda and shaken out with ether, and the residue after evaporation of the ether is treated with sodium nitrite and acetic acid, a brown colour — Bismarck-brown — is produced. If the urine is shaken out with ether, without being previously treated with zinc and I H'l, no effect is produced on the ethereal residue by sodium nitrite, showing that the dinitrobenzene is not decomposed in the system into phenylenediamine nor into nitraniline. 1 Vierteljahrsschr.f. ger. Med. (Supp.), 1S91. - Ueber acute u. chron. Intox. (lurch Nitroh&rp. d. Bern Ircihe, U 90. s Vircliow's Arch., 1891. 526 FORENSIC MEDICINE. Roburite being largely composed of
  • le la Suisse Bom., 1SSS. 2 Berliner kiln. Wochenschr., 1884. 532 FORENSIC MEDICINE. Kesorcin [C 6 H 6 2 ] in toxic doses produces symptoms analogous to those due to phenol. Murrel x records the case of a girl, aged nineteen, in which two drachms produced almost immediate giddiness, and a sensation of pins and needles all over the body ; she became insensible, and perspired profusely ; the temperature was low, the pulse imper- ceptible, the face pallid, the lips were blanched, the pupils normal, the conjunctiva 1 insensitive to the touch, and the chest-walls almost motionless. There was a state of general muscular relaxation; recovery took place. In another case epileptiform convulsions occurred. Tests.— Ferric chloride produces a violet colour. Sulpho-vanadic acid blue and then violet. If a crystal of sodium nitrite is mixed with a drop or two of concentrated sulphuric acid and a little resorcin is added, a violet colour, which changes to blue and then brown, is produced. Pyrogallol [C 6 H 6 3 ], or pyrogallic acid, when absorbed into the system in large amount, destroys the red blood corpuscles, causes dyspnoea, reduction of temperature, lessened sensibility, paralysis, and the presence of free haemoglobin in the urine ; methseinoglobin has been found in the blood. The dyspnoea, which may be excessive, is probably due to the formation of thrombi, which are the ultimate cause of death. Four cases of fatal poisoning have occurred since the introduction of pyrogallol in the treatment of psoriasis in 1878. When extensively applied to the surface in the form of an ointment absorption takes place ; the following is a resume of the results which occurred in all four cases: — The toxic symptoms came on very suddenly : in one case after the first rubbing, in a second case on the third day, in a third case on the sixth day, and in a fourth on the fifteenth day ; they comprised rigors, nausea, prostration, quick pulse, primary elevation, followed by rapid fall of temperature, acute anaemia, jaundice, vomit- ing, diarrhoea, hemoglobinuria, hematuria with albumen, broncho- pneumonia, and great dyspnoea. On section the blood was found bluish and fluid ; the kidneys black and intensely congested. Absorption does not appear to be so rapid when pyrogallol is taken internally. Benerji 2 records a case in which a man and his wife each swallowed more than a drachm ; vomiting was procured in half an hour, and only the man experienced any symptoms ; they were limited to a sensation of drowsiness coming on at intervals, nausea, slight paroxysmal numbness about the limbs and face, palpitation, dryness of the throat, and a black tongue ; the following day he was quite well. A case of mixed poisoning is related by Maillart and Andeoud, 3 in 1 Med. Times and Gaz., 1SS1. - The Lvicet, 1S92. a Revue Med. de la Suisse Rom., 1891. ANILINE. .j33 which a man swallowed about four grains of pilocarpine, and, imme- diately after, two drachms of pyrogallo] ; in three or four minutes most of the poison was rejected by vomiting. The symptoms that ensued were due to the pilocarpine ; profuse sweating occurred, and increased secretion from all the mucous surfaces and the glands, with pain and smus in the abdomen, reduction of temperature to , .» 1 '- F., and temporary abolition of sight, which was quickly restored by atropine; recovery took place. Both pilocarpine and pyrogallo] were det< ted in the urine. Treatment consists in evacuation of the stomach if necessary, the administration of stimulants, the inhalation of oxygen, and external warmth. The post-mortem appearances are not characteristic. Chemical Analysis.— Pyrogallol may be dissolved out of dried organic matter by digestion with alcohol. After filtration the alcohol is evaporated; the residue is extracted with water and shaken out with ether, which on evaporation leaves the pyrogallol behind. Tests.— With lime-water a purple-red is produced; with basic lead acetate a reddish colour, and with ferrous sulphate a bluish-black-. A solution of sodium molybdate added to a solution of pyrogallol pro- duces a brownish-red colour. Salicylic Acid [C r H 6 3 ] used in medicine for the most part in com- bination with sodium, has occasionally produced toxic effects. The s ymptoms vary; they comprise : — hemorrhage from the gums and the kidneys, retinal haemorrhage, epistaxis, hematuria, albuminuria, vomiting, irregularity of the pulse, urticaria, hallucinations and in- sensibility. Charteris and Maclennan 1 state that the toxic effects of sodium salicylate are due to impurities which exist in the artificially prepared salt, and that the natural salt is not toxic. In one of two cases recorded by Auld, 2 one hundred grains daily for six days caused great and stridulous dyspnoea, extreme slowness of the pulse, general paralysis, and some delirium ; in another case the delirium was more marked. Recovery has occurred after very large doses. A patient was given an ounce and a half of sodium salicylate in mistake for sodium sulphate; the symptoms produced were : — Burning sensation in the throat and stomach, thirst, nausea, vomiting, profuse sweating, coldness of the limbs, defective vision without alteration of the pupils, slow action of the heart, noise in the ears with deafness, and a state of collapse, which with the deafness lasted several days. Albumen was present in the ttrine. 3 i Glasgow Med. Journ., 1SS9. - The Lancet, 1S90. 3 Deutsche med. Wochenschr. , 1881. 534 FORENSIC MEDICINE. Chemical Analysis. — From organic matter salicylic acid may be separated by acidulation and then shaking out with ether. Tests. — Both salicylic acid and phenol strike a violet colour with ferric chloride ; the addition of acetic acid destroys the colour produced by phenol, but leaves that produced by salicylic acid unaltered. In ammoniacal solution salicylic acid undergoes no change on the addi- tion of bromine-water ; under like conditions phenol turns blue. Salicylic acid is chiefly eliminated by the kidneys and may be detected in the urine by the addition of ferric chloride. * PHENOL OR CARBOLIC ACID. Phenol [0 6 H 5 OH] when pure forms a crystalline mass without colour, which reddens if exposed to air. The change in colour is due to oxidation and not to the presence of bi-products, such as cresol and the like ; chemically pure phenol becomes red if frequently melted with free exposure to air. It has a penetrating odour indicative of its presence in the smallest amount. Although commonly called carbolic acid it has no acid r eaction, but it coagulates albumen, and destroys tissue ; it is slightly heavier than water, in which it dissolves in the proportion of 1 part to 15 ; it is freely soluble in alcohol and ether. For sanitary purposes crude carbolic acid is used, which consists of from 15 to 60 per cent, of phenol along with a varying admixture of other products of distillation from coal-tar ; it is a dark-coloured liquid having the odour of phenol, modified by the impurities which are present. When strong carbolic acid is applied to the skin it causes a white appearance ; the epiderm is destroyed and easily peals off, the part subsequently becoming brown and parchment-like ; absorption may take place through the unbroken skin to such a degree as to cause death. The t oxic action of carbolic acid is both local and remote ; locally it a cts as a corrosiv e, r emotely it exer cises a complex influence on the nervous system. In animals i! firsl stimulates and then paralyses the centres in the brain and cord, in human beings poisonous doses seem to paralyse from the first. The vasomotor and respiratory centres are early affected : the pulse becomes small and of low tension, and the breathing irregular and laboured ; almost at the same time the higher centres are attacked : giddiness, reeling gait, and tendency to delirium are quickly followed by profound coma. In some instances the rapidity with which the cortical centres are attacked is very strik- ing, and puts the local symptoms quite into the shade. Death is due to respiratory and cardiac paralysis. PHENOL OR CARBOLIC ACID. D35 Symptoms. — When the strong acid is swallowed, immediate burning pain is experienced from the mouth down to die stomach ; a sensation of giddiness and impending lossofcoi ss is felt, soon followed by coma with all the symptoms <>f collapse. The face is ghastly, the breathing is stertorous, the lips are livid, or stained and swollen fn m contact with the poison ; the pupils ;uv :•■ pulse, small and scarcely perceptible, is usually rapid ; the temperature is low, and the surface is bedewed with moisture, or it may be dry. Vomiting is not so constant as in poisoning by other corro-i\e- ; ii may not only be absent, but may be difficull to procure. The urine is usually diminished or suppressed, that which is voided is often dark in colour, or becomes so on exposure to the air, probably due to an oxidation product of phenol — hvdroquiiione. Much of the phenol and hydroquinone that is eliminated in the urine is in combination with the sulphuric acid of the sulphates; hence when freshly voided the urine may be of normal colour, but subsequently becomes dark from Liberation and further oxidation of these products. Albumen and casts and, exceptionally, blood may be present. The remote effi phenol have been developed by its injection into the bowel ; an instance occurred in which about 144 grains were diluted with water and ad- ministered to a boy of five, as an enema to kill worms ; no pain was produced but immediate insensibility, which terminated in death in about fourteen hours. 1 T he external application of phenol has proved fata l. Warren 2 men- tions a ease in which it was. applied to the back of an adult, producing coma, trembling of the muscles, and death in twenty minutes. Injec- tion of phenol into abscess-cavities has also caused death. Prolonged breathing of air impregnated with the vapour of phenol may produce symptoms of poisoning. Unthank 3 relates the case of a man who was exposed for three hours to the fumes of strong phenol \ he was seized with giddiness, stupor, and convulsions. When seen shortly after he was comatose; the neck and face were livid, the surface was cold, and the pulse scarcely perceptible \ recovery took place. Poisoning by carbolic acid is almost invariably either suicidal or accidental ; the facility with which it may be obtained accounts for the former, and carelessness for the latter. In poorer households it is frequently kepi in an ordinary wine bottle, which leads to its being drunk in mistake for some potable fluid J or, being contained in a medicine bottle, it is thoughtlessly given instead of physic. Fatal Dose. — One drachm has caused death in twelve hours. Some- times death occurs very rapidly in less than half an hour; it has 1 The Lancet, ISS.'l *Med. Press and Circ, 1882. *Brit, Med. Journ., 1872L 530 FORENSIC MEDICINE. occurred in three minutes, and, on the other hand, it has been delayed for sixty hours; the usual period is from three to four hours. Recovery lias followed enormous doses. Greenway l reports the case of a woman who swallowed more than an ounce of carbolic acid containing 90 per cent, of phenol ; there was profound collapse and total insensibility, but recovery took place. Davidson 2 records the recovery of a woman of forty, after she had swallowed four ounces of crude carbolic acid, the stomach-pump being used twenty minutes after the poison was taken. Hind 3 relates the case of a girl of seventeen who recovered after swallowing six ounces of crude carbolic acid ; vomiting was pro- voked at once; the acid only contained about 14 per cent, of phenol. Treatment.— Empty the stomach with a soft tube ; if nothing but the ordinary stiff stomach-pump-tube is to hand, great care should be exercised in its introduction, as the walls of the oesophagus are less resistant than in the normal condition. After emptying, the stomach should be well washed out with lukewarm water, in which some mag- nesium sulphate, or saccharated lime, may with advantage be dissolved, in order to afford an opportunity for the phenol to combine and form an innocuous ether-sulphate. White of eggs and milk may be given. Olive oil has been recommended, but with doubtful advantage. Several observers have noticed that apomorphine failed to produce emesis in phenol poisoning. External warmth, with stimulants such as ether administered hypodermically, or alcohol by the mouth or rectum, are of great value. If death from respiratory paralysis appears imminent, breathing should be promoted artificially. Post-mortem Appearances. — Stains produced by the poison may be present at the angles of the mouth and on the chin, and its odour may be perceptible. The mucous membrane of the mouth may be softened, and either white or ash-grey in colour, that of the oesophagus being similarly affected in parts ; on account of shorter period of contact, the changes in the mouth and (esophagus are not usually so well marked as those in the stomach. The peritoneal surface of the stomach may be injected, its mucous toat usually being corrugated, toughened, and of a brown colour ; in parts it sometimes appears stiff and leathery as though it had been tanned ; in other instances it is softened and easily detached. It has been observed to be of an ash-grey colour with small hemorrhagic points; actual erosion is uncommon. Blood-stained mucus has been found in the stomach. The duodenum may present a similar appearance, the brown colour being sometimes limited to the summit of the valvuhe conniventes ; in a preparation in the Museum of Owens College this is well shown in the form of a series of parallel brown lines running across the bowel for fully twelve inches. 1 The Lancet, 1S91. ~ Med. Times and 6V:., 1S75. 3 The Lancet, 1SS4. V PICRIC ACID. 537 Chemical Analysis.— After the addition of a little sulphuric acid, separation from organic matter may readily be effected by distillation. Tests.- -The presence of phenol in the distillate maybe recognised by its giving with bromine-water a precipitate of tri-bromo-phenol [C 6 H 2 Br 3 OH]; the pr ecipitate is soluble in excess of pheno l, [fa little ammonia water and a small quantity of bleaching-powder, or bromine water, are added to an aqueous solution of phenol, on gently heating the mixture a blue colour is produced ; acidulation alter cool- ing changes the blue to red or yellow. The addition of a solution of ferric chloride to a solution of phenol produces a violet colour, and acid nitrate of mercury (MiUon's reagent) a bright red. If a weak solution of furfural is added to a solul ion of phenol, and si rong sulphuric acid is allowed to trickle down the side of the tot tube, a red colour which changes to blue develops above the acid. Quantitative estimation of the phenol present in the distillate maybe made by precipitation wi th bromine-water, the precipitate being washed, dried, and weighed — 100 parts of tri-bromo-phenol equal 28'39 parts of phenol. The phenol may he liberated from its combina- tion with bromine by treatment with sodium amalgam, and then extracted with ether and the residue, after evaporation of the ether, tested as above described. Combined phenol-sulphonic acid in urine may be decomposed and the phenol estimated as follows : — Evaporate the urine to a syrup, extract with absolute alcohol, filter, and precipitate the alcoholic solu- tion with oxalic acid as long as any precipitate falls ; then add potassium hydrate to feeble alkaline reaction and evaporate again to a syrup. Render the residue acid and distil the phenol thus set free from the potassium phenol-sulphonate ; the amount is estimated by conversion into tri-bromo-phenol. PICRIC ACID. Picric Acid [C 6 H 2 NO > 3 OH], or trinitrophenol, is formed by the action of nitric acid on phenol. It consists of yellow prisma! ic or laminar crystals which are sparingly soluble in cold water, more soluble in hot water, and freely so in alcohol; it is somewhat soluble in ether and chloroform, but much more so in amyl alcohol. It is odourless, has an intensely bitter taste, possesses strong acid properties, and forms salts which detonate on percussion. A solution of picric acid stains objects yellow, and it has been used for this purpose in confectionery ; on account of its bitter taste it has been used to replace hops in beer. Very few cases of poisoning by picric acid are recorded and none with fatal results. 538 FORENSIC MEDICINE. Iii experimenting on animals Erb 1 found that picrates cause the blood to become dirty brown in colour, with the formation of distinct nuclei in the red discs and free nuclei in the serum; the white blood corpuscles show a tendency to undue numerical increase. The cause of death is heart paralysis. Elimination takes place by the kidneys, bowels, and mucous membranes. Symptoms. — The following case related by Adler 2 illustrates the effects of a toxic dose: — A girl, aged sixteen, endeavoured to commit suicide by swallowing about 300 grains of picric acid mixed with water. Violent pain in the stomach and repeated vomiting speedily occurred, and diarrhoea soon followed ; the sclera and the skin were coloured an intensely dark yellow almost brown ; the pupils were moderately dilated and reacted feebly to light ; the fingers were spastically stretched and bent at the metacarpophalangeal articulations. The urine was ruby-red in colour; it contained neither albumen nor bile pigment; a slight sediment formed which partially consisted of brown - stained epithelium ; the stools were fluid and ruby-red in colour. Both urine and faeces contained picric acid in considerable amount; six days after the reception of the poison traces of it were present in the urine. In a few days the discoloration of the skin diminished and the patient was quite well at the end of a week. Cheron 3 relates a case of poisoning from inhalation of picric acid dust which caused discoloration of the skin, pain in the epigastrium, depression, delirium, vomiting, diarrhoea, and red-coloured urine ; recovery took place. In another case symptoms of poisoning occurred from the application of about six grains of powdered picric acid to the vagina ; in one hour the skin was discoloured and erythematous, and the urine was red; pain in the stomach and the kidneys with somnolence were amongst the symptoms; recovery took place, but the skin was discoloured for a week, and the erythema peisisted for eleven days. A teaspoonful of picric acid has been swallowed without other ill effect than violent vomiting and purging. Treatment. — The stomach should be evacuated and well washed out, and elimination promoted by diuretics and, if necessary, aperients ; morphine will probably be required to relieve pain and cramps. Chemical Analysis. — Organic matter should be acidulated with hydrochloric acid and digested with alcohol over a water-bath; after filtration the alcoholic extract is evaporated to a syrup, taken up with boiling water, filtered, acidulated with sulphuric acid, and shaken out with ether, chloroform, or amyl alcohol. Dragendorff directs attention to the fact that if chloroform or benzene are used for extraction, the 1 Die Pikrinsaure, 1S65. - Wiener med. Wochenschr., 18S0. 3 Journ. de Tlwrap., 1SS0. CREASOTE. 539 solution though containing picric arid will be almost colourless ; if ether or amy] alcohol are used they acquire a yellow tint. The extract is evaporated to dryness and the residue dissolved in water and tested Tests. — An aqueous solution of picric acid, gently wanned with a little potassium cyanide, changes to a deep blood-red colour. Ammonio-copper sulphate yields a green precipitate with picric acid. Basic lead acetate gives a yellow precipitate. A piece of white silk allowed to remain a short time in a solution of picric acid is dyed yellow; the colour is not discharged by subsequent washing in water. CREASOTE. Creasote, which chiefly consists of cresol and guaiacol, is slightly soluble in water, and is freely soluble in alcohol and ether. It coagu- lates albumen and acts as an escharotic; when swallowed in poisonous doses it causes nausea, vomiting, abdominal pain, and diarrhoea, fatal poisoning by creasote is rare. A case is reported by Marcard 1 of an infant which suddenly became ill and died in fourteen hours; the child's jacket was stained with yellowish spots, and there was a strong odour of creasote in the room. Examined seven hours after tin' commence- ment of the symptoms the mucous membrane of the lips, tongue, and mouth was partly red and partly grey, and showed signs of the action of a caustic, but no smell of creasote was perceptible; the child vomited and passed motions mixed with blood. At the necropsy the lips and the tip of the tongue were brown and hard; various sized erosions were found in the mucous membrane of the stomach, but no odour of creasote could be perceived, nor could any trace be obtained by chemical analysis of the viscera; the spots on the jacket, however, yielded evidence of the poison. As the result of a series of experiments 03 animals it was found that when a minimum lethal dose of creasote is given and the animal lives some hour-, the "dour of the poison may entirely disappear. In another case reported by Piirckhauer, 2 a child ten days old was given from twenty-four to thirty drops of cr< it hecame insensible, was convulsed, and died in sixteen hours. At the necropsy, inflammation and corrosion of the digestive tract, dark- coloured blood,.and the odour of creasote were present. An adult who was taking creasote medicinially gradually increased the dose until it reached one hundred drops. On one occasion she took a second hundred drops after the usual dose; Freudenthal, 3 who reports the case, saw her afterwards and found her insensible, breathing stertorously, with 1 Vterteljahrsschr. f. ger. Med., 1SS9. 3 Friedreich's Blatter/. :/<■;•. Med., 1 *>.'!. l New York Med. Rec. 1892. 540 FORENSIC MEDICINE. clenched jaws s cyanotic lips, contracted insensitive pupils, and absence of the reflexes ; recovery took place. It is stated that creasote, unlike carbolic acid, does not cause the urine to become dark coloured, and only exceptionally does it produce nephritis. Creasote is eliminated by the kidneys, and after large doses its odour may be perceived in the urine. The treatment of tuberculosis by creasote has led to the adminis- tration of enormous doses, apparently without injurious effects; the system is gradually trained to toleration by daily augmentation of the dose from a drop or two up to as many as one hundred or more drops. In the case just quoted, the patient, after recovery from the effects described, still further increased the dose until it reached two drachms and three-quarters twice a day. In fatal cases death may take place in from seven to twenty hours. The treatment is the same as in poisoning by phenol. The post-mortem appearances resemble those produced by phenol. Chemical Analysis. — Separation from organic admixture is to be effected as is directed for phenol. Tests. — Creasote may be recognised by its odour. In alcoholic solu- tion it may be distinguished from phenol by adding a few drops of a solution of ferric chloride ; a green colour is produced, which disappears on dilution with water. Phenol similarly treated gives a lilac which does not disappear on the addition of water. CHAPTER XXXII. ALKALOIDS AND VEGETABLE POISONS. Alkaloids are basic bodies which may be considered as compound ammonias. Vegetable alkaloids are almost exclusively derivatives o1 pyridine ; they contain carbon, hydrogen, nitrogen, and — with tin exception of a few volatile alkaloids — oxygen. They are for the most part solid, crystalline, and colourless ; a few, such as nicotine an<< conine, are liquid and volatile. Alkaloids combine with acids, the xilts formed being much more soluble in water than the free alkaloid Unless specially qualified, the term alkaloid is applied to substances derived from plants or trees ; basic products of an analogous constitu- tion obtained from animal tissues are known as "animal alkaloids.'' Alkaloids possess certain properties in common, amongst which is thai of being precipitated from solutions by substances which thus serve as STRYCHNINE. ~j I 1 alkaloidal group reagents, some of wliicli throw down most of the alkaloids, others only a limited number : most of them also form pre- cipitates with ammonia. Group Reagents.- Phosphomolybdic acid, which may be extempora- neously prepared by dissolving sodium phosphomolybdate with the aid of heat in water freely acidulated with nitric acid, precipitates almost all alkaloids, whether vegetable or animal, together with ammonium salts, and derivatives of ammonia, such as phenylamine, methylamine, and the like; it also precipitates salts of lead, silver, and mercury, unless sufficient nitric acid is present to keep the m in solution. Phosphotungstic acid is another delicate group-reagent, yielding much the same reactions as phosphomolybdic acid. Iodine dissolved in water with the aid of potassium iodide gives a brown precipitate with most of the alkaloids. Potassio-mercuric iodide — made by adding a solution of potassium iodide to a solution of mercuric chloride until the red precipitate first formed is just dissolved, leaving a colourless solution — produces a gelatinous precipitate with a great many of the alkaloids. There are other alkaloidal group-reagents — as platinic chloride, picric and tannic acids, bismuth-potassic iodide, &c. — but the above-mentioned are the best. Special Reagents are described in the sections respectively devoted to the various alkaloids ; for the most part they are best applied to the solid alkaloid, obtained by evaporating to dryness a few drops of a solution which contains it. STRYCHNINE. Strychnine [0 21 H 22 N 2 2 ] occurs in several plants of the natural order Loganiacece, and is prepared from Nux Vomica, or from the Ignatius bean, in both of which it is associated with brucine. Strych nine forms colourless crystals, sparingly soluble in water and ether, rather more freely soluble in spirit, and much more freely so in chloro- form. It has an exceedingly bitter taste, which is perceptible in a solution composed of 1 part iu 70,000 parts of water ; it is one of the most permanent of the alkaloids, and may be detected in the putrefied remains of animals that have been poisoned by it. Strychnine has powerful basic properties, and will neutralise the strongest acids ; it may be exposed to the action of concentrated sulphuric acid for an indefinite time without undergoing decomposition. The salts of strychnine met with in commerce are the sulphate, the nitrate, and the acetate. Strychnine is easily accessible to the, public in the form of powders for killing rats, mice, and other vermin ; those most commonlv used 542 FORENSIC MEDICINE. are known as Cattle's vermin-killer, sold in threepenny and sixpenny packets. Analyses made of these powders purchased at retail shops show that a threepenny packet weighs about 0-713 gramme (11 grains), and contains about 0-11 gramme (1*6 grain) of strychnine, the rest of the powder consists of flour mixed with Prussian blue ; a sixpenny packet weighs 1-413 gramme (21-7 grains), and contains 0d82 gramme (2-7 grains) of strychnine. These pow r ders are prepared in large quan- tities ; they are roughly measured out, and the percentage of strychnine is not constant, but each may be regarded as containing a fatal dose for an adult human being. Butler's strychnine vermin-killer consists of flour and soot, with strychnine in much the same amount as in Battle's. In some of these powders ultramarine is used as colouring agent, and as the gastric juice is sufficiently acid to destroy the colour of this pigment, if such a powder is swallowed no coloured particles may be found in the stomach after death. Tn poisonous doses strychnine causes general clonic spasms, which, from experiments on animals, are found to be due to increased excita- bility of the reflex centres in the spinal cord. It appears as though strychnine had the power of lesseni ng the resistance of the cells i n the anterior cornua, both to reflex stimu li and to the reception of impulses from contiguous cells ; the result being that a stimulus which, under normal conditions, would produce a response limited to the muscles supplied by the cells actually stimulated, spreads from ■cell to cell, and sets up universal spasm ; an impulse set up in the cord travels wave-like in all directions, the motor cells having lost their self-inhibitory power. The inhibitory influence of the higher centres is probably not interfered with ; a striking illustration of this is occa- sionally seen in the human subject when under the influence of a toxic dose of strychnine : — The least external stimulus is sufficient to provoke the liberation of a torrent of motor nerve-impulses, which throws the whole of the skeletal muscles into the most violent movement ; the slamming of a door, the touch of a hand, or even a current of air will produce an attack ; yet the patient, in the lull after a seizure, will sometimes ask a bystander to rub his legs in order to ease the pain, and the action is unattended by reflex spasm. This points to a certain degree of inhibitory control, which the higher centres are capable of exercising over the spinal centres, notwithstanding their instability. Symptoms. — In three or four minutes, up to a quarter of an hour or longer, after a poisonous dose of strychnine has been swallowed, muscular twitchings, accompanied by a feeling of anxiety and impend- ing suffocation are experienced by the patient, and immediately after he is seized with a violent convulsion of a tetanic character. The arms and legs are stretched out, and the muscles of the trunk are hard and STRYCHNINE. 043 unyielding; then jerking movements occur, forcing the head and buck wards and the trunk forwards, the feet being strongly flexed and the hands clenched. The clonic spasms increase in severity, and the extensor muscles an- so forcibly contracted thai the body is arched in the posture of opisthotonos — the hack of the head and the heels forming the ends of a curve, of which the abdomen constitutes the most prominent part; exceptionally the body may be arched forward or sidewise. When this stage is reached the spasm for a time becomes tonic : the muscles of the chest and abdomen, including the diaphragm, are tense and rigid, and the whole frame remains arched and still': the pulse is very rapid and feeble, and respiration is much impeded or en- tirely arrested, producing marked cyanosis. The sufferer is fully con - scious,and experiences the most acute physical pain, v. ith mental anguish at the prospect of immediate deni h. which he feels to be imminent \ when capable, he cries out for something to he done to relieve his sufferi _- The terror-struck face, the prominent eyeballs, dilated pupils, and cyano- j tic complexion, vividly portray the agony suffered. After a minute or more the muscles relax, the eyeballs cease to protrude, and the pupils regain their usual size ; normal respiration recommences, the cyanosis disappears, and the pulse diminishes in rapidity. The patient lies exhausted, dreading a repetition of the spasm which sooner or later recurs, being provoked by the least external impulse. During the remission, which lasts from a few seconds up to five or ten minutes, the face, without losing its anxious appearance, looks less wildly agonised than during an attack. If the case is about to terminate fatally the spasms succeed each other in rapid sequence, and d eath usually occurs within two hours either f rom asphyxia produced by fixation of the respiratory muscles, or, during an interval, from exhau s- tion, probably the result of the excessive expenditure of force, leading to paralysis of the nerve elements. When recovery is about to take place the attacks diminish in severity, and the intervening periods are more and more prolonged, until at last the patient, free from convul- sions, is left feeble and exhausted, a condition from which he recovers in a few days : in some cases the recovery is more prolonged, but actual complications are very exceptional. Along with .the other skeletal muscles, those <>f the lower jaw participate in the spasm, it may be to such a degree as to clench a spoon or feeding vessel firmly between the teeth. The difference between the trismus of strychnine poisoning and that which accom- panies the tetanus of disease consists in the former being secondary to the spasms which affect the muscles of the limbs and trunk, whilst in tetanus it precedes the general spasms, in strychnine poisoning the muscles of the jaw are relaxed in the intervals between the attacks ; 544 FORENSIC MEDICINE. in tetanus the trismus persists during any mitigation of the general spasm. In fatal cases of strychnine poisoning death usually occurs within two or three hours, the patient being in his customary health previous to the commencement of the attack; tetanus is never so rapidly fatal : for several hours soreness and stiffness of the muscles of the face and neck precede the tetanic convulsions, and death rarely occurs within twenty-four hours, being usually delayed for several days. In exceptional cases a much longer interval than usual elapses between the reception of the poison into the stomach and the com- mencement of the symptoms, two hours and more have been known to intervene. When a narcotic has been simultaneously swallowed the interval may be still further prolonged. Macredy 1 reports a case in which a grain and a half of strychnine and two ounces of tincture of opium were taken ; the symptoms of strychnine poisoning did not appear until eight hours after, the opium producing narcosis in the meantime. The opposite extreme is illustrated in a case reported by Fegan :- a man sucked an egg which, for the purpose of killing vermin, had been charged with from two to three grains of strychnine ; symp- toms commenced in from four to five minutes, and death took place in one hour and a half. Hunter 3 records a case in which the first convulsion occurred within five minutes ; and Barker 4 one in which the symptoms began in from three minutes and a half to four minutes, after about six grains of strychnine were swallowed. The period of survival, after the commencement of the symptoms, is also subject to variation. In Barker's case above quoted death took place within thirty minutes ; in the case of Cook (Ren by the tip of the finger to the tongue, a characteristic bitter taste will be perceived unless the alkaloid is in very small amount and its bitterness is masked by the presence of some substance possessing a strong, pene- trating taste; this test should never be omitted when searching for alkaloids, and should precede chemical tests. A fragment of strychnine thoroughly mixed on a colour-slab with a couple of drops of strong sul- phuric acid undergoes no change of colour: if a few granul< manganese dioxide are then stirred in with the point of a irlass rod. a blue colour which rapidly becomes purple and more gradually changes to orange-red is produced. Lead peroxide, potassium dichromate, potassium permanganate, and other oxidising agents give the same reaction. Manganese dioxide is to be preferred on account of its slower action and freedom from any embarrassing intrinsic colour. On this ground eerie oxide has been recommended, as when pure it has little colour of its own; it is usually contaminated with didy- mium however which imparts a brownish-red hue almost as pr< as that of lead peroxide; eerie oxide is much slower in its action than any of the other reagents mentioned. A drop of a solution of am- monium vanadate in strong sulphuric acid (1:200) yields the same colour reactions as manganese dioxide. If a mixture of strychnine and sulphuric acid is placed on apiece of platinum foil connected with the anode of a voltaic couple, on touching the liquid with a platinum wire which forms the cathode the same colour reactions are produced as with manganese; by means of this, and the manganese test, the 1 Emige FaMe von Strychninvergiftung. Dissert., 1SS7. 2 Organic Analysis, 1^*7. 54S FORENSIC MEDICINE. merest trace of strychnine — -01 milligramme — may be identified. If strychnine is heated with dilute nitric acid, and a crystal of potassium chlorate is added, a scarlet colour is produced, which becomes brown on the addition of ammonia water. The physiological test may also be tried by injecting a few drops of a suspected solution into the dorsal lymph-sac of a small frog, and then placing it under a glass shade ; if the solution contains but a minute quantity of strychnine tetanic convulsions occur in a few minutes. After the convulsions have once occurred they may subsequently be provoked by rapping the shade, or the table on which the frog is placed. BRUCINE. Brucine [C 03 H 26 N o 4 ] is found associated with strychnine in nux vomica and in the Ignatius' bean. It is more soluble in water than strychnine ; is soluble in alcohol and in chloroform, but not in ether. It has a bitter taste like that of strychnine, and produces similar toxic effects, the potency of which has been variously estimated ; it has probably only about one twenty-fourth the physiological action of strychnine. Mays 1 states that with frogs the convulsions are later in coming on with brucine than with strychnine, and that even with a lethal dose they may be altogether wanting. Brucine, not being acces- sible to the public, is practically unknown as a poison. Symptoms and Treatment as in strychnine poisoning. Tests. — Nitric acid added to a fragment of brucine produces a bright blood-red colour which is destroyed by excess of stannous chloride If, after adding the nitric acid, the product is mixed with a little water and solution boiled, and then allowed to cool, the red colour is changed to purple on the addition of stannous chloride or of sodium thiosulphate. Ammonium sulphide produces a similar but less characteristic re- action ; if the reagent is in excess, free sulphur is precipitated. Sul- phomolybdic acid or Frohde's reagent [prepared by dissolving a little sodium molybdate in strong sulphuric acid with the aid of gentle heat] o-ives with a fragment of brucine a purple-red colour which changes to «reenish or blue. Sulphovanadic acid produces a yellow, changing to orange-red. A solution of ammonium selenate in strong sulphuric acid produces a pink changing to yellow. NUX VOMICA. The seeds of the Strychnos mix vomica are exceedingly hard and tough, and are too large to be swallowed whole unless with considerable 1 Journ. of Physiol, 18S7. COCCULUS INDICUS. 549 effort ; the powder, the extract, and the tincture of the seeds have pro- duced toxic effects resembling those of strychnine. The symptoms are usually longer in appearing than when strychnine is taken; in one case a man swallowed about five drachms of mix vomica and was not affected for two hours when he quickly died convulsed. Thirty grains of the powder and three grains of the extract have proved fatal. Stevenson 1 records the recovery of a boy of twelve after taking about eight grains of the extract; both strychnine and brucine were detected in the urine. COCCULUS INDICUS. Cocculus Indicus, or Levant nut, the fruit of the Anamirta cocculus, contains an active principle picrotoxin, along with other bases. Picrotoxin [C 12 H 14 6 ] is a colourless, neutral, crystalline body which does not form salts; it is not very soluble in water, but is freely soluble in alcohol, ether, and chloroform; it has an intensely hitter taste and is odourless. Picrotoxin acts as a gastro-intestinal irritant, and is a stimulant to the motor centres of the brain and cord. In small toxic doses it produces a tendency to stumble and reel — as in alcoholic intoxication — followed by stupor; in large doses it produces clonic spasms like those due to strychnine. Picrotoxin is eliminated in the urine. Fatal poisoning by cocculus indicus is exceptional, probably not more than a dozen instances are recorded. Sozinsky 2 relates the case of a man, aged thirty-nine, who drank by mistake several ounces of whisky in which cocculus indicus berries had been long steeping, the mixture being intended for killing vermin. When seen an hour after, he had vomited once; he was unconscious, and had powerful general convul- sions vwvy live minutes, each convulsion lasting about two minutes ; between the attacks there was complete muscular relaxation. Each convulsion commenced by twitching of the left corner of the month and a cry like that of an epileptic ; there was considerable opisthotonos; the pupils were contracted. The respirations were slow, the heart not being much affected; profuse perspiration and diarrhoea were present. Death took place in three hours from failure of respiration and from exhaustion. Shaw 3 records the case of a man who purchased, as he supposed, wild cherries, but which proved to be cocculus indicus berries; he put them into a bottle and filled it with brandy, and from time to time drank small doses without ill effect. One morning he drank a considerable quantity and felt dizzy and sick in consequence; 1 Guy's Hosp. Reps., 1S6S. 2 Med. News, Phil., 1SS3. 3 Ibid., 1S91. OOO FORENSIC MEDICINE. he produced vomiting by tickling his throat, but a few minutes after he fell on the floor in convulsions and became unconscious ; the con- vulsions continued for thirty minutes when death took place. At the necropsy nothing abnormal was found except congestion in patches of the mucous membrane of the stomach. Recovery has taken place even after very threatening symptoms. Dutzmann 1 records the case of a man, aged sixty, who crushed some of the berries and swallowed a handful ; half an hour after he fell to the ground, vomited, perspired profusely, and was unconscious. The temperature was elevated, the pupils normal in size but reactionless, the pulse 80 and full, and the respirations laboured and quickened. He then had convulsions which were attended with foaming at the mouth and cyanosis ; the pulse rose to 110. Recovery took place, but pain and oppression in the chest were felt for some days. Death has taken place in consequence of the external application of the poison. Thompson ' 2 states that a child, aged six, who had porrigo of the scalp and was infected with vermin, was treated externally with an alcoholic solution prepared by infusing one pound of cocculus indicus berries in three gallons of alcohol. Half an hour after tetanic spasms came on, during which the pupils contracted to the smallest size, dilating in the intervals between the spasms ; the spasms could be produced by touching the eyelid ; they continued for six hours when the patient died. The necropsy yielded negative results. Another child to whom a similar application was made also had clonic spasms but she recovered. In all these cases the convulsive action of the poison completely eclipsed any gastro-enteric symptoms that might be present ; in many ways the effects closely resembled those of strych- nine, even to the reflex excitation of the spasms ; they correspond to the action of picrotoxin experimentally produced on animals. A minor degree of poisoning by cocculus indicus, called "hocussing," has occurred from its surreptitious administration in admixture with alcohol in order to produce a helpless condition of stupor favourable to the perpetration of robbery from the person. Formerly low-class publicans sometimes added small quantities of cocculus indicus to beer in order to increase the intoxicating effects of the beverage, and thus obtain for it a fictitious reputation for alcoholic potency. Treatment. — Evacuate the stomach by the tube or an emetic. If clonic spasms are present chloral hydrate may be given, or chloroform administered as in strychnine-poisoning. Artificial respiration may be necessai-y. In the minor degree of poisoning evacuation of the stomach with symptomatic treatment will probably be sufficient. Chemical Analysis. — Picrotoxin may be shaken out of acid solution by ether or chloroform. 1 Wiener med. Presse, 1S69. 2 Med. Examiner, Phil, 1852. OPIUM AND ITS ALKALOIDS. 551 Tests. — Picrotoxin is not precipitated by phosphomolybdic acid, nor by a solution of iodine. It is dissolved by < -oncentrated sulphuric acid, producing a yellow colour which changes bo black on heating. It' pic- rotoxin is mixed with three times its weight of potassium nitrate, and the mixture is moistened with a few drops of sulphuric acid, and thru excess of a strong solution of sodium hydrate is added a brick-red colour is produced. Picrotoxin reduces Folding's solution. OPIUM AND ITS ALKALOIDS. Opium. — The inspissated juice of the pa/pa/oer 8on t ins a large number of alkaloids and alkaloidal substances, several of which 5 powerful toxic properties. Morphine is the alkaloid to which opium owes its potency as a poison; next in importance come narcotine and codeine, which act as hypnotics but are much less powerful than morphine. Thebaine, another alkaloid, and apomorphine, a derivative oi* morphine, act in a totally different way: the first is a convulsive and the second an emetic. With the exception of morphine the alkaloids of opium rarely come under the notice of the toxicologist ; but one other substance — Meconic acid — on account of its constant presence in opium and its characteristic reactions is frequently sought for. Of the preparations containing opium, which most frequently cause death from accidental, suicidal, or homicidal administration, some are official and some not. The former class comprises : — Tincture of opium or laudanum which contains one grain of opium in fifteen minims. Compound tincture of camphor or paregoric which contains one grain of opium in half an ounce. Compound ipecacuanha powder or Dover's powder which contains one grain of opium in ten of the powder. Of the non-official preparations of opium which come under the observation of the medical jurist from time to time are: — Napenthe, which is of the same strength as laudanum ; Dalby's carminative, which contains about two and a half minims of tincture of opium to the iluid ounce ; Atkin- son's infant's preserver, which contains three minims of tincture of opium to the tluid ounce; Godfrey's cordial, which contains from half a grain to a grain and a half of opium to the ounce. The three last named are frequently given to infants with fatal result, although usually without homicidal intention. So-called syrup of poppies not unfrequently contain laudanum. Chlorodyne contains about tour grains of morphine hydrochlorate to the ounce. Morphine [C^H^iS^] is a colourless crystalline substance, slightly soluble in cold water, more soluble in hot water and in ethyl alcohol, and freely soluble in amy] alcohol, especially when hot j it is also very soluble in acetic ether; in ethylic ether and chloroform it is but feebly 552 FORENSIC MEDICINE. soluble. The salts of morphine are freely soluble in water and spirit. Morphine has a bitter taste, and an alkaline reaction. Acute Poisoning by Opium and Morphine. Symptoms. — Excitation of the higher nerve-centres is the first result of the reception of a poisonous dose of opium or of morphine ; with opium it occurs in from half an hour to an hour after the dose is swallowed ; with a salt of morphine in solution the interval is less — from a few minutes to a quarter of an hour. The excitation may show itself by producing accelerated action of the heart, flushing of the face, and a feeling of increased mental activity accompanied by exhilaration of spirits, or it may simply cause physical restlessness ; its duration is short, and it is succeeded by an opposite condition of depression of the nerve-centres. A sensation of lassitude, oppression in the head, giddi- ness, and a strong desire to sleep steal over the patient, who becomes, more and more drowsy and less capable of responding to external stimuli ; before this stage is reached the pupil s are contracted ; the stupor subsequently deepens into profound coma. In the earlier stages of insensibility the patient may be partially roused by being shaken and loudly spoken to ; when the comato se condition is reached no external stimulus evokes any response. The muscles are relaxed, the surface is cold and moist, the features are shrunk and pallid, or cyanotic, the pupils are exceedingly contracted, the pulse is slow and compressible, and the breathing is laboured, irregular, and stertorous ; although the patient now presents all the appearance of a dying person, recovery may take place. If the case goes on to a fatal issue, the breathing becomes more embarrassed and may assume the Cheyne-Stoke's type;, mucous rales are heard, the pulse becomes more irregular and scarcely to be felt, the cyanosis deepens, and the face looks even more ghastly, the jaw drops, and but for the hard-drawn breaths, the appearance is that of a corpse. Twitching of groups of muscles is often observed, and at this final stage the pupils may be dilated — death is then imminent. The heart may continue to beat for a short time after respiration has ceased. Certain other symptoms may be present. If opium or the tincture has been taken its odour may be perceived in the breath. Vomiting may occur, and very exceptionally relaxation of the bowels ; almost invariably an opposite condition of constipation obtains. The urine and the saliva are suppressed in the later stages ; sometimes the urine is simply retained from paralysis of the bladder ; but the excessive per- spiration leaves little for the kidneys to do so that in any case the quantity of urine is lessened, although from accumulation the bladder ACUTE IOISONING BY OPIUM AND MORPHINE. may be full. The only secretion which is not diminished is the sweat , and this is usually increased from first to last. Amongsl symptoms of an • xceptional character are — dilatation of the pupils in the earlier stage, apart from thai which may occur immedi- ately before death; acceleration of the pulse, which has been known to alternate with, or to replace, the usual slow pulse; or con- vulsions of a tetanic character, which are less infrequent in the ease of children than in adults. The action of opium on the cerebral cort< : to increase its motor irritability ; this, so far as the evidence afforded by faradic stimulation goes lias been proved by CJnverricht. 1 Dired stimulation of the cortex, which under normal conditions would determine the occurrence of simple motor impulses, liberates them so freely when it is under the influence of opium as to give rise to convulsive move- ments; the condition produced by opium is the opposite of that due to ether, chloroform, and chloral hydrate, by which the cortical irrita- bility is lowered. In children the nerve-cells have not acquired their full self-inhibitory capacity, hence it is easily broken down during a state of increased irritability; in adults opium poisoning accompanied by trismus and general, spasms of a clonic, strychnine-like character, an extremely rare occurrence. In very exceptional instances morphine produces profound coma within a few minutes after it is swallowed, followed by death in forty minutes or an hour; in other exceptional cases the advent of the symptoms is delayed for two or even three hours, and death may aol take place for more than twenty-four hours. The interval between the reception of the poison and death usually ranges from six to tw hours. A noteworthy condition has been observed in severe cases of opium poisoning: partial recovery from the urgenl symptoms has taken pi to such a degree as to remove all apprehension, and then, after several hours' interval, the patient has relapsed into coma and died ; as suggested by von Boeck- it is probable that renewed absorption of the poison takes place under the influence of increased blood-pressure. lw Other instances patients who recover from the immediate symptoms succumb after a much longer interval, possibly of several days; in such cas cardiac disease probably has as much to do with the 1'atal issue as the poison. When recovery takes place it is, as a rule, complete, but in rare instances sequehe have been recorded. Albuminuria was presenl on the third day after the acute symptoms in a case recorded by < >livier, a and at about the same period in a case recorded by Huber. 4 A unique case is reported by Scheiber 5 in which acute poisoning produced by 1 Centralbl.f. klin. Med., 1S91, 1S92. 2 Ziemssen's Cyclop., Bd. 17. 3 Oaz. des Hdpitaux, 1871. * Zei(sc':r.f. /-.'"». Me '.. I'M'. 5 Ibid., 1SSS. 554 FORENSIC MEDICINE. the subcutaneous injection of morphine was followed by psychical dis- turbance, aphasia, and by the formation of bed-sores. Fatal Dose — Adults. — FourJ grains of opium in one case and two drachms of the tincture in another proved fatal. Recovery has taken place after three ounces of the tincture, equal to ninety-nine grains of opium (Burgess 1 ), and as recorded by Bowstead, 2 even after eight ounces of laudanum were swallowed by a woman, aged thirty-eight, who was not discovered for fourteen hours after she took the poison. One grain of morphine hydrochlorate has caused death ; recovery has taken place after thirty, thirty-six, and in one instance fifty-one grains, the greater part of which remained in the stomach thirteen hours (Morse). Disease of the kidneys, especially cirrhotic kidney, predisposes to a fatal issue from opium or morphine. Infants. — It is well known that infants are susceptible to the in- fluence of opium to an extraordinary degree ; on more than one occa- sion a single drop of laudanum has been recorded as fatal. A dose of paregoric equal to the ninetieth of a grain of opium, and in another •case a dose of Dalby's calminative equal to half a minim of laudanum, are stated to have caused death ; as regards such very minute doses as the last two named, there is reasonable ground for doubt, since the preparations concerned are made from crude opium, containing an un- known percentage of morphine. Recovery in an infant three months •old is recorded by Brain well, 3 after a teaspoonful of laudanum (vomiting occurring soon after it was swallowed). Chamberlain 4 witnessed the recovery of an infant six days old, which had swallowed a powder con- taining a grain and a half of opium ; two hours afterwards it was apparently dead, breathing having ceased ; artificial respiration was kept up for three hours, and in twenty-four hours the child was quite well. Morgan 5 saw an infant, one month old, which was comatose after three drops of laudanum, and the breathing gradually ceased; artifi- cial respiration was kept up almost continuously for three hours, and recovery took place after complete unconsciousness had lasted for forty- five hours. Preparations of opium have caused death from external application, but probably not without the skin being broken. Morphine sprinkled on an open sore has proved fatal. Treatment. — If the poison was swallowed the stomach-pump should be used, and the stomach well washed out ; in defiiult, an emetic may be administered by the mouth, or apomorphine may be injected sub- cutaneously. Persevering attempts are to be made to rouse the patient i Dublin Journ. of Med. 8c, 1S92. - The Lancet, 1S73. 3 Boston Med. Journ., 1SS7. 4 The Lancet, 1889. 5 Boston Journa 7 , 1S5S. V ^ ACUTE POISONING BY OPIUM AND MORPHINE. by exter nal sti mulation ; the faradic current, applied to various parts of the body with a wire brush, is an efficacious stimulant ; walking the patient to and fro between two assistants may be resorted to, but only in the less severe forms of poisoning. When the coma is profound, artific ia l respirat ion maybe needed; this constitutes a most va aid to recovery ; it may be supplemented by faradic stimulation of the phrenics. Ammonia may be applied to the nostrils in the form of smelling-salts; the vapour of ammonia-water should not be used, it is too irritating to the respiratory mucous membrane. Hot coffee may be given by the mouth if the patient can swallow; if not it may be administered by the stomach-pump or as an enema. One-twentieth of a grain of atropine sulphate, injected hypoderrnically, and repeated if necessary, is recommended for the purpose of stimulating the res- piratory centres, but its utility is doubtful, notwithstanding the number of successful cases in which it has been used. (See section on Antagonism of Poisons.) Hypodermic injections of ether are efficacious. Strychnine is strongly advocated by some. Lucatello 1 had a case in which a patient swallowed about forty-five grains of opium and twenty- two grains of morphine sulphate on an empty stomach. Symptoms did not appear for an hour. Breathing having nearly ceased, artificial respiration, with faradisation of the phrenics, were resorted to, but without effect; under the influence of hypodermic injections of strych- nine respiration was resumed. In cases which are not very severe, the cold douche and perambu- lating the patient may be sufficient, but the former should never be used when the surface is cold, nor should the latter be carried to excess, so as to exhaust the strength. In severe cases it is icorse than useless to dray a comatose individual about. Post-mortem Appearances.— Apart from discovery of the poison in the body, the post-mortem indications are not characteristic. When opium itself has been swallowed, its odour may be perceptiUe in the stomach; if the organ has been well washed out with the tube, or cleared with emetics, or if morphine was the poison, this indication will be absent. Injection of the gastric mucous membrane has been described; it is by no means constant, and, when present, is probably due to the treatment more than the poison. Hyperemia of the brain and its membranes is not unfrequent, and in addition there may be oedema into the subarachnoid space and (he ventricles. The amount of blood present in the lungs varies ; they may or may not present the appearance regarded as due to death from asphyxia. The blood has been found dark and fluid; it has also been found coagulated. Chemical Analysis.— The difficulty which attends the isolation of 1 Rivista Italiana, 1SSS. 556 FORENSIC MEDICINE. morphine from the organs and tissues of those poisoned by it has led to the supposition that it undergoes decomposition in the living organism. A number of researches have been made with the object of ascertaining what becomes of the alkaloid after its administration. Some investigators state that it is eliminated as such in both urine and fasces ; others have failed to find it in the urine, but have detected it in the fasces ; others again have found oxidation products — as oxi- dimorphine — in the urine, and hold that morphine is entirely changed in passing through the body. When the delicacy and the distinctiveness of some of the reactions of morphine are taken into consideration, the undoubted difficulties that surround its detection in the organs of those who have succumbed to its influence requires explanation. Neglecting for the moment the question of decomposition of morphine within the organism, there are one or two errors of procedure which may prevent its recognition. (One is excess of acid, especially after concentration, in the fluid used to extract the alkaloid from organic admixture ; another is the use of too high a temperature for the purpose of evaporating the solution obtained ; when these two adverse conditions are combined, the pro- bability is that small amounts of morphine which originally may be present will be decomposed and rendered incapable of recognition by the usual tests. Further, delay in shaking out after alkalisation, and the use of an inappropriate solvent, such as ether, impedes or prevents extraction ; if the aqueous solution is over alkalised with sodium or potassium hydrate (which are sometimes used), morphine is redissolved, and, if present only in minute amount, can not be shaken out by any solvent. The only solvents that can be depended upon to take up morphine from neutral or slightly alkaline aqueous solutions are : — amyl alcohol (preferably hot) and acetic ether. As a solvent the former is un- doubtedly the best, but it is disagreeable to work with, its evaporation demands a relatively high temperature, and, as met with in com- merce, it is liable to contain resinous substances which may vitiate the results. Udranszky l attributes the formation of coloured and resinous products in amyl alcohol to the presence of furfural, from which the alcohol can be purified, but the process is troublesome. The solvent action of amyl alcohol on urea and extractives constitutes a further objection. "Wormley 2 found that although amyl alcohol is nearly insoluble in water, 100 volumes of it agitated with water measure 109 after the liquids have separated. He also found that amyl alcohol dissolves a certain amount of the salts of morphine from aqueous solution, but that the amount is diminished if the alcohol is previously iZeitschr.f. physiol. Chemie., 1889. 2 The Chemical News, 1890. TESTS FOR OPIUM AND MOttPHINE. 557 saturated with water ; the acetate is taken up more freely than the sulphate or the hydrochlorate. As the result of a number of experi- ments, in which morphine was successfully extracted from urine with hot amyl alcohol, Wormley states that the presence of urea constitutes an almost insuperable difficulty as regards purification of the alkaloid. Acetic ether is not free from objections; it is soluble in water to a considerable extent (1 in 10), and dissolves extractives freely. The most convenient solvent consists of a mixture of e^ual parts of aceti c and ethylic ethers, well washed by being shaken with water. Alkalisa- tion with sodium bicarbonate (excess of which does not ^dissolve morphine) should be effected in the presence of the solvent, and extrac- tion accomplished without delay ; if time is allowed for the precipitated alkaloid to become crystalline, it is much more resistant to the action of all solvents. Tests. — A drop of strong nitric acid added to a fragment of morphine produces an orange-red colour. If a little of the alkaloid is dissolved in concentrated sulphuric acid and allowed to stand for fifteen to eighteen hours, and then treated with nitric acid, a blue violet colour, which changes to blood-red, is produced (Husemann). Sulphoinolybdic acid (see tests for Brucine) produces a reddish purple, which changes to blue ; this and the previous test are the most delicate and conclusive for morphine ; they will react to -01 milligramme. It is important to note that the initial colour-change is the one that is distinctive ; the subsequent changes are common to several alkaloids. If a fragment of morphine is mixed with a couple of drops of strong sulphuric acid no coloration, or but the faintest pink, is produced; the addition of a little ammonium selenate develops a pale yellow, which changes to light green, sap-green, and brown. A small crystal of potassium dichromate, added to morphine and sulphuric acid, yields a green colour. If a little iodic acid is dissolved in a cubic centimetre of water in a test-tube, and an equal volume of carbon bisulphide is added, agitation produces in it no change of colour ; the addition of a drop or two of a solution containing morphine liberates iodine from the iodic acid, and on gentle agitation the carbon bisulphide becomes pink or rose-red. A drop or two of a solution of ferric chloride added to a solution of a salt of morphine produces a blue colour ; it' the reagent is in excess, the colour will be green; with morphine meconate this t est produces a dark re d— the reaction of meconic acid, which displaces the blue of the morphine. Meconic Acid may be tested for when the presence of opium, in which it exists in combination with morphine, is Buspected As just stated, it gives a red colour with ferric chloride; the colour is not destroyed by mercuric chloride. With meconic acid lead acetate gives a white precipitate which is soluble in nitric acid. 558 FORENSIC MEDICINE. Elimination of morphine to a great extent takes place by the bowels, to a lessor extent by the kidneys ; some experiments made by Alt l at the instigation of Hitzig show, in a striking way, the part played by the stomach in the process of elimination. A subcutaneous injection of morphine was given to a dog ; in about four minutes after, the animal vomited, and the vomited matter was found to contain morphine. Further experiments show that, soon after morphine is subcutaneously introduced into the system, its elimination is commenced by the gastric mucous membrane even when the stomach is empty, and is continued until at least half of the dose injected is thus removed from the circu- lation, and is eventually voided with the fieces ; a portion of the alkaloid is said to be excreted in the bile. In some experiments of my own, conducted with the excretions from patients taking large medicinal doses of morphine, the alkaloid could always be detected in the faeces and occasionally in the urine ; it is exceedingly difficult, however, to obtain morphine in the crystalline form, either from the tissues or the excretions of those who have been subjected to its influence. Rosen- thal 2 finds that morphine is eliminated in the saliva, and also that it may to some extent accumulate in the system. The question of the decomposition of morphine in the organism must be regarded as undetermined. It is not improbable that a portion of the quantity taken may be changed into oxidimorphine, or some other derivative or combination of the alkaloid. For a chronological account of investigations on the subject, see Tauber: 3 " Ueber des Schicksal des Morphins im thierischen Organismus." Chronic Poisoning by Opium and Morphine. The habitual use of opium in gradually increasing doses produces an extraordinary degree of tolerance towards it ; the practice of this habit is known as opium- eating or morphinism. It is frequently originated by the legitimate use of opium to relieve pain, and is afterwards continued on account of the agreeable sensations it pro- duces, and to banish the feeling of depression which is experienced as soon as the effects of the drug pass off. A morphine habitue quickly loses his moral perception, and will descend to the lowest level of unblushing deceit in order to satisfy his cravings ; when fully under the influence of the habit his moral fibre is disintegrated in all directions ; ethically he is a coward, and avoids all methodic mental effort ; if taxed with taking opium or morphine, he will deny the imputation with an earnestness and apparent sincerity that would 1 Berliner hlin, Wochenschr., 1SS9. - Centralbl. f. Min. Med., 1S93. 3 Arch. f. exp. Path. u. Pharm., 1S90. BELLADONNA AND ATROPINE. convince any one unacquainted with the fuels. Physical symptoms develop after a time: visceral ne uroses are evinced by the recurrent of violent pains in the region of the stomach and abdome n, which might be mistaken for those due to the passage of gall-stones; attacks of vomiting resembling gastric crises occur, ami the bowels D relaxed from time to time. The a ppetite is capricious stive ; considerable — sometimes excessive — emaciation takes place, and the patient looks shrunken and pallid in the face, like one suffering from malignant disease. Later, symptoms resemblin g those due to pheral n euritis develop: as paresthesia?, neuralgias, trembling ol hands and ataxic gait, with numbness of the feet and tips of the fingers. The introduction of the hypodermic syringe has placed a convenient mode of self-administration of morphine within the reach of disposed to make use of it. When the rapidity with which the \ is brought under the influence of morphine injected subcutaneously is taken into consideration, the enormous doses that can be tolerated without producing the usual toxic effects are very astonishing. Stuart x records a case in which forty grains of morphine acetate were injected daily for months ; even this amount has been exceeded. The best treatment is to cut off the supply at once. This demands either great resolution on the part of the patient, or the bringing to bear of very powerful moral control on the part of a second person (which is seldom available), or, lastly, physical restraint. Conditions may exist which render a gradual deprivation necessary, but the process is tedious and uncertain. When there appears to be danger of collapse from sudden total deprivation, Erlenmeyer 2 advocates rapid withdrawal of the drug in from six to twelve days. Unless there is some very cogent reason for doing so, it is better not to carry out " treatment " by substituting some other drug for morphine. During and after the cure the patient must be restrained from the abuse of alcohol, otherwise an interchange of habits may occur. BELLADONNA AND ATROPINE. Atropa Belladonna (natural order Sol orthedeadlj nightshade contains the alkaloid atropine to which it owes its toxic effects. Poison- ing by belladonna occurs either from the improper use of one of the medicinal preparations of the drug, or from eating the berries in the fresh state. Atropine [C-H....XO.,] is a colourless crystalline substance with a 1 Brit. Med. Journ., 1889. - Die Morphiumsucht und ihrc Bchandlung, lbST. 500 FORENSIC MEDICINE. strong alkaline reaction. It is odourless, sparingly soluble in water but more so than most alkaloids ; it is much more soluble in ether, .still more so in spirit, and most of all in chloroform. The mydriatic alkaloids atropine, daturine (datura stramonium), hyoscyamine, and hyoscine (hyoscyamus niger), duboisine (duboisia myoporoides) are all isomeric and probably convertible. Atropine can be split up into tropic- acid and tropine, the latter being capable of forming combinations with other acids. For the physiological action of atropine see p. .391. Elimination rapidly takes place by the kidneys ; Dragendorff states that atropine will probably only be found in the urine which is first excreted after the reception of the poison. Symptoms. — The essential symptoms respectively produced by the plant, and the alkaloid are identical, but when portions of the plant — as the berries--— are eaten nausea, vomiting, and other signs of gastric irritation may be superadded. A hot, dry sensation, accom- panied by a feeling of constriction, is experienced in the throat, accompanied by thirst ; the saliva is inspissated, and the tongue dry ; swallowing is difficult or impossible. The pupils are dilated, usually to the uttermost, leaving only a narrow ring of the iris visible ; they are insensitive to light ; the conjunctivae are suffused. The pulse, accelerated to 120 or 160 in the minute, is small and some- times scarcely to be felt at the wrist. The skin, often covered with a scarlatina-like rash, which may be followed by desquamation of the epiderm, is hot and dry in the earlier stage, but may become cold during the stage of collapse. Alternate flushing and pallor of the face have been observed. In the early stage the patient complains of dizziness, indistinctness of vision — sometimes of diplopia ; later on there may be complete loss of vision ; he is unable to walk, and reels or stumbles on attempting to do so. Active delirium comes on which often partakes o f the imitat ive type ; the patient will industriously perform a series of movements resembling those of a person employed in sewing with needle and thread, or he will tear off strips from an imaginary piece of cloth ; in a case of poisoning by belladonna berries the patient imitated the acts of plucking fruit from a tree, conveying it to his mouth, and then swallowing it. These imitative acts are some- times performed with such gravity and persistency as to excite the risibility even of anxious friends who witness them. Hallucinations of sight are common, as may be gathered from the description of the mimic actions ; sometimes the patient in the attempt to escape an imaginary danger will try to jump out of the window, or to rush through the door. The voice is stammering and the utterances are in- coherent, but the patient is often extremely loquacious, intermitting BELLADONNA AND ATROPINE. 501 his loquacity with wild peals of laughter, or vociferous shouting. Twitching of the muscles of the face and limbs often occurs and may go on to tonic or clonic spasms affecting the en1 in • body, which to Bome degree appear to be reflex in character ; in a case recorded by Oliver 1 they were aggravated by the passage of the stomach tube and by the withdrawal of the contents of the stomach. Sensory disturbances such as numbness of tic fingers may be present. The urinary bladder and the intestines are usually paralysed. In severe cases total insensibility with cold surface may supervene and last for many hours; on awakening delirium has been known to recur. If the case is about to be fatal the insensibility increases ; there may be recurrent convulsions or simply progressively deepening coma. Death from paralysis of the heart and lungs occurs in from six to twenty-four o r more hours. "When recovery takes place it is slow ; several days elapse before the whole of the symptoms subside. The pupils continue dilated and only very gradually return to their normal size; accommodation may be defective for some time, and the memory is often enfeebled for three or four days, an aphasic condition existing in the meanwhile. Fatal Dose. — One drachm of belladonna liniment, which was swal- lowed, and the same amount of the extract have respectively proved fatal. Recovery has taken place after a tablespoonful of the liniment was swallowed, and in another case after half an ounce of the extract mixed with glycerine. Fourteen bell adonna berries caused the death of an old man ; recovery has taken place after fifty. Children are less susceptible to the toxic action of belladonna than adults ; recovery has followed in children after thirteen berries and even after thirty. Bella- donna applied externally as a plaster or in the form of extract has often produced toxic effects. Two grains of atropine have been fatal; severe symptoms have been caused by a quarter of a grain. In one case recovery followed three and a half grains of atropine sulphate, and in another live and a half grains. A child two and a half years old recovered from one quarter of a grain of atropine. Alarming and typical symptoms of poisoning have not unfrequently occurred after the instillation of a solution of atropine into the eyes for the purpose of dilating the pupils. Death has been caused by the application of atropine ointment to a blistered surface. Although atropine is not often used criminally, a few cases of homicidal poisoning have occurred; one took place near Manchester, and was the subject of judicial inquiry at the Assizes held there in 1872 {Reg. v. Steele). The resident surgeon at a workhouse died from 1 The Lancet, 1S91. 3G 5G2 FORENSIC MEDICINE. atropine poisoning, the alkaloid being detected in his body. He be- came ill after breakfast with typical symptoms and died in about twelve hours ; the poison had been added to some milk used at breakfast, ■which produced toxic symptoms in two other people who tasted it. A nurse, who it was alleged had a strong motive and the opportunity for committing the crime, was charged with the murder but was acquitted. A curious case of belladonna poisoning is recorded by Bachner. 1 A man became ill after eating some soup prepared by his wife. When seen by a doctor he was flushed in the face, the eyes were bright and slightly bloodshot, the pupils were dilated and insensitive to light, the tongue was dry and covered with sticky saliva, the speech was stammer- ing, the fingers trembling, the hands swollen and the limbs cold. The patient complained of dizziness, singing in the ears, heaviness and heat in the head, indistinct vision, thirst, vomiting, and partial retention of urine. He recovered, and on judicial investigation it was found that he himself had added some belladonna seeds to the soup in order to accuse his wife of attempting to poison him. Treatment. — When the poison has been swallowed the stomach- pump should be used and the stomach well washed out ; if the apparatus is not at hand an emetic must be given, after which stimulants and hot coffee are useful. Strong, stewed tea, or an infusion of tannic acid, helps to precipitate and render innocuous any of the poison which may remain in the stomach. Douching of the burning, dry surface in the early stage, and artificial respiration in the stage of collapse are to be resorted to. Hypodermic injections of pilocarpine (one- third or half a grain of the nitrate or hydrochlorate) tend to slow the pulse, tranquil- lise the respirations, and relieve the spasms if they are present. In default of pilocarpine a hypodermic injection of morphine may be given. Binz 2 directs attention to the tolerance of morphine exhibited by cases of atropine poisoning, and instances this as being in favour of the antagonism of the two poisons. Post-mortem Appearances. — In the absence of fragments of some parts of the plant there is no characteristic appearance in belladonna poisoning. If the berries have been eaten there may be signs of reddening of the mucous membrane of the stomach ; the seeds should be carefully sought for in the stomach and intestines. The blood has sometimes been recorded as dark and fluid, with hyperemia of the cerebral vessels, but such signs are of little value. The pupils usually remain dilated after death. Chemical Analysis. — Any seeds or fragments of leaves found in the stomach should be examined under the microscope. The seeds are 1 Friedreich 's Blatter/, ger. Med., 1887. 2 Cenird'-l.f. Miv. Med., 1893. BELLADONNA AND ATROPINE. 563 small, ovoid or kidney-shaped, and are covered with small project which, under a low power, present a honeycombed appearan ce. The fresh berries are blackish-purple in colour, and their juice stai white surface purple; the mucous membrane of the stomach has some- times been found thus stained. The addition of an alkali changes the purple to green; acids change it to red. Atropine may be extracted from organic matter by the usual pro- cess; like morphine, it is soluble in excess of potassium and sodium hydrate; it is very prone to undergo hydrolysis, especially in the presence of free alkalies. The evaporation of a solution containing atropine should be conducted at a temperature not exceedi: ig 35 C, and excess of acid avoided. A mixture of three volumes of ether and one of chloroform is the best solvent for extracting the alkaloid from an aqueous solution. Tests. — The chemical tests for atropine do not of themselves . I conclusive proof of the presence of the alkaloid ; they give place to the physiological test, and are to be regarded only as corroborate it. Alone among the ordinary fixed alkaloids free atropine reddens phenolphthalein ; a minute fragment placed on phenolphthalein paper and moistened with a drop of water causes the paper to become red; if alcohol is dropped on to the stain, the colour disappears, but returns when the alcohol has evaporated ; the reddening of phenolphthalein paper by alkalies is not affected by alcohol. With a little atropine mix two or three drops of strong nitric acid and evaporate to dryness over a water-bath; add to the yellow-coloured residue a few drops of alcoholic solution of potash — a reddish-violet or purple colour is pro- duced. A fragment of atropine yields a yellow colour with sodium nitrite and strong sulphuric acid, which changes on the addition of alcoholic potash to reddish-violet, fading to pale rose. Physiological Test. — After proving the presence of an alkaloid by means of one of the alkaloidal group reagents, a drop or two of a neutral aqueous solution prepared from the ether-chloroform extract should be instilled into the eye of a cat, or preferably a kitten; if atropine is present in only infinitesimal -'001 mgrm. — the pupil is dilated in from a few minutes to an hour, according to the amount present. The test may be repeated on the eye of a human being. Cocaine also dilates the pupils when dropped into the eye, but a much stronger solution is required, and ansesthesia i-> also pro- duced. The above reactions, chemical and physiological, are yielded by all the tropines. Dragendorff detected atropine after it had been mixed with organic matter, which was then allowed to remain in a warm room two and a half months, until it was quite putrid. 564 FORENSIC MEDICINE. HENBANE. Hyoscyamus Niger, or henbane, contains two basic substances — hyoscyamine and hyoscine— which are isomeric -with atropine. The fresh plant has a disagreeable odour ; its juice, when dropped into the eye, dilates the pupils. Hyoscyamine [C ir H 23 N0 3 ], with which hyoscine is isomeric, is obtained from several atropaceous plants ; it is convertible into atro- pine. Hyoscyamine is a colourless crystalline substance, without odour, moderately soluble in water, and freely soluble in spirit, ether, and chloroform. It has art alkaline reaction, and combines with acids to form salts. Symptoms. — In many respects the symptoms produced by hyoscyamus are identical with those of belladonna, certain differences, however, have been observed. The face is flushed, the surface is hot and dry, the mouth and throat are parched, the pupils are enlarged and insensitive to light, vision is impaired, the pulse is quick and small, the respira- tions are of a sighing character, and in the early stage there is delirium. It has been noticed in cases of poisoning by hyoscine that the tendency to busy, wild delirium is not so great as with atropine. Trismus and clonic spasms of the muscles of the jaw and limbs have been observed. In the later stages the patient is comatose and collapsed ; there is greater tendency to sleep and insensibility with hyoscyamine, and more : especially with hyoscine, than with atropine. Recovery is slow, as is the case with belladonna poisoning. The fatal dose of henbane is not known ; recovery has taken place after six drachms of the tincture were swallowed. Death followed one-eighth of a grain of hyoscyamine swallowed along with the same quantity of morphine sulphate. A hypodermic injection of one-thirtieth of a grain of hyoscine in one case, and the swallowing of about one- fortieth of a grain in another, produced severe symptoms of poisoning, followed by recovery. Some non-fatal cases of poisoning recently occurred through the accidental admixture of henbane seeds with celery seeds, for which they were purchased. Treatment. — As in poisoning with belladonna. The Post-mortem Appearances are not characteristic. Chemical Analysis. — The alkaloid may be isolated by the usual pro- cess, and submitted to the same tests as those described for atropine. STRAMONIUM. Datura Stramonium, or thorn-apple, is another solanaceous plant which yields an alkaloid or alkaloids, that act in much the same way as those STRAMONIUM. 5G5 of belladonna and henbane. All parts of the plant are poisonous. The seeds are dark-coloured and kidney- shaped ; they are about one-eighth of an inch in length, and have a rough surface. Daturine is an isomer of atropine. According to Ladenburg the kind known as "light daturine" consists principally of hyoscyamine. Symptoms. — The following case related by Steiner 1 illustrates the toxic action of stramonium. A man aged forty-five drank a decoction prepared by boiling the leaves and fruit of the datura stramonium, to relieve pain in bis chest. About three-quarters of an hour afterwards he sprang out of bed and ran about the room, looking into all the corners like a person bereft of reason ; he was put to bed by force and held there as he made violent efforts to escape, being all the while un- conscious. The face was red ; the pupils were widely dilated and did not react to light; the limbs moved spasmodically ; the pulse, which intermitted, was 130 in the minute; the respirations were deep and quickened ; the skin was dry, and the temperature 9G°-J F. Swallow- ing was difficult ; cutaneous sensibility was abolished ; the abdomen was distended but not painful on pressure. The patient subsequently lay quiet and became comatose, the redness of the face changing to pallor ; the respirations became quieter and slower, and the pulse sank to 120. The patient appeared to be dying, but shortly after began to improve and gradually recovered, weakness and trembling of the limbs persisting for a week. A man swallowed a teaspoonful of Himrod's asthma-specific which is intended for inhalation. Many of the symp- toms of stramonium poisoning occurred, but the pulse was very slow. only twenty-five to the minute. Recovery took place. The remedy contains stramonium with probably lobelia and jDotassiuin nitrate. The fatal dose is not known. About one hundred seeds, and seven- teen or eighteen grains of the extract, have caused death. Death has occurred in seven, and in twenty-four hours. Treatment. — As in poisoning with belladonna. The Post-mortem Appearances are not characteristic. Chemical Analysis. — After isolation and proof of the presence of an alkaloid, its physiological effect should be tested as with atropine ; the same chemical tests may also be used. The tropines, ■ respectively derived from belladonna, henbane, and stramonium being isomeric, and possessing the same chemical pro- perties, indentification of the group, one of which was the poison administered, is all that can be accomplished in a toxicological in- vestigation; there is no reliable test by which one of these alkaloids, in minute quantity, can be distinguished from another. i Berliner Jdin. WochaiscJir., 1SS7. 566 FORENSIC MEDICINE. Duboisine, obtained from the leaves of the duboisia myoporoides, is another isomer of atropine. It is considered by some to be identical with hyoscyamine; Ladenburg believes it to be identical with hyoscine. It is a powerful mydriatic, and produces symptoms like those of atropine. A case is recorded by Chadwick 1 in which one-hundredth of a grain i >f duboisine sulphate, dropped into the eyes of an old man, produced dizziness, weakness, and loss of control of the legs, dryness, with bitter taste in the mouth, huskiness and indistinctness of speech, visual hallu- cinations — the patient grasping at imaginary objects in the air, and glancing suspiciously under the bed clothes and behind his back — slow pulse, and a copious flow of words without relevancy. Kollock 2 relates an almost parallel case caused by the instillation of two drops of a solution of duboisine sulphate (one grain to two drachms) into the eyes. The face was flushed, the pupils dilated, the patient was dizzy and moved himself from side to side ; though ap- parently rational he made remarks devoid of meaning and relevancy, and was unconscious of all that had occurred whilst in this condition. The treatment is the same as for atropine. INDIAN HEMP. Cannabis Indica, or Indian hemp, is a deliriant and hypnotic, and has been used in the form of haschish to procure sensuous halluci- nations. Cannabin, an active principle prepared from it is a brown syrupy liquid which has the odour of Indian hemp. Cannabinon is a dark- blown resin which has sedative properties. The symptoms of an overdose are thus described by a medical man who took forty drops of the tincture. Giddiness and fulness in the head ; heaviness and numbness of the feet and legs ; complete loss of sensation as far as the knees, which rendered standing difficult and walking impossible. The same symptoms commenced in the tips of the fingers and reached to the elbows, but the ansesthesia was not so com- plete as in the legs. Anxiety and dread of death were experienced, and the heart's action was tumultuous and irregular. The mental con- dition was emotional — laughing and crying alternating ; no pleasur- able excitement was experienced. In a case recorded by Casiccia 3 two drachms of the alcoholic extract produced the following symptoms in half an hour : — Mental exaltation with a tendency to physical movements ; paresthesia? of hands and feet ; heat in the epigastrium ; 1 Brit. Med. Journ., 1887. - Med. Neios, 1887. z Eiv. di Chim. Med. e. Farm., 18S3. GELSEMIUM. 5G7 dryness of the fauces; dilatation of the pupils which reacted to light ; and full, slow pulse of fifty-eight to the minute. The patient talked incoherently without intermission, uttering cries or howls at intervals ; recovery took place. The fatal dose is not known. Seven and a half minims of the tinc- ture have caused toxic symptoms. Death has occurred in twelve hours ; it may be delayed for several days ; in one case it did not occur until the nineteenth day. Untoward effects have also been observed after the medicinal use of Cannabinon. The treatment is the same as for opium. GELSEMIUM. Gelsemium Sempervirens or the yellow jasmine of North America owes its toxic properties to the presence of an alkaloid gelsemine, which when instilled into the eye is a powerful mydriatic; when administered internally in small doses it contracts the pupils, in poisonous doses it dilates them. It paralyses the spinal cord and the respiratory centres, and produces tetanus specially affecting the facial muscles and the muscles of articulation ; it also gives rise to ataxic symptoms. It has little effect on the heart and brain. Gelsemine is eliminated by the kidneys. Symptoms. — A case in which a comparatively small cpuantity of the tincture produced toxic symptoms is related by Jepson. 1 A woman who had been previously taking the drug without obtaining any benefit took an increased dose of twenty minims of tincture of gelsemium e\ ery three hours for three or four doses. She lost power over her tongue, being unable either to articulate or to swallow except with great difficulty; the pupils were widely dilated and vision was indistinct. She had a sensation of uncertainty in the movements of her hands and arms, but retained consciousness, and recovered under treatment. Myrtle 2 prescribed some pills containing one-tenth of a grain of gelsemin (the powdered alcoholic extract of gelsemium root, the dose of which is from half a grain to two grains) for which the dispenser substituted hydrochlorate of the alkaloid gelsemine, the dose of which is from a sixtieth to a twentieth of a grain. The patient became giddy, was sick, and lost the power of speech; the tongue was drawn to one side, the muscles on the right side of the face quivered, and she could not guide her hand. Trismus, clonic spasms, exhaustion, and unconsciousness for two hours were amongst the symptoms ; recovery took place. Three teaspoonfuls of the fluid extract of gelsemium caused the death of a woman in seven and a half hours. 1 Brit. Med. Journ., 1891. 2 IUd., 1889. 568 FORENSIC MEDICINE. Treatment. — If taken by the mouth the poison should be evacuated either by the tube or an emetic; then stimulants should be administered, warmth applied, and artificial respiration resorted to if necessaiy. Atropine and strychnine have been recommended as antidotes in order to stimulate the respiratory centre. Chemical Analysis. — Separation from organic matter is effected as -with the alkaloids in general; ether or benzene may be used to shake out from aqueous solution. Test. — Gelsemine has a bitter taste. If a fragment on a colour-slab is dissolved in a little strong sulphuric acid, and a granule or two of manganese dioxide is stirred into the mixture, a deep crimson-red colour is produced which changes to green. COCAINE. Cocaine [C 17 H 01 N0 4 ], benzoyle methyl-ecgonine, one of several alkaloids yielded by the erythroxylon coca, is a colourless crystalline substance ; it has a bitter taste, and leaves a sensation of numbness on the tongue. It is only slightly soluble in water, much more soluble in alcohol, and still more so in ether, benzene, and chloroform. It is largely used as a local anaesthetic and acts in that capacity by paralysing the terminals of the sensory nerves; it blanches mucous membranes, and produces some dilatation of the pupils. Taken internally cocaine first stimulates and then paralyses the nerve-centres of brain and cord. With poisonous doses the action of the heart, in animals, is slowed and the blood pressure reduced; the respiratory function after an initial increase is lowered and finally paralysed. The temperature is raised. Convulsions may occur. Cocaine probably undergoes decomposition in the body into ecgonine — free or combined — although it has been found in the urine. Symptoms. — The following case related by Haenel 1 illustrates the course of acute cocaine poisoning. A dentist injected into the gums of a girl of nineteen a solution equal to about one grain and a-third of a salt of cocaine, to lull the pain of tooth-extraction. The patient became pale, fell down, and was severely convulsed, clonic spasms of both trunk and limbs being present; she was unconscious; the pupils were widely dilated and reactionless to light. At first the pulse was too quick to count, subsequently it dropped to 176 in the minute; the temperature was 100° -8 F., and the respirations were 44 in the minute. The patient remained unconscious for seven hours, and on regaining consciousness experienced diminished sensibility of the hands, anaesthesia of the mucous membrane of the mouth and nostrils, with 1 Berliner kiln. Wochenschr., 1SS8. ' "' A|S|: - 5G9 loss of taste and smell; during the first twenty-four hours there was retention of urine. The stimulating effects of the poison on the piratory centre, with paralysis of the vagi would account for the heart and lung disturbance. Montalti 1 records th< f a man who took twenty-two grains of cocaine hydrochlorate ; 6fteen minute - after delirium came on; he tried to vomit but did not rigors occurred; the face was pale; the pupils were lips cyanotic; he became pulseless and unconscious and died forthwith. Zambianchi 2 states that a woman had about three and a half grains of cocaine injected into the breast preparatory to an operation; she immediately had epileptoid convulsions and died in twenty minu Fatal Dose.— A bout two-thirds of a -rain injected subcut aneously caused the death of a woman aged seventy-one in five hours. A man died almost immediately after taking twenty-two grains by the mouth. On the other hand a man habituated to the use of cocaine, injected under his skin twenty-three grains daily for some time. In another ease recovery took place after forty-six grains were taken into the stomach. Death has occurred from the injection of a solution of cocaine into the tunica vaginalis. The injection of one drachm of a 20 per cent, solution of cocaine hydrochlorate into the urethra caused immediate dilatation of the pupils, Hushing, twitching of the face, and convulsions ; death occurred twenty minutes after the first convulsion. Treatment — The danger usually arises in consequence of the hypo- dermic injection of a solution of cocaine, and the treatment is con- sequently limited to the administration of stimulants, with the inhalation of chloroform if necessary to relieve the spasms which interfere with respiration. Post-mortem Appearances.— The principal cbanges-whieh are due to vaso-motor paralysis— are hyperemia of the membranes of the brain and cord, and of the viscera generallv. Chronic poisoning by cocaine occurs in those who have acquired the habit of injecting the alkaloid hypodermically, in the same way in which morphine habitues use morphine. A number of ill-effects are produced on both the moral and the physical well-being of those who have become victims to the habit. Mental apathy and moral defener- ation are accompanied by disturbances of the digestive organs anomalous pains, and general emaciation. Chemical Analysis.— Separation from organic matter is effected in the usual way; ether or chloroform being good solvents. Tests. — Mezger 3 recommends the following tests: — To a solution of cocaine hydrochlorate in water add a few drops of a o percent, solution 1 Lo Sperimentale, 1SSS. "- Oazz. degli Ospidali, 1SS8. 3 Chan. Ccntralblat, 1S90. 570 FORENSIC MEDICINE. of chromic acid ; as each drop of the chromic acid solution is added a precipitate is formed which immediately redissolves; if a small quan- tity of strong hydrochloric acid is now added a heavy yellow permanent precipitate is formed. Several alkaloids are precipitated from neutral solution by chromic acid — strychnine, brucine, veratrine, quinine, for example but no alkaloid except cocaine requires the addition of hydrochloric acid after the chromic acid before permanent precipita- tion takes place. If a little cocaine is treated with a few drops of strong nitric acid, and the mixture is evaporated to dryness on a water bath, on adding a few drops of a strong alcoholic solution of soda or potash to the residue and stirring them well together, an agreeable, aromatic, ethereal odour is given off somewhat resembling that of the flower called the meadow-sweet. The physiological action of cocaine can be tried on the tongue, or the lips. SOLANUM DULCAMARA. Solanum Dulcamara, or bittersweet, contains two alkaloids — solanine and dulcamarine. Poisoning by substances containing solanine occurs from eating the berries of the bittersweet or other plants of the same species. Vomiting and diarrhoea, with more or less collapse, pain in the stomach, cramps in the legs, followed by clonic spasms, dilatation of the pupils, pallor, and coldness of the surface, hallucinations, and coma are amongst the symptoms which may be met with. The respiratory function is lowered, and in fatal cases the respiratory centres are paralysed, death taking place from asphyxia. The treatment consists in furthering the evacuation of the stomach — vomiting almost invariably occurring spontaneously — the administration of stimulants, and possibly opium, with the application of warmth. MALE FERN. Felix mas, or male fern, is extensively used as an anthelmintic in oases of tape-worm. It contains filicic acid, an amorphous, white, tasteless powder without smell, which is probably the active principle of the rhizome. Experiments on animals made by Poulsson l show that filicic acid produces tetanic convulsions, followed by paralysis, the convulsions resembling those produced by strychnine; heart paralysis occurs along with the general paralysis, although the heart may beat a few times after respiration has ceased. Symptoms. — A man, thirty years old, was given a draught containing ^Arch.f. exp. Path., 1891. MALE FERX. 571 one ounce and a half instead of one drachm and a half of the extract of male fern, which he took in two doses. Soon after the first dose he felt unwell, and after the second, which was given some hours subsequently, he began to vomit, and was purged; then followed cramps, profuse sweating, delirium, and coma, which ended in death about twenty hours after the draught was taken. At the necropsy the omentum and the peritoneal covering of the small intestines were bright red, and in the submucous tissue of the stomach were ecchy- moses with linear extravasations on the surface of the mucous mem- brane. An instructive case is related by Freyer, 1 in which a child, aged two and three-quarters, took eight capsules — each containing about fifteen grains of extract of male fern, along with the same quantity of castor oil — in five hours ; she became somnolent, and as though paralysed, and died after the occurrence of some spasms. Section showed petechial ecchymoses in the mucous membrane of the stomach, pronounced injection of the mucous membrane of the intestines and venous filling of the various organs. The interesting point to note is that three weeks previously the child took double the quantity of the extract, but without the castor oil. A case is recorded by Hofmann, 2 in which a child, five and a half years old, had very nearly two drachms of the extract given to her in three draughts ; death took place in six hours, with symptoms of trismus and general spasms. Much the same appearances were found as in the other cases. The case recorded by Freyer has a practical bearing. The toxic properties of the extract of male fern are augmented by the presence of additional oil to that contained in the extract itself ; the sauie child tolerated twice as much of the extract alone as that which proved fatal when given in combination with castor oil. It is advisable, therefore, not only to avoid giving a mixture of the extract with castor oil, but also to give some other laxative than oil, if one is subsequently needed. A case is recorded by Schlier, 3 in which an adult very nearly lost her life, probably owing to a tablespoonful of castor oil being given one hour after a draught which consisted of extract of male fern mixed with the powdered root. Treatment. — If spontaneous vomiting does not occur, the stomach should be emptied either by the tube or an emetic; after which general treatment will be required, and probably the administration of stimulants. 1 Therapeutische Monatsliefte, 1S89. - Wiener Bin. Wochenschr., 1S90. 3 Miinchner med, Wochenschr., 1S90. OrfU FORENSIC MEDICINE. LOBELIA. Lobelia Inflata, or Indian tobacco, contains a basic substance, lobeline, which is the active principle of the plant. Lobeline is an oily, yellowish-coloured fluid, with a burning taste ; it is soluble in ether, and slightly so in water ; it resembles nicotine in many of its pro- perties. When taken in large doses lobelia acts as a depressing emetic, like tobacco. Cases of poisoning by lobelia chiefly result from its free administration by quacks, especially by a class designated Coffinites, from Coffin, the appropriate name of the man whose therapeutic creed they adopt, one article of which is that lobelia is not a poison, and that it is important when administering it to avoid falling into the vulgar error of not giving enough ! In a case recorded by Wharton and Stille, 1 a woman was poisoned by one of these quacks giving her half a teacupful of infusion of lobelia, seeds and all ; she died in half an hour, and on examination the stomach was found to contain a t:\blespoonful of lobelia seeds ; its mucous membrane was softened and much inflamed ; the intestines were also inflamed. In another case 2 one drachm of the powdered leaves was given by a quack ; great pain was produced, with vomiting, small pulse, contracted pupils, insensibility, spasmodic twitchings of the face, collapse, and death in thirty-six hours. In this case also the mucous membrane of the stomach was found much inflamed. The treatment consists in emptying the stomach in those exceptional cases in which vomiting has not occurred spontaneously, and then administering stimulants freely. Warm applications should be made to the surface, and the recumbent posture maintained until the heart has quite recovered itself. Chemical Analysis. — The basic principle may be extracted with ether from an alkaline aqueous solution. Tests. — On evaporation of the ether, the residue gives a violet coloration with sulphomolybdic acid ; this is like the reaction of morphine, but the fluidity, odour, and colour of lobeline will prevent any confusion between the two ; moreover lobeline turns red on the addition of strong sulphuric acid — a reagent which does not affect morphine. TOBACCO. Nicotiana Tabacum, or tobacco, contains an alkaloid nicotine — in combination with malic or citric acids — upon which its toxic pro- perties depend. 1 A Treatise on lied. Jurisprudence. - Pharmaceutical Times, 1874. TOBACCO. 573 Nicotine [C 10 H u N o ], liberated by the action of alkalies from tobacco, is closely allied to pyridine ; it is a colourless, volatile, oily liquid, which turns brown and resinous on exposure to air. It has a marked alkaline reaction, and forms salts with acids ; it is freely soluble in water, alcohol, and ether, and has an acrid taste, and a strong odour like that of the juice of an old well-used pipe. After tirst stimulating the vagus both centrally and peripherally, thus slowing the heart-beats, nicotine paralyses the cardiac terminals and causes rapid, irregular action of the heart. The respiratory rale is first accelerated and then retarded. The peripheral blood-vessels are contracted by poisonous doses of nicotine, hence the pallor and coldness of the surface. Nicotine first stimulates and then paralyses the cerebral and spinal centres. With small doses the pupils may at first be contracted, but they are dilated when the toxic symptoms are fully developed. Nicotine is to some extent eliminated in the urine. The symptoms of acute poisoning by swallowing tobacco juice or nicotine are : — A burning acrid sensation in the throat, a sudden feeling of depression, with giddiness, loss of power over the limbs, faintness, nausea, vomiting, tremors, coldness of the surface with clammy sweat, loss of consciousness with or without convulsions, con- traction of the pupils, which in fatal cases are subsequently dilated, feeble irregular action of the heart, laboured sighing respirations, com- plete relaxation of the whole musculature, with possibly delirium and convulsions. Before the patient loses consciousness he may experience a feeling of oppression or of sinking in the cardiac region, accompanied by great anxiety, dimness of vision, and loss of power of speech. Occasionally the bowels and the bladder are involuntarily evacuated. In some instances the lethal action of the poison is exceedingly rapid : in one case death occurred in eighteen minutes ; in another in three or four minutes. In the celebrated case of Count Bocarme — who poisoned his wife's brother, Fougnies, with nicotine which he prepared for the purpose — death took place in five minutes. The leaves of the tobacco plant applied to the unbroken skin have caused symptoms of poisoning ; an infusion of them similarly applied in order to kill parasites, has on several occasions caused death. The infusion injected into the rectum as a vermifuge, has frequently proved fatal ; on one occasion after only twelve drops, and on another after an infusion prepared from half a drachm of tobacco. Even smoking tobacco has caused acute fatal poisoning, although most of the nicotine present is converted into pyridine-bases during the combustion of the tobacco. A boy smoked a pennyworth of twist tobacco and afterwards became very sick and fell in the street ; he went home to bed, and at four o'clock in the morning vomited again ; three hours after he was found 574 FORENSIC MEDICINE. lying on the bed, dead and cold. 1 Two or three drops of nicotine taken into the stomach would probably be fatal in a few minutes. A drunken man was killed by his companions emptying the juice of their pipes into some spirit and giving it him to drink. Tobacco in the form of infusion or juice has caused death in from twenty minutes to seven or eight hours. Treatment. — If the poison was swallowed the stomach-tube should be used, or an emetic given, followed by stimulants, external warmth, artificial respiration if necessary, and the maintenance of the recumbent posture. Hypodermic injections of strychnine (one twenty-fifth grain) have proved serviceable. Strong tea, or a solution of ten or twenty grains of tannin in water may be given. Post-mortem Appearances. — The odour of tobacco is usually per- ceptible on opening the abdomen. When the poison has been swal- lowed the mucous membrane of the stomach may be injected or ecchymosed ; the intestines have been found contracted and to contain blood-stained mucus. Chemical Analysis. — Nicotine may be separated from organic admix- ture by the usual process for the isolation of alkaloids. Ether is the best solvent : after its evaporation the residue consists of oily looking drops. Tests. — Nicotine is freely soluble in water. If a solution of mer- curic chloride is added to an aqueous solution of nicotine a white precipitate is formed which subsequently becomes yellow and crystal- line. Silver nitrate produces a white precipitate which subsequently becomes black. Chlorine-water added to an aqueous solution of nicotine produces no turbidity. A little ethereal solution of iodine added to an ethereal solution of nicotine produces an oily mass in which red crystals are formed which have a watch-spring lustre when viewed by reflected light. The odour of nicotine and its toxic effects on animals afford further means of identification. Chronic nicotine poisoning results from excessive smoking, and also from the inhalation of tobacco-charged air in manufactories. The symptoms are dyspepsia, anaemia and nervous disorders, among which amaurosis, intermittent action of the heart, and a tendency to faintness and dizziness are the most prominent. SPOTTED HEMLOCK. Conium Maculatum or spotted hemlock, so named from dark purple spots on the stem, is a plant belonging to the natural order umbeUiferce ; its leaves resemble parsley sufficiently to cause them to have been mis- 1 The Lancet, 1SS5. spotted nEiiLocK. 575 taken and eaten for that plant. It has a peculiar, very characteristic " mousy" odour, which can be developed by pulpifying the leaves or other part of the plant in the presence of a little caustic soda or potash. The plant contains two alkaloids— conine and methyl-conine— along with other bases. Conine [C 8 H ir N] is a colourless oily liquid, which turns brown on exposure to air ■ it possesses the " mousy" odour of fche plan! in a high degree, and has an acrid bitter taste. It is strongly alkaline, and coin- bines with acids to form salts ; it is sparingly soluble in water, and is freely soluble in alcohol, ether, and chloroform. Conine paralyses the motor nerve-terminals, and subsequently the motor centres of the brain and spinal cord, the paralysis spreading from the periphery to the centre. Death is clue to respiratory paralysis, and is usually preceded by asphyxic convulsions. Conine is eliminated m the urine. Methyl-conine [C 9 H 19 N] abolishes the reflex of the spinal cord. Symptoms.— A burning sensation with a feeling of constriction in the throat is experienced, followed by nausea, vomiting, pain, oppres- sion in the stomach and bowels, and diarrhoea. The nerve-symptoms are variable, probably on account of differences in the relative pro- portion of conine and methyl-conine present in the poison swallowed. Progressively increasing muscular weakness with dysp noea, the respiratory movements becoming slower and slower, without disturb- ance of the higher centres, are the symptoms usually met with, but sometimes delirium, coma, and partial convulsions are prominent from the first. The pupils are dilated, and the surface of the body is cold. In the pure motor-paralysis type the patient first feels weakness in the legs which causes him to stumble when trying to walk ; this deepens into complete paralysis which creeps up towards the trunk ; the arms are not so rapidly affected. The paralysis eventually in- vades the muscles of respiration, the patient becomes cyanotic, and death takes place from dyspnoea. In the pure paralytic type convulsions are not infrequent during the final stage, but they are due to asphyxia caused by the respiratory paralysis. The sensory nerves are relatively but slightly affected. A peculiar case is recorded by Schulz 1 of a student who, after re- peatedly smelling at some conine, experienced weakness of the limbs, inability to keep the eyes open, burning sensation of the conjunctiva*, pain in the head, affection of speech, general feeling of heat followed by profuse perspiration ; he rambled and was unable to sleep. The headache continued for twenty-four hours, along with a tendency to perspire profusely on the least movement. 1 Deutsche med. Wochenschr., 1887. ■57G FORENSIC MEDICINE. Treatment. — Evacuate the stomach and then give stimulants and apply warmth. Artificial respiration is sure to be required in severe cases and should be persistently kept up ; life may be saved by this means when the condition appears almost hopeless. Post-mortem Appearances. — In the absence of traces of the poison in the viscera, there is no characteristic appearance. The blood will probably be dark and fluid, with other indications of death from asphyxia. A child, eight months old, had given to it one teaspoonful of a mixture containing one drachm of extract (prescribed in mistake for succus) of conium with one drachm of potassium bromide in an ounce and a half of chloroform water. When seen, the legs were paralysed ; occasional twitchings of the arms and head occurred, but no decided convulsions ; the pupils were dilated, the face was livid, and the respirations were diaphragmatic; death took place in seven hours. Pepper, who made the post-mortem examination, found the organs generally congested, along with an increased amount of serum in the cerebral ventricles and under the arachnoid, and an injected condition of the membranes of the spinal cord. The right heart was distended with blood, the bases of the lungs were hyperremic, and punctiform extravasations were observed on the surface of the liver. The contents of the stomach yielded no odour of conium until they were treated with potassium hydrate and heated ; the " mousy " odour was then apparent. An ethereal extract obtained from the contents of the stomach, when treated with hydrochloric acid, yielded crystals of conine hydrochlorate. 1 Chemical Analysis. — Separation of conine from organic admixture may be accomplished as with nicotine. Considerable caution is necessary in the identification of conine, since substances somewhat resembling it may be obtained from cadavers that have undergone putrefactive changes. Any such products, however, do not yield the chemical reactions of conine, nor are they strongly toxic ; they probably consist of or contain cadaverin — a ptomaine which has an odour somewhat resembling that of conine, but it is scarcely so "mousy." Tests. — Conine is less soluble in hot water than in cold, therefore if a cold saturated arpueous solution is heated it becomes turbid, like albuminous urine similarly treated, but, unlike the urine, it clears up again on cooling. If conine is exposed to the vapour of hydrochloric acid crystals of conine hydrochlorate are formed. A few drops of a solution of mercuric chloride added to a solution of conine in water produce a white amorphous precipitate, which does not change to 1 The Lancet, 1S85. FOXGLOVE. 01 I yellow nor become crystalline, as is the case with the precipitate formed by nicotine when similarly treated. Silver nitrate produc is a dark-brown precipitate, which turns black. Chlorine water added to an aqueous solution of conine produces turbidity. Treated with chromic acid, conine yields butyric acid, which may be recognised by its odour. CENANTHE CROCATA. CEnanthe crocata, or water dropwort, is another umbelliferous plant with toxic properties. The symptoms comprise convulsions, cyanosis, insensibility, laboured respirations, collapse, dilated pupils, delirium, small, feeble, slow pulse, with gastro-enteric disturbance. On one or two occasions the convulsions have been of a strychninedike character. In some instances the symptoms have been almost entix-ely psychical, consisting of hallucinations, wild laughter, and actions like those seen in delirium tremens. FOXGLOVE. Digitalis Purpurea, or foxglove, is a plant belonging to the natural order Scrophulariacece, the leaves of which possess toxic properties due to the presence of three glucosides — digitalin, digitalein, and digitonin— with one other active principle. A variety of preparations are sold under the name of digitalin, which differ in chemical constitution and physiological effects, in accordance with the mode in which they are obtained. The most poisonous of the active principles is digitoxin, which is not a glucoside. Digitalis is essentially a heart poison, and causes death from heart paralysis, the pulse usually ceasing before respiration; the respiratory rate is often slowed, especially when death is imminent. The active principles of digitalis probably undergo decomposition in the body ; very exceptionally traces of them have been found in the urine. Symptoms. — The digestive tract is primarily affected by a poisonous dose either of digitalis or of its active principles. Nausea, vomiting — which is often very obstinate and persistent — pain, with a sensation of oppression in the region of the stomach, thirst, and colicky pains in the abdomen, with or without diarrhoea, are common. After a varying interval the more specific effects of the poison manifest themselves — giddiness, with a feeling of faintness, headache, increased oppression in the epigastric region, moisture and coldness of the surface, especially of the limbs, prostration and various affections of the special senses, as dimness of vision, noise in the ears, are present, with which mental disturbances, in the form of hallucinations or delirium, may be asso- 37 578 FORENSIC MEDICINE. ciated. The action of the heart is profoundly affected : the pulse sinks hour by hour in rapidity and tension, and becomes very intermittent and fluttering. The respirations are slow and assume a sighing character. If the patient lifts his head when in the recumbent posture a tendency to syncope asserts itself, and if he stands upright actual syncope probably occurs, which may prove instantaneously fatal. An inclination to somnolence, which may deepen into coma, is not un- frequent ; cyanosis, with or without asphyxic convulsions, may precede death. It is to be noted that the special action of digitalis on the heart renders the patient liable to fatal syncope for sevei'al days after the immediate effects of the poison have passed off. In the acute stage, the pulse-rate may be lowered to under forty beats per minute ; in the case of a woman who drank some infusion prepared from fresh digitalis leaves, the pulse sank to thirty-six, with periods of entire cessation of the heart's action at short intervals. Fatal Dose. — J^ine drachms of the tincture of digitalis have proved fatal, and recovery has taken place after more than three times as much. Thirty-eight grains of the powdered leaves have caused death , and recovery has followed one drachm. The fatal dose of digitalin is not known ; Mawer l relates the case of a woman who swallowed fifty- six granules, each containing one milligramme of Homolle's digitalin. the total dose being equal to eighty-four grains of digitalis-leaf. The effects produced were giddiness, vomiting, pain in the stomach, duski- ness of the face, dilatation of the pupils, coldness of the extremities, oppression in the precordial region, slow respirations with prolonged inspiration, and slow, irregular, weak pulse, which sank to forty-four in the minute ; recovery took place. Death has taken place in twenty hours, but it may be delayed to a much more remote period. Treatment. — If necessary use the stomach-pump or give an emetic such as mustard or zinc sulphate with hot water. Stimulants should be freely given and external warmth applied, the patient being kept in the recumbent posture for several days. Hot applications, friction, or mustard leaves, to the epigastrium are useful. Hot coffee with brandy in it may be given. If the vomiting is prolonged, ice in small quantities will be useful. The Post-mortem Appearances are not characteristic. There may be some signs of irritation, or of inflammation of the gastric mucous mem- brane. Chemical Analysis. — Fragments of the leaf, should the poison have been taken in that form, may be detected in the stomach, in which case they should be examined microscopically. 1 The Lancet, 1880. colciiicum. 579 The aqueous extract obtained in the usual way from organic matter is best shaken out with chloroform, in which all the active principles of digitalis are soluble ; they are not all soluble in ether nor in benzene ; it is to be remembered that digitalin in acid solution is taken up by chloroform. Tests. — If digitalin is dissolved in a little concentrated sulphuric acid, and some bromine-water is added to the mixture, a violet-red colour is produced. A little digitalin gently heated with a few of a mixture of equal parts of sulphuric acid and alcohol turns y brown ; on the addition of a drop of a dilute solution of ferric chloride a green or bluish-green colour is produced. The physiological test may be resorted to as performed by Tardieu in the celebrated case of Pommerais, who was convicted of fatally poisoning a woman with digitalin. Three frogs were prepared so that their hearts were exposed — one frog was left unpoisoned, into the pleural sac of the second a solution of digitalin was injected, and into thai of the third some of the suspected poison obtained from the body of the deceased ; the heart-beats of the three frogs were respectively counted at stated intervals. The heart of the unpoisoned frog showed little change ; that of the one to which digitalin was administered promptly and progressively slowed until it ceased to beat ; the heart of the frog to which the suspected poison was administered behaved like number two, excepting that the effects were less rapidly produced. COLCHICUM. Colchicum Autumnale, or meadow saffron, is dependent for its toxic effects upon the presence of an active principle colchicine, with a small trace of veratrine, both of which are chiefly contained in the root and the seeds. Colchicine [0 22 H 25 "NO 7 ] is a yellowish crystalline powder when pure, but is often met with as an amorphous resinous-looking substance. It is soluble in water, and freely so in alcohol and chloroform ; it is slightly, if at all, soluble in ether, and is insoluble in petroleum ether. Colchicine is decomposed by acids with the exception of tannic acid, with which it combines. Colchicine in poisonous doses causes irritation of the nerve-endings in the intestines, along with gastro-enteritis. The motor centres in the cord and medulla arc paralysed, and death is produced by paralysis of the respiratory centres : the sensory nerves are also paralysed. From experiments on animals Jacobj l concludes that colchicine may be converted into oxydicolchicine within the organism. Colchicine is partly eliminated by the kidneys and bowels, chiefly by the latter. i Arch. f. exp. Path. u. Pharm., 1S90. 580 FORENSIC MEDICINE. Symptoms. — A burning pain in the throat which extends clown the oesophagus to the stomach, where it assumes an aggravated form, is experienced shortly after the poison is swallowed ; then follow copious vomiting and purging, the latter being accompanied by violent colicky pains in the abdomen. There is intense thirst ; the face is shrunken and pallid, or cyanosed ; the surface is cold and moist ; the pulse is small, irregular and rapid; the breathing is slow and laboured — the whole symptoms in fact resemble those due to an attack of cholera. This resemblance is increased by the nature of the evacua- tions from the bowels, which, after the normal contents are discharged, chiefly consist of serous fluid; subsequently they become blood- stained. A sensation of oppression is felt in the region of the heart ; the patient is profoundly depressed, and, being fully conscious suffers greatly. Muscular twitchings or spasms may occur, the whole body occasionally being convulsed ; the pupils are sometimes dilated, some- times contracted ; stranguary may be present, with increased or diminished amount of urine. Towards the end the cyanosis often becomes more marked, the collapse then being very profound ; the mind usually remains clear till towards the last ; in exceptional cases stupor occurs earlier. Fatal Dose. — Three and a half drachms of colchicum wine have caused death. Recovery has taken place after ten drachms, which produced severe toxic symptoms. The lethal dose of colchicine is not known ; a woman, aged forty-three, swallowed about six grains, which had been substituted for another drug, and died in thirty-one hours (Albertoni e Casali 1 ). Death has taken place in seven hours; it usually occurs within thirty hours, but has been delayed for three, and even seven days. Treatment.— The stomach should be emptied by the tube, and well washed out with a solution of tannic acid ; or an emetic may be given, followed by strong tea ; then brandy, by the mouth, or if vomiting forbids, ether injections, external warmth and friction, with artificial respiration if required. Probably a subcutaneous injection of morphine will be advisable to relieve the intense colicky spasms of the bowels. Post-mortem Appearances. — They are not characteristic ; there may be signs of inflammation in the mucous membrane of the stomach and bowels, possibly with spots of ecchymoses ; but in some cases there has been an entire absence of such indications. Chemical Analysis. — Advantage may be taken of the insolubility of colchicine, in petroleum ether, to dissolve out fatty substances from an aqueous solution obtained from the organic matter. Colchicine is 1 Bollet. delle scienze med., 1890. VERATRl'.M. 581 dissolved out of acid solution by chloroform. The chloroform solution may either be evaporated to dryness, or after it has undergone some degree of concentration, petroleum ether may be added so as to cause the colchicine to crystallise out. Tests. — A drop of nitric acid, S.G. 1-4, brought in contact with col- chiciue, produces a violet colour, which changes to brownish-yellow. One part of ammonium vanadate dissolved in two hundred parts of sulphuric acid produces a green coloration (sometimes very evanescent, and not distinct except with the pure alkaloid), which changes to a brownish-violet ; the reagent should be freshly prepared. The physio- logical test does not afford decisive information ; the conclusions arrived at by a committee of French experts, who were appealed to in a case of suspected colchicine poisoning, were : — that experiments on animals do not afford the means of determining that poisoning by colchicine has taken place. Ogier x was able to obtain the reactions of colchicine isolated by the usual process, from the exhumed bodies of dogs which he had poisoned with it five and a half months before. In the bodies of animals poisoned with it, Oblonski 2 detected colchicine four and a half months after death. VEEATRUM. Veratrum Album, or white hellebore, and Veratrum Viricle, or green hellebore, contain a number of alkaloids ; Wright and Luff 3 found jervine, pseudo-jervine, rubi-jervine, cevadine, veratralbine, and vera- trine. Commercial veratrine is an impure alkaloid obtained from sabadilla seeds. Veratrine [C 37 H 5: .NO u ] is a white, crystalline powder, having an acrid burning taste ; when it comes in contact with the nasal mucous membrane it excites violent sneezing. It is insoluble in water, and is soluble in ether, chloroform, and spirit. It has an alkaline reaction. Veratrine first stimulates the motor nerves, and then paralyses their endings. It alters the character of muscular contractility : contraction is prolonged, and relaxation takes place slowly — a condi- tion resembling, but not identical with, tetanic spasm. The sensory nerves also undergo primary stimulation, followed by paralysis, which is more complete than is the case with the motor endings. The activity of the heart is reduced, the vaso-motor apparatus paralysed, and the blood pressure consequently lowered. Respiration is first quickened, then slowed, and finally arrested from paralysis of the respiratory centres, and probably also of the vagus endings in the lungs. The 1 Annates d 'Hygiene, 1S8G. - Vh rteljahrsschr. f. ger. Med., 1SSS. 3 Jour n. Chcm. Soc, 1S79. 582 FORENSIC MEDICINE. result of all this is that the temperature is lowered. Veratrine is quickly eliminated by the kidneys. Symptoms. — An acrid, burning sensation, with constriction, is ex- perienced in the throat; the burning sensation extends along the oesophagus down to the stomach, and is followed by vomiting and great thirst. Diarrhoea is not invariable, but may occur ; if it does there is usually tenesmus. The pulse is feeble, and the respira- tions slowed and sighing in character; the pupils are sometimes dilated. Pallor and coldness of the surface, with rapid collapse, twitching of the muscles, and even convulsions, have been observed. Giddiness and paraesthesiae, followed by superficial anaesthesia, may occur in the early stage ; consciousness is usually maintained until the stage of collapse is reached, but occasionally, early on, there is a tendency to delirium and stupor. Fatal Dose. — Not known. In one case death took place after about eighteen grains of the powdered root of V. album; recovery has occurred after more than twelve times that amount. Grenander 1 records the case of a woman who drank some liniment containing four and a half grains of veratrine. The pupils were dilated, the pulse was slow (50 per minute) and feeble, the respirations were slow and shallow; consciousness was not impaired. Salivation and profuse sweating occurred. Vomiting was frequent, great oppression was felt in the epigastric region, together with soreness of the throat, and profound prostration; there was no diarrhoea; recovery took place under prompt treatment. In another case reported by Blake 2 nearly three grains of veratrine were accidentally swallowed by an adult. The patient com- plained of giddiness, sickness, constriction of the throat, thirst, diarrhoea with tenesmus, and a tired, weak, faint feeling. The tongue was swollen and the mouth and throat were sore; the pupils were extremely contracted, the respirations hurried, and the pulse was quick and small; micturition was frequent. A continued tingling was felt over the entire body, with now and then intolerable fits of itching in different parts; there was no sneezing. Recovery took place under treatment, the irritation of the skin being the last symptom to subside. Treatment. — After evacuation of the stomach with the tube or an emetic, stimulants and hot coffee should be administered. External warmth and friction may be required, with maintenance of the re- cumbent posture and artificial respiration. If excessive diarrhoea is present, morphine will be advisable. Post-mortem Appearances are not characteristic ; only few reports are extant and they afford no definite information. Chemical Analysis. — Chloroform, or a mixture of chloroform and iHygeia, 1SS5. 2 St. George's Hosp. Rep., 1S70. MONKS-HOOD. 583 ether, is the best solvent to extract veratrine from aqueous solution. It can be shaken out of an acid solution, but more perfectly after alkalisation. Tests. — Applied to the mucous membrane of the nostrils veratrine causes violent sneezing. A drop or two of strong sulphuric acid added to a little veratrine in a watch-glass and well mixed, develops a' yellow- colour, which quickly changes to orange and finally to cherry-red; if the mixture is warmed it becomes red immediately. .Salicine treated with sulphuric acid turns red immediately without heating. Narcotine gives a similar reaction but takes hours to acquire the red colour. Hydrochloric acid with veratrine produces no change until the mixture is heated, when it becomes red. Sulphomolybdic acid added to a fragment of veratrine produces a brick-red, which becomes dirty brown, greenish, and finally blue. If a little veratrine is mixed with five or six times the amount of cane-sugar, and moistened with concentrated sulphuric acid, a yellow colour is first produced, which changes to green and finally to blue. With ammonium selenate and sulphuric acid veratrine yields a brownish-yellow which changes to rose-red. MONK'S-HOOD. Aconitum Napellus or monk's-hood, sometimes called wolf's-bane, is a common plant belonging to the natural order Eanunculacece ; it is extremely poisonous in all its parts. The root has been eaten for horse-raddish although the difference between the two is so marked as to make it impossible for any observant person to mistake one for the •other : — Aconite-root quickly tapers to a point whereas horse-raddish is cylindrical or thereabouts; aconite-root is brown, horse-raddish is a dirty white. On section, aconite-root is soft in texture, and white in colour,_the cut surface quickly changing to pink on exposure to air; horse-raddish is tough and white, and retains its colour unchanged. The taste also of the two roots is different: aconite is acrid and imparts a tingling sensation, followed by numbness, to the tongue and lips, with a feeling of constriction in the throat ; horse-raddish is simply pungent. The aconite ■ plants contain a number of alkaloids and derivatives, which have been investigated by Wright, Luff, and Menke, 1 several of them not being poisonous. Commercial aconitines consist of variable admixtures of some of these alkaloids, and therefore greatly differ in potency; English and French aconitines are the strongest; German aconitine is much less powerful. Eecent investigations by Dunstan, Passmore, and Umney 2 indicate that aconitine is mono-benzoyl aconine. 1 Journ. Chem. Sue, 1877, 1879. - Proc. of the Chan. Soc, 1S92. 58 I FORENSIC MEDICINE. An exhaustive account of the aconite bases is contained in Allen's Commercial Organic Analysis, vol. iii., part ii., 1892. Aconitine [C 33 H 45 N0 lo ] is one of the most active, if not the most active, poison known; it is crystallised with difficulty, and is usually met with in white amorphous masses; it has an alkaline reaction, and forms salts, of which the nitrate is preferred. English aconitine is but slightly soluble in water, and is not very freely soluble in alcohol and ether, whilst the German alkaloid is soluble in all three, and freely so in ether. German aconitine has a bitter, sharp, burning taste; the English alkaloid is not bitter, but is sharp and burning. All aconitines produce a peculiar tingling and numbness of the lips and tongue, which comes on shortly after a drop of a dilute solution is applied to them; the 1 sensation lasts for some time and is very characteristic of the poison. When introduced into the system in poisonous doses aconitine pro- duces a general tingling all over the body, the parts liberally supplied with sensory nerves being most affected. The poison first stimulates and then paralyses the sensory nerve-terminals; it produces the same effect on the motor nerves and centres of the medulla and cord. The higher cerebral centres are little affected. The heart-beats, at first retarded, may consequently be quickened; the motor ganglia and the muscular substance of the heart are eventually paralysed. Respiration becomes slow, and afterwards shallow, due to the action of the poison on the respiratory centre. Death is usually due to arrest of respira- tion, after cessation of which the heart may continue to beat for a short time. The temperature sinks from the first. Aconitine is eliminated in the urine and probably in the fieces ; in experimenting with animals Dragendorff found it in both. Symptoms. — Shortly after swallowing a poisonous dose of a prepar- ation of aconite, tingling, followed by numbness of the lips, mouth, and throat, is experienced, due to the direct contact of the poison with the jiarts affected; then a feeling of nausea and pain in the stomach develops which is usually followed by vomiting and sometimes by purging. A tingling, numb sensation — due to the poison which has been absorbed — is now felt over the whole body, with giddiness, imperfect vision, restlessness, anxiety, twitching of the muscles (sometimes with spastic contractions), darting pains in the legs, and muscular prostration. The pulse is feeble and intermittent, the respirations are laboured and spasmodic, and the temperature sinks, the limbs especially being cold and moist to the touch. The pupils may alternately dilate and con- tract, and there may be delirium, or a tendency to drowsiness and stupor; towards the end convulsions may occur, which are probably not altogether asphyxia In an instance of multiple aconite poisoning monk's-iiood. 585 related by Baker, 1 in winch four boys, from fourteen to eighteen years of age, chewed pieces of aconite root, the symptoms developed in from a few minutes to half an hour. All the patients felt heavy and sleepy, and experienced most of the symptoms just described; in the worst case the pupils were widely dilated; the respirations were spasmodic, but the pulse though small was quiet and regular; all recovered. Fatal Dose. — One drachm of aconite root, two grains of the pharma- copeia] extract, and one drachm of the tincture li;i\ e respectively proved fatal. The smallest recorded fatal dose was eighty minims of the pharma- copceal tincture taken in ten doses, spread over four days, the largest individual dose being ten minims ; this is quite an exceptional case. Twenty-five minims of Fleming's tincture, equal to about two drachms of the official tincture, have proved fatal, and recovery has followed one ounce. A fatal case of poisoning by aconite liniment is recorded by M'Whannell. 2 A woman swallowed one ounce of the pharma- copoeal liniment (equal to about five and one-third drachms of dried aconite root), and became collapsed, with small, irregular pulse, slow, laboured breathing, cold clammy limbs, and pallid lips. There were no convulsions; the pupils dilated immediately before death, which took place in sixty-five minutes after the poison was swallowed. Death has occurred in from three-quarters of an hour up to fifteen or even twenty hours after the poison was swallowed. The usual period of survival is from thr ee to fo ur hours. As regards the fatal dose of aconitine, experience is more limited. An instructive case is recorded by Tresling. 3 A medical man, who had prescribed aconitine nitrate, was informed that the medicine produced strange symptoms, and, in order to demonstrate its harm- lessness, took a dose himself equal to about one-fifteenth of a grain j in about an hour and a half after he began to feel ill. When seen four hours after he was pale, the surface was cold, the pupils were contracted, the pulse was small and irregular, but not rapid, the tongue was swollen, and the patient experienced a burning sensation in the throat, with pain down to the stomach, headache, weakness of the limbs, and shivering. The pupils suddenly dilated, and syn- chronously there was loss of vision ; shortly after the pupils, resumed their previous condition, vision returning. Vomiting occurred both spontaneously and in consequence of emetics. In four hours and forty minutes a convulsion occurred, followed by a succession of others; respiration became more laboured, and tho pupils again dilated with accompanying loss of vision. Later, the vomiting became very violent, unconsciousness supervened, the pupils remained dilated and insensi- 1 Brit. Med. Journ., 1882. -Ibid., 1S90. 3 Weekbl. van het Xederl. Tijdschr. r. Genecsl; 1SS0. 58G FORENSIC MEDICINE. fcive to light, the respirations grew slower, and the heart ceased to beat ; death occurring five hours after the aconitine was taken. At the necropsy pallor of the skin and of the muscles was observed, with hyperemia of the stomach and first part of the intestines; the colon was pale and the rectum bloodless. The lungs were hypersemic/and the heart contained fluid blood. The cerebral membranes were injected, the ventricles contained blood-stained serum, and blood was extrava- sated on the choroid plexus ; the blood throughout was fluid and cherry-red in colour. Death was attributed to heart paralysis. In this case French aconitine (Petit's) was dispensed in place of a weak German preparation (Friedlander's) ; by experiments on animals, Plugge 1 afterwards found that the alkaloid dispensed was one hundred and seventy times more potent than that which was prescribed. The cause celebre of aconite poisoning was that of Reg. v. Lamson (C. 0. C, 18S2), the prisoner being a medical practitioner who was accused of having poisoned his brother-in-law. He paid a visit to his victim, a boy of nineteen, who was a boarder in a school, and persuaded him to swallow a gelatine capsule, which he pretended to fill with sugar, but which, as the result showed, contained aconitine (Morson's). In about twenty minutes the boy complained of heartburn, and then vomited ; he had great pain in the stomach, a sense of constriction in the throat, was restless, and tossed himself violently about whilst in bed ; the breathing became slower, the heart's action feebler, and he died about four hours after swallowing the capsule. At the necropsy the membranes of the brain were slightly congested, but there was no fluid under them nor in the ventricles ; the lips were pale, the pupils dilated, the lungs congested, especially at the lower part, the heart was empty, the liver, spleen, kidneys, and mucous membrane of the stomach and of the first part of the duodenum were congested ; on the surface of the gastric mucous membrane were six or eight small, slightly raised patches. From a portion of the vomited matter, from the urine obtained after death, and from the viscera, Stevenson and Dupre obtained aconitine, which responded to the usual physiological tests. The prisoner was condemned and executed. A fatal case of poisoning due to aconite and belladonna combined is recorded by Lipscomb. 2 A girl of seventeen swallowed two table- spoonsful of a liniment composed of equal parts of the aconite and belladonna liniments of the pharmacopoeia. The face and neck were flushed : the neck, arms, and to a slighter degree the legs, were con- vulsed, the movements being aggravated by external stimuli. The pupils were dilated, the heart's action was quick, turbulent, and irregular — probably 300 per minute ; the radial pulse could not be 1 Arch. der Pharm., 1SS2. "Brit. Med. Journ., 1S8S. HELLEBORE. 581 felt. In one hour and forty minutes the heart suddenly ceased to beat, respiration continuing for a few seconds longer. Treatment. — Evacuate the stomach with tube or emetic. Administer stimulants freely: brandy, by mouth or rectum ; ether subcutaneous! v. External warmth, friction, artificial respiration, and the recumbent posture will be required. Post-mortem Appearances. — Not characteristic; sec the accounts already given. If the poison has been taken in the crude form scare] i should be made for fragments of the root or other parts of the plant. In a recent case in which six persons were poi." three fatally, by the accidental addition of aconitine to quinine-wine, the only special feature noticed at the necropsy was the presence, in all tlrree, of sub-pleural ecchymoses. 1 Chemical Analysis. — Separation from organic matter is accomplished by the usual process, in the course of which exceptional care is neces- sary to prevent decomposition of the alkaloid, which easily und< hydrolysis. The alcoholic extract is preferably made without the addition of an acid ; in any case a mineral acid must not be used. Tests. — After proving the presence of an alkaloid, the only reliable procedure is to make use of the physiological test. A tingling sensation, followed by numbness of the lips or tongue, produced by the application to them of a drop of a solution of the product obtained from the vomit, excreta, or tissues, is strongly indicative of aconitine ; the subsequent administration of a known quantity of the solution to one of the smaller animals, the toxic effects being compared with those produced by aconitine on other animals of the same species and weight, will yield sufficient evidence of its presence. Opposite opinions are given with regard to the permanency of aconi- tine in the presence of putrefying organic matter. Lewin maintains that it is not destroyed; Stevenson states that if allowed to remain some time along with decomposing animal* matter which has become alkaline it cannot be detected. HELLEBORE. Helleborus Niger, or true hellebore, has a dark coloured root which is sometimes used as a vermifuge by herbalists and others ; the leaves are also used for the same purpose. The toxic properties of hellebore depem 1 upon the presence of two glucosidal active principles : helleborin and helleboreill, both of which tend to produce muscular paralysis and to cause vomiting and diarrhoea. Helleborin acts on the brain ami causes insensibility; it also produces local anaesthesia, and if applied 1 Annates d'Ifygiine, 1892. 588 FORENSIC MEDICINE. to the nostrils occasions sneezing. Helleborein produces first slowing and then quickening of the heart, and also dyspnoea. Symptoms. — A stinging, numb feeling of the tongue extending to the throat, with colicky pain in the stomach and abdomen, followed by violent vomiting and purging, are experienced, together with dizziness, heavy sensation in the head, drowsiness, prostration, collapse with cold, pallid, perspiring surface, feeble pulse, and laboured respiration ; in event of a fatal issue, death may be preceded by convulsions. The pupils are frequently dilated. In a case recorded by Ilott, 1 a young man put about two teaspoonsful of powdered hellebore into some water and drank it off. He was seized with violent cramps, giddiness, dimness of vision, inability to stand, and violent vomiting ; the pulse was only 40 in the minute ; the pupils were dilated ; a burning pain was felt in the epigastrium and a sensation of constriction in the throat ; the fauces were red and swollen ; recovery took place. The fatal dose is not determined. Half a drachm of a watery extract is recorded as having been fatal. Death has occurred in from three to twelve hours. Treatment consists in promoting evacuation of the stomach, followed by the administration of stimulants and morphine to allay excessive action of the bowels ; external warmth should be promoted. The Post-mortem Appearances are not characteristic ; as with other vegetable irritants, signs of inflammation in the mucous membrane of the stomach have been observed. Chemical Analysis. — Helleborin, but not helleborein, may be shaken out of acid aqueous solution with ether; it is still more soluble in chloroform. After evaporation of the solvent, the residue immediately yields a bright red colour on being touched with a glass rod which has. been dipped in strong sulphuric acid. STAVESACRE. Delphinium Staphisagria, or stavesacre, a plant belonging to the natural order Thalamijiorce, yields seeds which contain several active principles, among which are the two alkaloids dephinine and staphisa- grine ; in toxic action the former resembles aconitine and the latter- curare. Poisoning with stavesacre is exceptionally rare. A case is recorded in which a man by mistake swallowed two teaspoonsful of a powder, two- thirds of which consisted of powdered stavesacre-seeds. The heart was slowed to 35 or 40 beats per minute and was very feeble in its action ; severe collapse came on, the surface being very cold ; the 1 Brit. Med. Journ., 1889. LABURNUM. 5S9 breathing was laboured, the pupils were dilated, and the abdomen was distended and exceedingly painful ; consciousness was undisturbed. Under treatment recovery took place in a few hours. 1 LABURNUM. Cytisus Laburnum, or common laburnum, contains an alkaloid — cytisine [C. H. 2 -N.,O], which has basic properties and forms salts with acids. Cytisine is freely soluble in water, alcohol, acetic ether, and chloroform ; it is insoluble in ether. It has a bitter taste and is powerfully toxic. Cytisine first stimulates and then par- alyses the cord and motor nerves, the paralysis beginning in the peripheral endings ; the respiratory centres also are first stimulated and then paralysed, death being due to respiratory paralysis. The heart-beats are accelerated. After slight excitation of the brain, cytisine produces somnolence and coma. Cytisine is eliminated in the urine and to some extent in the faeces ; it has been found in the saliva. The symptoms of fatal poisoning by laburnum flowers, seeds, bark, wood, or root supervene in from five minutes up to an hour or more. They comprise : — A hot feeling in the throat, thirst, vomiting, eructa- tions, pain in the stomach, diarrhoea, collapse, cold moist surface, feeble, irregular pulse, gasping respiration, profound prostration and coma ; in some cases delirium and convulsions have occurred. The pupils are usually dilated, but they have been observed to be contracted. Death is usually due to asphyxia and may be preceded by cyanosis. Poisoning by laburnum is most frequent in children who are tempted to chew or eat parts of the tree on account of its sweetish taste ; out of 155 cases collected by Falck 120 were in children. An instance of wholesale poisoning resulted from 58 boys chewing pieces of the root of a laburnum tree which had been recently cut across. In the worst •cases vomiting occurred with slowing of the pulse, irregular dilatation of the pupils, unconsciousness, and convulsive movements of the legs, followed by profound sleep ; in all the cases the pupils were dilated, and the symptoms were of a purely narcotic type ; the patients all re- covered.' 2 A case is recorded by Johnson 3 of six children, from eight to ten years of age, who ate laburnum seeds; they perspired and then went cold and shivery, and vomited ; the pulse was scarcely perceptible at the wrist, the pupils were dilated ; giddiness, drowsiness, and collapse were observed. One child was purged once, and another repeatedly — in this case purging was the chief symptom ; the rest were not purged ; 1 Friedreich's Blatter/, get. Med., 1S68. -Brit. Med. Journ., 1875. * Ibid., 1891. .590 FORENSIC MEDICINE. they all recovered. Two children, respectively aged three and eight years, presumably ate some laburnum seeds or pods. Vomiting, diarrhoea, and prostration occurred in one, with death in fourteen hours. The younger child felt tired and sleepy, and then vomited and was convulsed until death occurred eight hours after the symptoms commenced. At the necropsy irritation of the gastro-intestinal mucous membrane was found ; no fragments of the seeds were present in the stomach, but cytisine was detected in its contents. 1 Out of the 155 cases collected by Falck only four died. Of the fatal cases two had violent cramps and died within an hour ; a third died in twelve hours, and the fourth not until the seventh day after taking the poison. Treatment consists in thoroughly washing out the stomach, or in giving emetics followed by copious draughts of warm water. Warm applications and friction to the surface, artificial respiration, strong coffee, and stimulants may be necessary. The Post-mortem Appearances are negative. The signs of inflamma- tion of the gastric mucous membrane which the symptoms during life •would indicate have not always been found after death. Chemical Analysis. — Cytisine is best extracted from an acjueous solution by chloroform. Eadziwillowicz 2 recommends amyl alcohol for this purpose, but Moer and Plugge 3 state that the pure alkaloid is much more soluble in chloroform than in amyl alcohol. Tests. — Cytisine dissolves in concentrated sulphuric acid without undergoing change of colour ; on warming, the mixture becomes yellow. If to a little cytisine dissolved in a few drops of concentrated sulphuric acid in the cold a drop of nitric acid is added a yellow colour is produced. If to a mixture of cytisine and sulphuric acid a fragment of potassium dichromate is added, a yellow colour is produced which changes to dirty-brown and finally to green. With a solution of a ferric salt cytisine yields a red colour, w r hich disappears on the addition of a few drops of a solution of peroxide of hydrogen ; on subsequent warming a blue colour is produced. This test is very delicate : according to Moer and Plugge it will indicate the presence of -05 mgrm. of the alkaloid. MEZEREON. Daphne Mezereum, or mezereon, occasionally gives rise to accidental poisoning in 'children who pluck and eat the berries. The juice is strongly irritant, and tends to destroy mucous surfaces with which it comes in contact. ' 1 Brit. Med. Journ., 1SS2. 2 Ueber Kacliw. u Wirl: des Cyt'mns. Diss., 18S7. 3 Arch, der Pharm., 1S92. TURPENTINE OIL. 591 The symptoms are illustrated by the following cases. Eagar a saw a child, four years old, after it had eaten at least twelve mezereon berries. Convulsions occurred before any other symptoms; an emetic was given, and vomiting procured ; three hours after, the lips and tongue were swollen; the tongue, twice its natural size, was raw, and protruded beyond the lips ; there was difficulty in swallowing, the limbs were cold, and the pulse — 130 in the minute — was very weak; recovery took place. Dunne 2 saw a child of the same age which had also eaten some mezereon berries. It was restless, and complained of pain in the mouth and throat ; vomiting took place spontaneously before the child was seen ; an emetic was afterwards given which brought away further portions of the berries. The child was drowsy, prostrate, pale in the face, with dilated pupils, scarcely perceptible pulse, and cold limbs; the mucous membrane of the tongue and of the roof of the mouth was white from the action of the acrid juice of the berries; the child recovered. Treatment. — Evacuate the stomach, and afterwards administer an aperient, with such further treatment as the symptoms require. TURPENTINE OIL. Symptoms. — A poisonous dose of turpentine oil causes a burning sensation in the mouth and stomach, followed by symptoms of gastro- enteritis. Vomiting, thirst, diarrhoea, tympanites, and a condition like that of the early stage of alcoholic intoxication are present ; the pulse and respiration vary ; the surface is cold, and, in fatal cases, coma supervenes; there may be muscular spasms. Strangury is a constant symptom, and the urine has an odour resembling that of violets, a similar odour being often observable in the breath ; severe pain in the loins, with hematuria, may be present. Turpentine is excreted by the lungs, kidneys, and skin. The urine excreted after- poisonous doses of turpentine has been found to reduce Fehling's solution. Prolonged inhalation of the vapour of turpentine produces toxic- symptoms which are occasionally observed in those who have slept in newly painted, rooms. A case, illustrative of poisoning by the vapour of turpentine, is recorded by Reinhard. 3 A man who was occupied in a room in filling small vessels out of a large vessel containing tur- pentine, began to feel dizzy on the first day ; on the second day dryness of the mouth and depression came on, and on the third day increased heaviness and painful micturition. When seen, the patient 1 Brit. Med. Jourv., 1887. *Ih\d. y 1S90. 3 Deutsche med. Wochenschr., 1SS7. 592 FORENSIC MEDICINE. was very drowsy, the bladder was distended to the umbilicus, and the urine contained blood and albumen ; it had an odour of violets which it continued to yield for a week after the patient ceased to inhale the turpentine vapour. Fatal Dose. — A tablespoonful has caused the death of an infant five months old, whilst another infant recovered from four ounces. Six ounces were fatal to an adult. Treatment. — The stomach-pump, or an emetic, will be required, fol- lowed by demulcents ; a pui'ge should be given if diarrhoea has not occurred. Opium and other general treatment may be advisable. Post-mortem Appearances. — The blood has been observed to be dark coloured, and hemorrhagic spots have been found in the stomach, sometimes with erosion of the mucous membrane. SAVIN. Juniperus Sabina, or savin, is a coniferous plant containing, as a toxic principle, an essential oil, odour of which is given off by the plant ; it is peculiar, and is easily recognisable ; both the leaves and the oil have an acrid burning taste. Savin is rarely taken for the purpose of committing suicide, but it is regarded as an ecbolic by the lower classes, and death has frequently resulted after its use for this purpose. Savin possesses no ecbolic properties ; it is an irritant, and when abortion has ensued after its administration, the result has been due to general disturbance of the system, and not to any specific action of the poison on the womb. The symptoms comprise a burning sensation from the throat to the stomach, colicky pains in the abdomen, vomiting, purging, and strangury. Laboured respiration may occur, followed by unconscious- ness, collapse, coma, and death ; blood may be present in the motions. It is very exceptional for abortion to take place without the woman paying the penalty with her life ; on the other hand, death of the woman has frequently occurred without abortion being produced. The Post-mortem Appearances are limited to signs of inflammation of the mucous membrane of the stomach and bowels, with the possible presence of fragments of the leaves. Sometimes no signs of inflam- mation have been visible ; at others, punctiform ecchymoses in the irastric mucous membrane have been observed. YEW. Taxus Baccata, or common yew, another conifera, owes its toxic action to the presence of an alkaloid — taxine — which is present in the PENNYROYAL. 593 leaves and in the seeds of the fruit ; it is most abundant in the leaves. It is soluble in alcohol and ether, and feebly so in water. Poisoning occurs from the use of the leaves as an emmenagogue, or as an ecbolic, or from accidental causes. As a uterine stimulant yew, like savin, is inert, nevertheless the lower orders make use of the leaves from time to time to determine menstruation, or to procure abortion. Symptoms. — Giddiness, vomiting, muscular weakness, pain in the stomach and bowels, irregular action of the heart, laboured breathing, collapse, general spasms or convulsions, and delirium, have been observed. A girl, on four consecutive mornings, drank a tumblerful of a decoction of yew leaves to promote menstruation; vomiting occurred, and death, preceded by delirium, took place eight hours after the last dose ; the post-mortem appearances were negative. 1 Taylor relates the case of a lunatic woman who, whilst preparing evergreen decorations, ate a few pieces of yew leaves ; she became collapsed, and died in less than three hours after the symptoms first appeared ; the fragments of leaves in the vomit and in the contents of the stomach after death amounted to less than a teaspoonful. Treatment. — Evacuate the stomach, give stimulants, relieve the bowels, and apply external warmth, with general treatment of pro- minent symptoms. Post-mortem Appearances. — Fragments of leaves or the seeds may be found in the stomach, with signs of inflammation of the gastric mucous membrane. In a case recorded by Carter, 2 a girl was found dead in bed with a history leading to the assumption that she had taken yew leaves as an abortifacient ; no vomiting occurred, and death took place within nine hours. The stomach contained fragments of the leaves, and the mucous membrane was inflamed. PENNYROYAL. Hedeoma, or pennyroyal, much used as an emmenagogue, contains a volatile oil which may produce toxic effects. Wingate 3 states that a pregnant woman, aged twenty, took a teaspoonful of oil of pennyroyal as an ecbolic ; she became unconscious ; the limbs were cold, the pulse was small, and the pupils were slightly dilated ; vomiting, delirium, and two attacks of opisthotonos occurred. Recovery, without abortion, took place. 1 L' Imparzlale, 1S70. - lint. Med. Journ., 1SS4. 3 Boston Med. and Surg. Jouri:., 1S89, 38 591 FORENSIC MEDICINE. TANSY. Tanacetum Vulgare, or tansy, contains a volatile oil, which, along with the leaves of the herb itself, has a reputation as an ecbolic. enimenagogue, and also as an anthelmintic. It is poisonous, and has caused death after being taken for the above-named purposes. In a case recorded by Jewett 1 the symptoms were as follows: — A woman. aged twenty-nine, took fifteen drops of oil of tansy at eleven in the forenoon ; three hours afterwards she took a teaspoonful, having had dinner between the two doses. Fifteen minutes after the second dose she threw herself on the sofa and then sprang up with a wild cry and was convulsed ; respiration was for a time suspended and she became deeply cyanosed especially about the face, neck, and hands ; the eyes were open, the pupils were widely dilated, and there was great restlessness. The surface was cold and moist ; the pulse was 120, and the respirations 35 to the minute, the odour of the oil being perceptible in the breath and also in the matter which the patient vomited after taking an emetic; recovery took place. In a case com- municated by Dalton a woman was found on the floor in violent con- vulsions ; she was unconscious, the cheeks were flushed and of a bright red colour, the eyes were open and very brilliant, with widely dilated and fixed pupils ; the respirations were hurried, laboured, and ster- torous, the breath having the odour of tansy; the pulse (128) was full. Spasms occurred at intervals by which the head was thrown back, the arms were raised and rigid, and the fingers spastically contracted. The pulse gradually grew feeble and suddenly ceased three-quarters of an hour after the first appearance of the symptoms. At the necropsy no indications were discovered except the odour of tansy oil which per- vaded the entire body, and was perceived as the cavities were respec- tively opened ; globules of the oil were found in the stomach ; a foetus, at about the fourth month was found in the uterus. There was reason to believe that about eleven drachms of oil of tansy were taken. OIL OF WINTERGREEN. Oil of Wintergreen, or oil of gaultheria, consists for the most part of methyl salicylate ; it has an agreeable odour and a sweetish taste. The symptoms produced by poisonous doses may be gathered from the following cases : — Hamilton 2 saw a woman after she had swallowed half an ounce of the oil ; she was dizzy, drowsy, and delirious. An emetic caused evacuation of the contents of the stomach which were coated with a film of the oil and contained shreds of mucous membrane. ^Boston Med. and Surg. Journ., 18S0. 2 New York Med. Journ., 1875. ERGOT. .30.") The pupils wore contracted, the inspirations quick and laboured, and the limbs cold ; hallucinations of audition and vision, pain in the head, and a strong disposition to sleep, verging towards coma, were present. Hemiparesis of the left side, with extreme irritability of the nervous system — starting at the least sound — and profuse salivation were pro- minent symptoms ; recovery slowly took place. Pinkham x reports the case of a Avoman who swallowed one ounce of oil of gaultheria which caused profuse sweating, pain in the abdomen, frequent painful mictu- rition and purging, followed by convulsions, loss of sight and hearing, flushed face, rapid respirations, feeble pulse, and death in fifteen hours. At the necropsy the blood was found black and fluid, and the mucous membrane of the stomach and duodenum intensely congested ; the contents of the stomach yielded the odour of the oil. ERGOT. Ergot is a parasitic formation consisting of the mycelium of the Claviceps purp urea developed from the ovary of various graminiae, especially rye ; it occurs in wet seasons, and may be so widely diffused as to give rise to epidemics of ergotism in the districts where the diseased grain is grown. Ergot contains more than one active principle ; Robert has found three: — e rgot inic acid, spliacdinic acid, and cornutine ; the last is re- garded as an alkaloid ; the substance known as ergotin is an admixture of these principles. Although by means of experiments on animals, considerable information has been obtained as to their respective actions, the specific effects produced by them on the human subject have not yet been satisfactorily differentiated ; from the toxicological standpoint therefore ergot and ergotin are to be regarded as complex bodies which possess certain definite toxic properties. Ergot poisoning may be acute or chronic; the latter is frequently named ergotism. Symptoms of Acute Ergot Poisoning. — When one or more poisonous doses of ergot, or of ergotin, are taken, giddiness, pain in the stomach, thirst, nausea, vomiting, great oppression in the cardiac region, numb- ness and tingling — beginning in the fingers and toes, and tending to spread along the limbs — cramp, dyspnoea, shivering, coldness, especially of the limbs, great anxiety, delirium, coma, and convulsions are among the symptoms which may be produced. In a case recorded by Debierre 2 a woman recovered after swallowing one drachm and a half of Bonjean's ergotin. In a few hours intense dyspnoea, faintness, dryness of the mouth and throat, giddiness, noises 1 Boston Med. and Surg. Journ., 1S88. 2 Ballet. Gin. de Therap., 1884. 596 FORENSIC MEDICINE. in the ears, dimness of vision, tingling, and a sensation of coldness in the limbs were experienced. There was complete anaesthesia of the tongue and of the surface of the hody, with severe pain in the epigas- trium and the abdomen; the temperature was 96°-SF., the pulse 50 per minute, and the respirations also 50 per minute ; epileptiform con- vulsions occurred. In another and fatal case recorded by Davidson 1 a woman who was pregnant had been taking the liquid extract of ei-got for several months; she then swallowed "two handfuls " of powdered ergot without infusing it. When seen the day after, the face and the upper part of the body were jaundiced ; ecchymoses were present under the skin around the eyes ; the lips and tongue were swollen and coated with dry black blood ; there was intense thirst ; the skin was pale, and the temperature 96° F. The pulse was peculiar — it could not be counted, but could be just perceived, and then disappeared before its character could be estimated ; the heart- beats were of a rolling character — 150 per minute; the respirations were 48 per minute. The patient had periods of stupor and apathy ; she vomited red pultaceous matter and pure blood ; the urine also contained blood. An attempt was made to effect instrumental delivery, but the woman died before it could be accomplished ; the respirations increased to 56, and stupor with paroxysmal movements supervened immediately before death. At the necropsy much fluid blood, effused from small vessels, was found extravasated in the abdominal cavity, but no large vessel was ruptured. The liver, kidneys, and lungs were bloodless, the liver and kidneys presenting a pale yellow, waxy appearance ; all the viscera, though bloodless, were ecchymosed, and ruptured vessels were found within the stomach and bowels. In the uterus, which contained no blood, a five months' foetus was found. The bladder was empty. The effect of ergot on the quiescent uterus is discussed in the section on criminal abortion. Treatment. — Evacuate the stomach with tube or emetic, and clear out the bowels. Stimulants and external warmth will be needed. Inhalations of amyl nitrite, or, as recommended by Murrell, nitro- glycerine, administered by the mouth, may be tried. Post-mortem Appearances chiefly consist in pi-esence of ecchymoses and extravasation of blood on and into the internal organs, as described in the above quoted case. The bodies of three pregnant women who died in consequence of taking ergot to procure abortion, all presented unusual post-mortem appearances ; externally they were jaundiced to some extent ; internally the usual ecchymoses were found, and in addition, the liver in all three, and the kidneys in two, showed fatty i The Lancet, 1SS2. ERGOT. 597 changes, so pronounced as to give rise to suspicion of phosphorus poisoning. On chemical examination ergot was found in the intestines, but no trace of phosphorus. In two of these cases the uterus contained a four months' and a six weeks' foetus respectively ; in the third, a foetus surrounded by its membranes was at the vaginal outlet. 1 Symptoms of Chronic Ergot Poisoning.— Chronic ergot poisoning mostly occurs as a consequence of eating bread made from grain con- taminated with the fungus; it has occurred epidemically for many centuries, and still appears from time to time in Germany, Russia, and other countries. The early symptoms indicate disturbance of the gastro-intestinal tract; they comprise pain and oppression in the gastric region, general depression, either loss or increase of appetite, nausea, occasional vomit- ing, sometimes diarrhcea and at others constipation, together with dizziness, sleeplessness, and a general feeling of weariness and absence of energy. Subsequently the symptoms may take one or both of two courses— gangrenous or nervous (spasmodic ergotism). Gangrenous Ergotism is first indicated by the occurrence of patches of anaesthesia — the patient experiencing a sensation of cold in the parts affected— or by a burning sensation, accompanied by redness of the skin. Gangrene, mostly of the dry type, which may or may not be preceded by the formation of serous blisters, then sets in ; the peri- pheral parts of the limbs — the toes and fingers — being most frequently affected. The gangrene, which seldom affects the trunk, may advance as far as the knees or elbows ; when it has readied its limit, separation by slow ulceration takes place, unless the process is expedited by surgical operation. In rare cases the skin only is at- tacked, the entire cutis undergoing necrosis, and separating from the underlying tissues. Spasmodic Ergotism is preceded by paresthesia? of various kinds, such as a creeping sensation beginning in the fingers and toes and spreading along the limbs; in some instances there is complete anaesthesia. Motor disturbances follow : first, twitching of the muscles occurs, then spastic contraction of groups of muscles, by which the fingers and toes are flexed and drawn together; the hands are flexed at the wrists, presenting the' appearance of clenched fists with the thumbs drawn towards the palms ; the ankles are extended, the heels being sometimes so powerfully drawn up that the feet and the legs form straight lines. The spasm may extend along the muscles of the limbs to those of the spine, so as to produce opisthotonos ; rarely, the muscles of the lower jaw are similarly affected. The spasms are exceedingly painful, and cause the patient to roll about in agony, the surface being covered with 1 Pitersb. med. Wochenschr. , 1884. 598 FORENSIC MEDICINE. a cold sweat ; tliey last from a few minutes to many hours ; when they pass off the patient is left exhausted and powerless. Sometimes the contractions are tetanoid in character, at others, clonic spasms resem- bling epilepsy occur ; the breathing may be affected as though the diaphragm participated in the spasmodic seizure. Dysuria due to spastic contraction of the bladder may be present. Paralysis, with complete superficial anaesthesia, sometimes follows. Disturbances of the special senses have been recorded, as diplopia, alterations in the field of vision for colours, deafness, and aphasia. Exceptionally cataract has been observed. Psychical disorders, as hallucinations, delirium, mania, mental enfeeblement, with stupor, and, exceptionally, indications of tabes — lightning pains, girdle sensation, staggering gait, and unsteadiness in the erect posture with the eyes closed — have occurred. Tuczek 1 found sclerosis of the posterior columns of the cord, implicating the root-zones as in tabes. Both the gangrenous and spasmodic types of ergotism are probably due to persistent contraction of the smaller arteries, which deprives the tissues respectively implicated of their normal supply of blood ; as previously stated, the two varieties may co-exist : a patient with spasmodic ergotism may lose the toes and fingers from gangrene. From a report made by Griasnoff, 2 on seventeen cases of ergotism which were admitted into the Poltava hospital in Russia during the epidemic of 1881, the following statements are taken : — The ages of the patients varied from twelve to forty-five years; thirteen were males and four were females ; four died — two males and two females. All suffered from agonising pains and numbness of the limbs, sleeplessness, exhaustion, diarrhoea, weak accelerated pulse, and, all but one, from loss of appetite. Five suffered from spasms, a few from headache, nausea, and vomiting. In all but one, gangrene — of the humid type in eight, and of the dry in seven — occurred ; all of these patients had pyrexia (104° F. and more), with evening exacerbations. The quantity of ergot present in the rye-meal which had been eaten by the patients, was not more than one per cent., which is much lower than the per- centage usually stated as liable to cause ergotism. The treatment of ergotism is mostly prophylactic, with ordinary medical or surgical treatment of the symptoms as they arise. Chemical Analysis. — Bread or flour suspected of containing ergot should be extracted with hot alcohol acidulated with sulphuric acid. The extract is red in colour, and, if examined with the spectroscope, yields two bands : one in the green and another in the blue, the latter being the broadest and best defined. It is practically impossible to 1 Arch./, rsychiat., 1SS2. - The London Med. Record, 1883. JAB0RAND2. 599 separate ergot from the tissues so as to identify it ; in acute poisoning the contents of the stomach may be treated as above, and the ergot if present identified. JABORANDI. Jaborandi, the dried leaflets of the pilocarpus pennatifolius, owes its toxic properties to the presence of an alkaloid pilocarpine, with possibly two others. Pilocarpine [C 11 H 16 N" 2 0, ) ] is a colourless, syrupy-liquid, without odour; with acids it forms crystallisable salts, of which the hydro- chlorate and the nitrate are most used. Pilocarpine powerfully stimulates almost all the secretions, especially the saliva and the sweat ; it also stimulates the motor nerves of the in voluntary muscles. In small doses it stimulates, and in large doses it paralyses the vagus- endings in the heart, and thus slows or accelerates the pulse. Respira- tion is impeded by excessive secretion of mucus into the bronchi ; the temperature is lowered, the pupils are contracted, and increased peristalsis of the intestines occurs. Pilocarpine is eliminated in the urine. Symptoms. — The following case by Fuhrmann 1 illustrates the effects produced by a large dose. A man aged thirty-one had "01 grm. (about one-sixth of a grain) of pilocarpine injected subcutaneously ; the face immediately grew red, then the neck, and shortly after the whole body, which began to perspire freelv. In a few minutes the patient experienced sudden severe oppression of the heart and extreme difficulty of breathing, as though the chest was filled with fluid ; the severe cardiac oppression subsided in ten minutes, but traces could be felt for two hours. Increased secretion of saliva, tears, and of mucus from the nostrils occurred. Cramps were experienced in the stomach, as though the organ "would turn round"; nausea and vomiting fol- lowed, with movements of the intestines which produced a strong desire to evacuate the bowels. Great thirst, prostration and a tired feeling, especially in the legs, were experienced ; the pupils were con- tracted and vision was impaired ; the pulse was small and frequent, and the patient became collapsed. The amblyopia lasted two hours ; the sweating two and a half hours ; the salivation four and a half hours, during which time 500 grammes of saliva were expectorated ; the patient recovered. A case is recorded by Sziklai - in which a patient by mistake had a Pravaz-syringeful of a 20 per cent, solution of pilocarpine injected under the skin. Immediately on withdrawing the canula salivation, copious sweating, and shortly after dizziness, 1 Wiener med. Wochenschr., 1S90. 2 Ibid., 1881. GOO FORENSIC MEDICINE. vomiting, diarrhoea, oppression, and a tearing-pain in the eyeballs ■with pronounced myopia occurred ; the pupils were contracted to the uttermost. The patient micturated twice; the salivation and diapho- resis lasted two hours ; after five hours the acute symptoms began to- disappear, and the patient recovered. Jaborandi has also produced psychical disorder with hallucinations. Treatment. — If necessary evacuate the stomach and then give stimu- lants. One-fiftieth of a grain of atropine sulphate should be injected subcutaneously, and repeated if necessary. CALABAR BEAN. Calabar Bean, the seed of the physostigma venenosum, is kidney- shaped, having a groove with elevated borders along its convexity ; it is blackish -brown in colour, and its surface has a texture like that of the fine morocco leather used for book-binding. The bean varies from an inch to an inch and a half in length ; if split lengthwise it is seen to consist of a brown-coloured rind containing two white cotyledons which adhere to the shell. It contains two alkaloids — physostigmine and calabarine, its characteristic toxic effects being due to the former. Physostigmine [C 15 H 21 N" 3 2 ] or eserine when pure, is a white crys- talline body which rapidly changes colour on exposure to air and light ; it is not very soluble in water, but is easily soluble in alcohol, ether, and chloroform. It has an alkaline reaction, and forms salts with acids, which are colourless and soluble in water ; on exposure to air they deliquesce and acquire a red colour. Physostigmine increases the irritability of both the voluntary and the involuntary muscles — shown by twitching of the skeletal muscles, and peristalsis of those of the intestines. It eventually pai'alyses the respiratory centres in the medulla and causes death from arrest of respiration. It augments the irritability of the vagus, and thus tends to slow the heart ; it increases the secretions, probably by direct action on the secreting elements themselves, and paralyses the motor centres in the brain and cord. "When applied directly to the eye physostigmine contracts the pupils and causes spasm of accommodation, probably from stimulation of the third nerve. Physostigmine is eliminated in the urine, faeces, and saliva. Calabarine resembles strychnine in its action and causes clonic spasms. Symptoms. — After a poisonous dose of calabar bean giddiness and faintness are experienced, quickly followed by profound prostra- tion ; rain is felt in the stomach usually followed by vomiting ; CALABAR BEAN, G01 diarrhoea may occur but is not very frequent. The heart's action is enfeebled, the pulse being usually small and slow, and there may he dyspnoea. The surface is cold and moist ; the pupils may he, hut are by no means invariably contracted ; salivation and thirst have occurred. The mental condition varies : in some instances it is undisturbed, in others drowsiness and even unconsciousness have been observed. Muscular spasms have been present in rare cases, probably due to calabarine. In the year 1864, forty-six children were poisoned in Liverpool through eating calabar beans which had been discharged from a ship ; they all suffered from pain in the region of the stomach ; thirty-eight were attacked jwith vomiting, and fifteen with diarrhoea; only one died. A unique case of suicidal poisoning with physostigmine is recorded by Leibholz. 1 Two girls, aged twenty-four and eighteen respectively, obtained possession of a sealed tube containing 0-1 grm. of physostig- mine sulphate, which they dissolved in water, and each girl drank half of the solution ; for half an hour they pursued their household avoca- tions without experiencing any effects, they then suddenly became unconscious. In each case the face was red and shining, the pupils, dilated to the maximum, were reactionless ; the pulse, GO to the minute, was full and of high tension ; the respirations were shallow, rapid, and moaning ; pain was experienced in the region of the stomach and abdomen ; vomiting occurred early and persisted for some time after return to consciousness. Dilatation of the pupils, with feeble reaction to light, lasted for several days, perfect recovery ultimately taking place. The activity of the alkaloid was vouched for by Merck- after chemically examining a companion sample. Tested physiologi- cally three milligrammes injected under the skin of a rabbit weighing- four pounds produced paralysis of the voluntary muscles, difficulty of respiration, violent diarrhoea and death in ten minutes ; a solution dropped into the human eye caused marked contraction of the pupil. The dilatation of the pupils in the above recorded cases is remarkable ; cases of calabar bean poisoning have occurred without contraction of the pupils, but none with dilatation. The absence of diarrhoea is in marked contrast to its universal occurrence in animals poisoned with physostigmine. - Eserine (physostigmine) has produced symptoms of poisoning after being dropped into the eyes for ophthalmic purposes. Dunlop 2 relates the case of a man, aged sixty, who had one drop of a solution of eserine (inadvertently prepared with one grain to the drachm instead of to the ounce) dropped into each eye ; a quarter of an hour after, clonic spasms of the eyelids, stiffness of the lips, a feeling of tremor in the arms and 1 Vierteljahrsschr. f. oisoning. The mucous membrane of the intestinal canal is injected, and the urine may contain haemoglobin. In a case recorded by Handford 2 a man, aged thirty-two, ate about a quarter of a pound of cooked A. phalloides. In nine and a half hours he experienced a sense of weight and constriction in the chest, and pain in the bowels ; he subsequently vomited and was purged ; profuse sweating, dimness of vision, and headache occurred. When seen, about twenty-four hours after eating the fungi, the pulse was 92, small, scarcely to be felt at the wrist, and the respirations, of a sighing character, were 17 to the minute ; the pupils were normal. The patient complained of pain in the abdomen ; he was drowsy, passed very little urine, and became delirious ; death took place on the third day. At the necropsy punctiform ecchymoses were found on the lungs and under the pericardium ; the liver was in an advanced stage of fatty degeneration ; the mucous membrane of the stomach was much con- gested and presented numerous points of capillary haemorrhages and small superficial erosions ; the whole of the intestines were slightly 1 Petersb. mcd. Wochenschr., 1S91. - The Lancet, 18S6. FUNGI. Gil congested. A daughter of the deceased, who ate part of one of the fungi along with her father, vomited and was purged, but had no abdominal pain ; she died in twenty-nine hours. At the necropsy no signs of gastro-enteritis were found. Treatment of Poisoning by Fungi. — Evacuate the stomach with an emetic and the bowels with castor oil, and then treat the symptoms. Atropine is recommended as an antidote. In poisoning by muscarine, it acts as nearly like a true physiological antidote as any .antagonist well can do; unfortunately, in poisoning by fungi, even by the fly- fungus, its antagonism is less efficacious ; still, it should be tried, especially if the symptoms partake of the muscarine type. Warmth and stimulants will probably be required, and morphine if the gastro- enteric symptoms prevail. Post-mortem Appearances. — The necropsies of the cases already quoted illustrate the salient post-mortem indications : — Inflammation of the gastrointestinal mucous membrane, with hemorrhagic spots and erosions; punctiform sub-pleural, and sub-pericardial hemorrhages; and not unfrequently signs of fatty changes in the solid viscera, especially in the liver, comprise the most important indications. The fatty changes scarcely seem to have received sufficient attention ; Maschka, Husemann, and Boudier x observed them many years ago both in animals and in the human subject, and since then numerous cases have occurred in which fatty liver has been recorded as one of the post-mortem signs of poisoning by fungi. It appears to be most common after poisoning by amanita muscaria and amanita phalloides ; in Handford's case of poisoning by the last-named fungus, already quoted, the liver was in an advanced stage of fatty degeneration. Midler 2 examined the body of a woman who was found dead four days after having eaten part of a fly-fungus. The heart, kidneys, and liver, all showed fatty changes ; the liver especially presented such a typical " phosphorus-liver" appearance as to give rise to doubts whether death had been caused by phosphorus or by the fungus. 1 Des Champignons, 1S(3S. - Vierteljahrsschr. f. ger. Med., 1890. 612 FORENSIC MEDICINE. ANIMAL POISONS. CHAPTER XXXIII. CANTHARIDES. }Jdt Cantharides, or Spanish flies, contain an active principle or acid — cantharidin, partly free and partly combined with organic and inorganic bases. It is insoluble in water, slightly soluble in cold alcohol, and more freely so in hot alcohol, fixed oils, ether, and chloroform. When combined with bases, its solubility in these solvents, respectively, is the converse of that which obtains when it is in the free state. Can- tharidin is eliminated in the urine and faeces. Symptoms. — When taken internally in poisonous doses cantharides causes a burning pain in the throat, which quickly extends to the stomach, with difficulty in swallowing, intense thirst, salivation , swelling of the salivary glands, and vesication of those parts of the digestive tract with which it first comes in contact. Xausea and vomiting occur, the rejected matter containing shreds of membrane, and probably blood ; diarrhoea, with tenesmus, may follow. Fain in the lumbar region , accompanied by strangury and irritation of the urethra, is almost invai'iable ; the urine contains albumen, and occasionally blood. In severe cases, collapse, coma, and convulsions may lead to death, which is usually due to paralysis of the respiratory centres. When cantharides are criminally administered it is not with homi- cidal intent ; the object is either to excite the sexual feeling or to procure abortion. In more than one instance death has accidentally resulted from a delirious patient eating a blister which was applied to his head. Cantharides are harmless to fowls; if, after being fed with them, a fowl is eaten by a human being, symptoms of cantharides poisoning are produced. Severe symptoms of poisoning have occurred from the external use of cantharides. Fatal Dose. — The smallest recorded fatal dose is twenty-four grains of powdered cantharides ; recovery has occurred after one drachm. One ounce of the tincture has caused death ; recovery has followed after six ounces were swallowed. Very small doses may produce severe poisonous effects. Sedgwick 1 records the case of a girl, thirteen and a half years old, to whom one Spanish fly was given in a tart ; 1 J.'ed. Times and Ga~.., 1SG4. CANTHARIDES. 613 half an hour after giddiness, pain between the shoulders, and a burning sensation in the throat were experienced. The following morning, the abdomen was distended, there was strangury, and the vulva were swollen and irritable ; the patient vomited half a pint of blood, and complained of a strong disagreeable odour in the nostrils. For three days there was occasional vomiting of blood ; recovery took place. About seventy-five centigrammes (11.V grains) of cantharidin caused the death of a man of seventy in twelve or fourteen hours. 1 Treatment. — Evacuate the stomach, and, if possible, wash it well out. Demulcents and morphine, with warm baths or fomentations, will be required. Fatty or oily substances must not be given. Post-mortem Appearances. — Indications of inflammation are usually present in the mouth and along the digestive canal; they may diminish in intensity after the first part of the intestines is reached, or they may be continued as far as the rectum. Excoriation and ulceration of the mucous membrane, with swelling and softening, will probably be visible, producing in some cases the appearance of a raw blood-stained or purulent surface deprived of all trace of epithelium. If the powdered insect has been swallowed, bright, glistening particles are generally to lie seen on the mucous or raw surface, especially of the intestines ; in such cases, e xamination of the dige stive tract with a lens should never be omitted. If death has occurred very shortly after the poison was swallowed, the changes in the stomach and bowels may be less pro- nounced. The kidneys are usually large, red, and gorged with blood ; the epithelial cells of the glomeruli are swollen, softened and detached, frequently blocking up the tubules. The internal surface of the bladder is injected, and is often ecchyrnosed ; the mucous membrane of the urethra is also injected. The spleen has been found enlarged. Chemical Analysis. — If the solid poison has been swallowed, the mucous membrane of the stomach and intestines should be scraped with the edge of a piece of glass and the scrapings distributed in water; by means of alternate agitation and decantation fragments of the shin- ing wing-cases, which are easy of recognition, may be separated for microscopical and chemical examination. In order to obtain an extract of cantharidin from the tissues it will probably be necessary first to free it from combination, either by simply acidulating with .sulphuric acid or by Dragendorff's method, after which it may be dis- solved out by shaking with chloroform. Dragendorli's met hod consists in boiling the organic mixture with potash and water, filtering, adding sulphuric acid to the filtrate to liberate the cantharidin from the potash, and then boiling the filtrate with four times its volume of alcohol; after cooling, the alcoholic solution is filtered, the alcohol 1 Annates d'Hygttne, 1892. G14 FORENSIC MEDICINE. evaporated, and the residue extracted with chloroform. On evapora- tion of the chloroform, a portion of the final residue may be taken up with a little oil. Tests. — A morsel of cotton-wool saturated with the oily mixture obtained from the chloroform extract, and retained for some hours in contact with the skin on the arm or the breast, will raise a blister if even but a very minute quantity of cantharidin is present. An aqueous solution of cantharidin in combination with potash or soda yields a gi-een precipitate with copper sulphate, and a red precipitate with cobalt sulphate. Cantharides resist putrefaction for a long time. PTOMAINES. The putrefactive processes by which complex animal tissues, step by step, are resolved into their primary elements, partake to some extent of a synthetical character. The bacteria of putrefaction split up highly organised matter into primary constituents, and groups of primary constituents ; at the same time that ammonia is being yielded by de- composing animal matter, temporary derivatives of ammonia are being formed, which possess special chemical and physiological properties. It is characteristic of the mode in which these substances are formed that they are fugitive and are continually undergoing changes by which they are transformed into other bodies of an analogous constitution, but which may possess different properties : a physiologically inert substance of definite chemical composition may give place to a toxine of equally definite but slightly dissimilar composition. These ch ange s vary not only according to the stage of putrefaction which the cadaver has reached, but also according to temperature, free or restricted access of air, with other conditions which are but imperfectly understood. Most of these new combinations are strongly hasic ; they have certain, points of resemblance to the vegetable alkaloids, but they are of less complex constitution, being of the nature of amines (although some contain oxygen), whereas most of the vegetable alkaloids are to be regarded as derivatives of pyridine. To this group of basic substances the name Ptomaine (irruna, a corpse) was applied by Selmi. Ptomaines may be isolated by Stas' process, described on p. 401, qr_ by Brieger's method : — An alcoholic extract obtained from the organic 1 matter which contains the ptomaine is precipitated with neutral lead acetate (in order to remove amorphous albuminoid and other inert matter), filtered, and the filtrate evaporated to a small bulk ; the residue is dissolved in water through which H 2 S is passed until the lead is thrown down. After filtration the solution is evaporated to CADAVERIC ALKALOIDS. G13 a syrup, which, when cold, is extracted with alcohol, and the filtered extract precipitated with an alcoholic solution of HgCl 2 . Advantage is taken of the varying solubility of the double salts formed by ptomaines with mercuric chloride to effect their separation by treat- ment with boiling water. The solutions thus obtained are severally decomposed by R.S and, after removal of the mercurews sulphide, are evaporated down so as to cause the ptomaine salts to crystallise out. Further separation is accomplished by forming double salts of the ptomaines with Pt01 4 and AuCL. During the various pro- cesses, especially in the early ones, t he temperature should not ex ceed 4(P, nor should the solutions be allowed to acquire more than a feebly acid reaction. As free bases ptomaines are mostly liquid, some are crystallisable ; some are volatile, others are not; they form salts, more or less easily crystallisable. Like vegetable alkaloids, ptomaines are precipitated by most of the alkaloidal group-tests. Some ptomaines are actively toxic, others are feebly so, and others again are devoid of toxic properties. The study of ptomaines is a subject too extensive to be exhaustively dealt with in a text-book on Forensic Medicine; they will therefore be considered in two aspects only :— In relation to toxicological investiga- tions made on the dead body, and to abnormal changes in food-stuffs which are thus rendered poisonous. Ok CADAVERIC ALKALOIDS. In the course of medico-legal investigations in cases of criminal poisoning a defence occasionally tendered is— that the poison found in the body of the deceased was a product of post-mortem changes under- gone by the tissues themselves— a defence most commonly urged in cases of poisoning by one of the rarer alkaloids, which yields no special chemical reactions. In default of distinctive chemical reactions, the expert is obliged to rely on physiological tests ; it becomes important therefore to ascertain the toxicity of those ptomaines that have been found in the human body after death, together with the symptoms they produce in animals to which they are experimentally administered. A recent tabulation by Brieger 1 of all ptomaines and toxines, which up to the present time have been isolated, enables this to be easily and reliably accomplished ; toxines due to the presence of pathological micro-organisms in the body during life— such as those of tetanus, cholera, and typhoid fever— are obviously excluded. Of ptomaines that have been isolated from the cadaver, two only are activelv poisonous— neurin am! mydalein ; others have toxic properties, but the lethal dose in relation to the body-weight is immeasurably greater 1 Virchow's Arch., 1SS9. G16 FORENSIC MEDICINE. than that of the vegetable alkaloids for which it is alleged they might be mistaken. Neurin does not appear until five or six days after death r and mydalein not until seven days after, and then only in traces ; it is not present in amount sufficient for analysis until after a lapse of two to three weeks. During the period after death, within which post- mortem examinations are usually made, the only ptomaine present is cholin — a feebly poisonous substance probably derived from lecithin. Time and the access of air are required to develop actively toxic pto- maines, and when formed they exist in small amount, are very unstable and require special processes for their extraction. Although cadaveric alkaloids respond to many of the alkaloidal group-tests, they do not respond to special tests like the vegetable i alkaloids. If the reaction yielded by a cadaveric alkaloid to a special reagent somewhat resembles that produced by the same reagent with one of the vegetable alkaloids, it will behave differently towards a second special reagent ; it will further have a different physiological effect to that of the vegetable alkaloid which, as regards one special chemical reaction, it may in a degree resemble. There is no test by which animal alkaloids, as a class, can be distinguished from vegetable alkaloids ; on the other hand, no animal alkaloid has yet been dis- covered which yields the same chemical reactions, and possesses the same physiological properties, as any of the vegetable alkaloids. According to Brieger 1 the symptoms in rabbits produced by the subcutaneous injection of neurin hydrochlorate are : — Moisture of the nostrils and upper lip, followed by movements as in the act of chew- ing, with the formation of drops of thick mucus at the angles of the mouth; profuse salivation then occurs, which continues to the end. The breathing is at first accelerated, it then becomes shallow and irregular, with marked symptoms of dyspnoea. The heart-beats much quickened at first are then slowed and enfeebled, becoming weaker and weaker until contractions finally cease, and the heart stops in diastole, respiration continuing for a time after the heart ceases to beat. Occa- sionally, but not constantly, the pupils are contracted after injection of the ptomaine ; on the other hand, a concentrated solution of it dropped into the eye almost always produces narrowing of the pupil. Active peristalsis of the bowels comes on early. Clonic spasms, which are not altogether respiratory, and paralysis of the hind- and then of the fore-legs precede death. Five milligrammes produce symptoms of poisoning in, and four centigrammes constitute a lethal dose for, rabbits^ weighing one killogramme. The symptoms strongly resemble those produced by muscarine, and like them are combatted by atropine. Mydalein produces the following symptoms in rabbits : — The secre- 1 Ueber Plonalne, Theil, i. ii. POISONING BY MUSSELS. G17 tion from the nostrils and the lacrymal glands is increased ; the pupils are dilated and reactionless, and the vessels of the ears are injected ; the temperature is elevated l°to 2" C. ; the pulse and respirations at first increase in rapidity and then become slower, the heart ceasing in diastole. Peristalsis is increased, and there is diarrhoea and vomiting ; clonic spasms and paralysis with a tendency to stupor precede death. Five milligrammes of mydalein hydrochlorate injected into a kitten caused rapid dilatation of the pupils, which were reactionless, diarrhoea, vomiting, salivation, sweating of the feet, stupor, muscular spasms, paralysis first of the hind- and subsequently of the fore-legs, slow laboured breathing and death. The heart was found in diastole ; the mucous membrane of the bowels was somewhat injected, and they contained some thin fluid secretion. PTOMAINES IN FOOD. Instances occur from time to time in which people, individually or collectively, are suddenly attacked with violent symptoms of poisoning shortly after partaking of food ; examination of the remains of the food, and, in fatal cases, of the organs of the deceased and their contents, fails to afford evidence of the presence of an added poison. It has long been known that in certain stages of incipient putrefaction food is capable of acting as a poison, but it is only of late years that some knowledge has been obtained as to the nature of the toxines thus formed ; so far, the information obtained is very imperfect, but the way has been opened out and the direction indicated by which a more exact knowledge of these decomposition products may be obtained. Basic substances having toxic properties have been found in fish, in various kinds of animal food, in milk, cheese, and other food-stuffs. In some instances the changes which produce the toxine take placi during life ; more usually they are non-vital phenomena. Poisoning by Mussels. Mussel poisoning is due to the formation of a toxine whilst the fish (mytilus edulis) is still alive. It was formerly believed that mussels owed their poisonous properties to the presence in them of copper derived from ships' bottoms, or from copper-covered fixtures in har- bours; to a special disease from which the fish laboured under ; to the presence of specimens of a poisonous species along with the edible fish ; to incipient putrefaction taking place after the harmless fish were removed from the water, and to various other conditions which were €18 FORENSIC MEDICINE. naturally assumed in default of positive knowledge. Brieger 1 was the first to succeed in isolating from poisonous mussels a basic product in a condition sufficiently pure to admit of ultimate analysis. A number of cases of mussel poisoning, several of which were fatal, occurred at "Wilhelmshaven in 1885; from a quantity of the noxious mussels Brieger obtained a poisonous base which he called mytilotoxin, to which he ascribed the formula C 6 H 15 N0 2 ; other bases, among which is betaine, are also present. The conditions which lead to the development of this toxine in mussels are : — stagnant water, or water which is not in free communica- tion with the sea ; or water which is contaminated with sewage, or other organic matter undergoing decomposition. It is not essential that the water should contain noxious matter ; mere absence of fresh- ness is sufficient to interfere with the metabolism of the mussels to such an extent as to lead to abnormal changes in their tissues, which result in the formation of a toxine during life. If mussels which have thus become poisonous are placed in water in free communication with the sea, they rapidly lose their poisonous properties. Poisonous mussels have invariably been obtained from harbours, docks, the mouths of rivers, and other places where either a deficiency of tidal interchange takes place, or where the water is contaminated with decomposing organic matter. Symptoms. — The mild and common form of mussel poisoning is characterised by the appearance of an exanthematous, or urticarial eruption, all over the body, which may be associated with a feeling of ■oppression in the chest and difficulty of breathing. In the severer forms gastro-intestinal disturbance occurs, and in the most dangerous of all paralysis. The following cases illustrate the etiology and the symptoms of fatal mussel poisoning. Permewan 2 relates the case of a man aged forty who ate uncooked a large quantity of mussels obtained from the bottom of a graving-dock. When seen a few hours after he was absolutely unconscious, the face was livid, the pulse almost imperceptible, and the pupils were widely dilated and inactive ; he took gasping breaths about once or twice in the minute ; there was no vomiting nor purging. The temperature did not materially fall until the circu- lation failed. The limbs were flaccid — there was complete paralysis and unconsciousness. Neither stimulants, atropine, strychnine, nor artificial respiration, evoked any attempts at natural respiration, and death took place in about twelve hours after the mussels were eaten ; the heart continued to beat for many hours after voluntary i Ueber Ptomaine, Drifter Theil, 18S6. 2 The Lancet, 188S. POISONOUS FOODS. G19 respiration had ceased. In another case, reported by Cameron, 1 a woman and five children ate some mussels which had been gathered from a sheet of water to which the sea had access ; fresh water and some sewage also flowed into it. In twenty minutes symptoms of poisoning commenced in the form of prickly pains in the hands ; in less than an hour one child died ; in two hours the mother and three other of the children were dead. They suffered from violent vomiting, dyspnoea, swelling and lividity of the face, and spasms ; they appeared to have died asphyxiated. One child and a maid who ate but few of the fish recovered. Cameron found an alkaloidal substance, and Mc"V\ eeney 2 found bacteria in some mussels from the same source. Other shell fish besides mussels may develop toxines. Cameron relates a case in which ten out of twelve persons, who lunched to- gether, ate of some oysters j nine out of the ten were attacked with nausea, vomiting, diarrhoea, abdominal pain, and prostration ; they all recovered. The oysters had been grown in a place to which sewage had access. Treatment.— Evacuate the stomach with an emetic, and the bowels with an aperient, unless both vomiting and purging have already emptied the digestive canal ; then give stimulants ; apply external warmth and friction, and perform artificial respiration if required. Atropine has been recommended. Morphine may be advisable if the purging and abdominal pain are excessive. Post-mortem Appearances are not characteristic; there may be indica- tions of gastro-intestinal irritation. POISONOUS FOODS. Food-Stuffs which are undergoing chemical changes not unfrequently develop toxines. Poisoning from this source has followed the use of tinned meats and fish ; sausages, black puddings, and liver; ham, veal, and other meats ; milk, cheese, &c. From time to time large numbers of people are simultaneously attacked with symptoms of acute poison- ing after partaking of a common meal. Symptoms. — They comprise nausea, dryness in the mouth and throat, vomiting, diarrhoea, heaviness in the stomach, headache, giddi- ness, prostration, rigors, quick shallow breathing, feeble pulse, profuse sweating, dyspnoea, delirium, and coma. Dilatation of the pupils, par- alysis of accommodation, ptosis, and paralysis of the organs of speech have been observed. The symptoms do not always run the same course even when produced in a number of people at the same time and by the same food— a condition closely resembling that due to a 1 Brii. Mfd. Journ., 1890. - Ihid. G20 FORENSIC MEDICINE. metallic irritant may be produced in some, whilst in others the nervous system bears the brunt. The gastro-intestinal symptoms may be so intense as to resemble an attack of cholera, sometimes after profuse diarrhoea obstinate constipation occurs. la Germany where large quantities of sausages are eaten, poisoning from this cause is not uncommon; the term boiulismus has been applied to it. Liver and blood enter into the composition of some of these sausages, which appear to be specially prone to develop toxic bases. Finely-divided meat is very liable to become toxic because of the large surface that is thus exposed to the air ; as previously stated, the pre- sence of oxygen appears to be necessary for the development of poison- ! ous ptomaines. Instances have occurred in which poisoning has followed the use of perfectly fresh meat derived from cows that have recently calved, the toxic effects being presumably due to pathological changes taking place during life. In one or two such instances the cows were known to have had milk fever. Tinned Food may undergo toxic changes which do not affect its ap- parent freshness so far as taste and smell are concerned. Fish thus preserved appears specially liable to become toxic ; the following is a case in point: — Six persons ate of tinned salmon to supper ; early the following morning they were seized with violent pain in the stomach, vomiting, profuse diarrhoea, pain in the head, thirst, a tem- perature of 102°-103° F., and a pulse-rate from 110 to 160 in the minute. One patient became semi-unconscious, with a tempera- ture of 104 F. ; the pulse was almost imperceptible, the skin was cold and clammy, and pupils were widely dilated ; death ensued. At the necropsy the brain was found superficially congested ; the stomach and the intestines were so deeply inflamed as to be almost gangrenous in parts. 1 Stevenson' 2 records the case of a man, aged 21, who ate six sardines to breakfast • a few hours after he complained of feeling un- well, and vomited. Next morning there was slight pain in the stomach ; the abdomen was tense, but not enlarged, and the patient was perspiring ; shortly after noon collapse rapidly set in, and death occurred almost immediately. At the necropsy made the following day the features were found bloated so as to be unrecognisable, although the weather was cold (17° F.) ; blood-stained fluid exuded from mouth, nostrils, and ears ; except the hands and feet the whole body was emphysematous, and there were large bullae on the buttocks. The abdomen was distended with gas ; the mucous membrane of the stom- ach and intestines was emphysematous ; the liver was cavernous and friable, and along with the kidneys and bladder was hyperaemic ; the ^Brit. Med. Journ., 1891. 2 Brit. lied. Journ., 1892. POISONOUS FOODS. C21 Wackier was distended with gas. The large intestine was normal and contained solid faecal matter. Stevenson obtained alkaloidal extracts from four of the remaining sardines, from the contents of the stomach, and from a portion of the vomit, all of which were highly toxic and respectively killed three rats to which they were administered sub- cutaneously. From other experiments it was shown that the toxine was not present in all the fish, and that it was probably generated in the poisonous sardines before they were tinned. Milk has caused severe poisoning owing to the occurrence in it of chemical changes. Newton and Wallace l give an instance in which a number of people living in two hotels were suddenly taken ill four hours after supper with symptoms of gastro-intestinal irritation — nausea, vomiting, cramps, and collapse ; a few had diarrhoea. The following week a second series of cases, of precisely the same nature, ■occurred in another hotel. The symptoms were traced to the milk, but no added poison was found in it. Further investigation shown! that the cows from whence the milk was derived were healthy, but that after milking, the milk was at once placed in cans and carted ■eight miles during the warmest part of the day and in a hot season of the year ; the method usually adopted being to allow the milk to cool in shallow open vessels surrounded with cold water or ice previous to transport. Chemical examination of the suspected milk revealed the presence of a substance — identical with Vaughan's ty rotoxicon — whicl 1 produced symptoms of poisoning in a cat ; it is probably chemically allied to butyric acid. Cheese.- — Numerous instances of poisoning by cheese have occurred, especially in Germany and America. The symptoms which appeared in a number of cases (nearly three hundred) that happened in America in 1884 and 1885 were as follows : — Violent vomiting and diarrhoea, pain in the stomach, and cramps in the legs ; the tongue at first coated white, was later red and dry; the pulse was weak and irregular, and the face pale and cyanotic. None of the cases were fatal. The cheese which caused the symptoms was not old nor decayed; Vaughan 2 found that it possessed the characteristic of instantly and intensely reddening litmus-paper ; good cheese when new slightly reddens litmus-paper, but does not produce immediate and pronounced change of colour. By extracting the poisonous cheese with water, alkalising, and shak- ing out with ether, Vaughan obtained needle-shaped crystals, which had a distinct toxic action, and to which he gave the name tyrotoxicon. The substance is not an alkaloid nor does it respond to the alkaloidal group-tests ; it is soluble in water, alcohol, ether, and chloroform. It 1 Medical News, 1SSG. - The Practitioner, 1SS7. G22 FORENSIC MEDICINE. appears to be due to the action of micro-organisms present in the milk from which the cheese is prepared. Subsequently Vaughan x found a toxalbumose in some cheese in which no tyrotoxicon was present. Old decayed cheese yields an alkaline reaction, and has frequently given rise to colic, diarrhoea, dizziness, diplopia, precordial pain, and collapse. Brieger obtained trimethylamine from decayed cheese. ^ riul. Med. and Surg. Repr., 1890. INDEX. Abdomen-, Injuries of, 275. Abortifaciants, 121. Abortion, 119. Cause of death in, 126. Drugs used for procuring, 121. General violence as a cause of 123. Law as regards, 120. Local violence as a cause of 124. Modes of procuring, 121. Period when resorted to, 126. Signs of, 127. Absorption and elimination of poisons 3S4. Acetylene and oxides of carbon, Poison- ing by, 496. Acid, arsenic, Poisoning by, 428. ,, arsenious, ,, 427. Tests for, 435. '» 5 . Treatment of poisoning by, 432. , , boric, Poisoning by, 490. ,, carbolic, ,, 534. >> ,, Tests for, 537. " )> Treatment of poisoning by, 530. ,, hydrochloric, Poisoning by, 415. >j >> Tests for, 416. ,, hydrocyanic. Poisoning by, 501. 5 > > , Tests for, 506. »j :> Treatment of poison ing by, 505. ,, meconic, Tests for, 557. ,, nitric, Poisoning by, 412. ,, ,, Tests for, 413. ,, oxalic, Poisoning by, 416. )> ,, Tests for, 418. , , , , Treatment of poisoning by, ■417. ,, picric, Poisoning by, 538. ,, ,, Tests for, 539. > 3 ,, Treatment of poisoning bv 538. ,, salicylic, Poisoning by, 533. Tests for, 53 i, ,.. sulphuric, Poisoning by. 407. Tests forj 411. Acids, Burns by, 254. mineral, Treatment of poisoning by, 409. ° Aconite, Poisoning by, 5S4. " )> treatment. 5^7. Acomtine, „ 585. Aconitine, Properties and physiological action of, ,"j s 4 . Tests for, 587. Varieties of, 583. Adipocere, 57. Age, 21. „ in relation to power of procreation 83-80. ,, in relation to poisons, 383. ,, Determination of, in new-born infant, 23. ,, Marriageable, 22. ,, Medico-legal bearings of, 21. Air in stomach as sign of respiration, 141. Alcohol, amyl, Poisoning by, 510. ,, ethyl, Diagnosis of poisoning by, 507. >> ,, Tests for, 510. ?> ,, Treatment of poisoning by, 509. Alcoholic insanity, 334. paralysis, 336. Alkalies, Burns by, 255. Alkaloidal group reagents, 541. Alkaloids, Characters of, 540. ,, Isolation of, from organic- matter, 401. Almonds, bitter, Poisoning by, 502. 506. . ". » oil °f, ,, 501,505! Amanita muscaria, Poisoning bj^, 611. ,, phalloides, ,, 610. Ammonia, Excess of, in urine in acute phosphorus poisoning, 4S1. ,, Poisoning by, 420. Ammonium carbonate, Poisonin- bv 422. ° * Amyl alcohol, Poisoning by, 510. „ nitrite, „ 511. Anesthetics, Responsibility in death from, 305. Aniline, Colour of surface in poisonino- by, 528. ,, Poisoning by, 527. ,, Tests for, 529. Antagonism of morphine and atropine 391. ,, of poisons, 391. Limited, 394. Antidotes, 300. Antifebrin, Poisoning by, 530. _ ,, Tests for, 530. Antimony. Acute poisoning by, 442. „ chloride, ,, 444. ,, Sub-acute 44:;. 624 Antimony, Tests for, 44.5. ,, Treatment of poisoning by, 444. Antipyrin, Poisoning by, 531. ,, Tests for, 531. Aphasia in relation to testamentary capacity, 375. Aqua fortis, 412. Argyria, 467. Arsenetted hydrogen, 428. Arsenic, Acute poisoning by, 428. ,, Chronic ,, 433. ,, Combinations of, 427. ,, eaters, 434. ,, Fatal dose of, 431. ,, Poisoning by, post-mortem ap- pearances of, 432. ,, ,, Treatment of, 432. Arsenious sulphide, 428. Artificial inflation, 135. ., respiration, 232. Asphyxia, 33. ,, Signs of death from, 34. Assizes, 6. Atkinson's infant's preserver, 551. Atropine, Fatal dose of, 501. ,, Poisoning by, 560. ,, Properties of. 559. ,, Tests for, 563. ,, Treatment of poisoning by, 562. Back, Wounds of, 292, 298. Baines, Reg. v., 360. Banks v. Goodfellow, 373. Barium, Poisoning by, 425. , , Tests for, 426. ,, Treatment of poisoning by, 425. Battle's vermin-killer, 542. Belladonna, Fatal dose of, 561. ,, Poisoning by, 560. ,, Treatment of poisoning by, 562. Benzene and its derivatives, 522. ,, Poisoning by, 522. ,, ,, vapour of, 522. Berry, Beg. v., 412. Bestiality, 109. Birth, Concealment of, 165. ,, in relation to the civil law, 166. Birth-marks, 60. Bismuth, Poisoning by, 471. ,, Tests for, 472. ,, Treatment of poisoning by, 471. Bisulphide of carbon, Acute poisoning by, 518. ,, ,, Chronic poison- ing by, 519. Bitter almonds, Oil of, Poisoning by, 501-505. ,, Poisoning by, 502-506. Bittersweet, Poisoning by, 570. Blackening of hand by fire-arms, 296. ,, wound ,, 296. Bladder, Rupture of, 276. Bleaching-fluid, Poisoning by, 490. Blood, Bright-red, after death from aconi- tine, 586. ,, ,, ,, exposure to cold, 234. CO, 497- 499. HCN, 503. „ ,, ,, fire, 247. human, from of ,, Distinction animal, 64. ,, -stains, 63. ,, ,, Chemical examination of, 70. ,, ,, Microscopical ,, 64. ,, ,, Spectroscopic^ ,. 66. ,, ,, in rape, 108. ,, ,, on knives, 71, 29.">. Bodies, Exhumation of, 21. Body, Cooling of, 38. ,, Examination of, 17. f, ,, in cases of poison- ing, 19. Bones, Fractures of, 279. ,, in relation to identity of the dead, 74. ,, Unnatural fragility of, 2S0. Boracic acid, Poisoning by, 490. Tests for, 491. Born alive, Legal definition of, 142. Botulismus, 620. Brain, Concussion of, 265. ,, Contusion of, 266. Bromine, Poisoning by, 487. Tests for, 489. ,, Treatment of poisoning by, 4S8. Brucine, Tests for, 548. ,, Toxic action of, 548. Bruises distinguished from post-mortem stains, 42. Burns, Accidental, 249. ,, and scalds, Cause of death from, 242. ,, ,, Post-mortem appear- ances of death from, 245. ,, by corrosive fluids, 254. , , Colour of blood' after death from, 247. ,, Homicide in relation to, 250. ,, Identification of bodies after death from, 251. ,, produced before and after death, 24S. Burns, Reg., v. 360. Butler's vermin-killer, 542. Butter of antimony, 444. INDEX. G25 Cadaveric alkaloids, 615. ,, hypostases, 39. ,, rigidity, 4.'!. ,, ,, Causation of, 44, 47. ,, ,, Conditions which hasten. 44. ,, ,, in respect to the heart, 4.3. j, spasm, or instantaneous rigor, 47. ,, Examples of, 48. Cadmium, Poisoning by, 470. Calabar bean, Poisoning by, GOO. ,, Treatment of poisoning by, 002. Camphor, Poisoning by, G03. Cannabin, 566. Cannabinon, 566. Cannabis Indica, Poisoning by, 566. Canonical impediment to marriage, 1S2. Cantharides, Poisoning by, 612. ,, ,, Treatment of, 613. Cantharidin, Properties of, 012. ,, Tests for, G14. Capacity of child's stomach, 27. skull, 27. ,, Testamentary, 373. Carbolic acid, Poisoning by, 535. ,, Tests for, 537. ,, Treatment of poisoning by, 336. Carbon bisulphide, Acute poisoning by, .3 IS. ,, ,, Chronic ,, 519. ,, ,, Treatment of poison- ing by, 519. ,, dioxide, Air containing, 494. ,, ,, Chemical analysis of, 49-3. ,, ,, Poisoning by, 49 1. ,, monoxide, Acute poisoning by, 496. ,, ,, j Chronic ,, SCO. ,, ,, haemoglobin, 497. ,, ,, Intrinsic toxic action of, 497. ,, ,, Sources of, 495. ,, ,, Spectroscopic examina- tion of the blood in poisoning by, 499. ,, ,, Treatment of poisoning by, 497. Carburetted hydrogen, 495. Carnal knowledge, 89. Castor-oil seeds, Poisoning by, GOG. Cathartics, Treatment of poisoning by, 606. Causes of death from wounds, 299. Cephalhematoma, 160. Certificates in lunacy, 361, 364, 307. ,, ,, Responsibility as regards, 369. Chancery lunatics, 372. I e, Poisoning by, 621. ,, Trimethylamine in decayed, 622. Chemical combination of poisons, Influ- ence of, 385. ,, evidence of poisoning, 399. . -laurel « ater, 502. Chest, Injuries of, 272, 291. Children, Supposititious, 170. Chloral hydrate, Poisoning by, 514. ,, ,, Tests for, 516. ,, ,, Treatment of poisoning by, 515. Chlorine, Poisoning by, 489. ,, ,, treatment, 490. Chlorodyne, 551 . Chloroform, Poisoning by, 512. ,, Tests for, 513. ,, Treatment of poisoning by, 513. Choke-damp, 494. Chromate of lead, Poisoning by, 47-3. Chrome-yellow, ,, 47">. Chromic acid, ,, 473. ,, ,, Treatment of, 474. Chromium, Tests for combinations of, 475. Chronic alcoholic insanity, 33.3. Cicatrices, 59. Circular insanity, 325. Circulation, Cessation of, 37. Civil disability as regards marriage, 1S2. ,, rights, Deprivation of, in insanity, 372. Classification of poisons, 385. Clothing, Blood-stains on, 0.3. Coal-gas, Poisoning by, 495. Cocaine, Fatal dose of, 5G9. ,, Poisoning by, 508. ,, Tests for, 569. ,, Treatment of poisoning by, 5G9. Cocculus Indicus, Poisoning by, .349. „ ,, treatment of, 5.30. Colchicine, Properties and physiological actions of, 579. Tests for, 5S1. Colchicum, Poisoning by, 579. ,, ,, Treatment of, 580. Cold, Death from, 233. ,, ,, Post-mortem signs of, 234. Cole, Reg. v., 352. Colocynth, Poisoning by, G05. Colostrum, 1 10. ( Soma, 35. Combustibility, Preternatural, 251. ,, ,, medico-legal bearing of, 2.34. Commission of inquiry in lunacy, 372. Common witness, 8. 40 626 INDEX. Concealment of birth, 165. ,, pregnancy (Scotch law), 166. Concentration of poisons, Influence of, 3S5. Concussion of the brain, 265. Conine-methyl, 575. Conine, Properties and physiological action of, 575. ,, Poisoning by, 57a. ,, Tests for, 570. ,, Treatment of poisoning by, 570. Conium maculatum, 574. Contusion of the brain, 2C6. Contusions, 256. Cooling of the body after death, 38. Copper, Acute poisoning by, 402. ,, arsenite, 428. ,, Constant presence of, in the body, 465. ,, Chronic poisoning by, 463. ,, in tinned green peas, 464. ,, Tests for, 465. ,, Treatment of poisoning by, 462. Cord, Mark of, in hanging, 11)1. ,, „ strangulation, 201. Coroner's act, 3. , , court, 2. Corpus luteum, 116. Corrosive fluids, Burns by, 254. ,, poisoning, General symptoms of, 394. ,, ,, Postmortem signs of, 396. ,, sublimate, Poisoning by, 447. Corrosives, 407. Courtesy, Teuancy by, 167. Courts of Justiciary, 16. Creasote, Poisoning by, 539. Tests for, 540. Cretinism, 340. Criminal abortion, 119. ,, ,, Modes of procuring, 121. Signs of, 127. ,, responsibility, 350. ,, ,, plea of delirium tremens, 360. ,, ,, ,, delusional insanity, 356. ,, ,, ,, drunken- ness, 359. ,, ,, ., impulsive insanity, 356. ,, ,, ,, moral in- sanity, 354. ,, ,, ,, recurrent insanity, 354. Crockery-ware, Wounds from broken, 25S. Cross-examination, 7- Cross, Peg. v., 435. Croton oil, Poisoning by, 605. Cryptorchids, Virility of, 82. Cut-throat wounds, 289. Cyanogen, Compounds of, 501. Cyanide of potassium, Poisoning by, 505. ,, ,, Tests for, 506. Cytisine, Properties and physiological action of, 589. , , Tests for, 590. Daley's carminative, 551. Daphne mezereon, Poisoning by, 590. Datura stramonium, ,, 565. Daturine, 565. Dead, Identity of the, 72. Death of foetus in utero, 175. ,, of infant from accidental causes, 146. ,, from anaesthetics, 305. ,, cold, 233. ,, ,, ,, Post-mortem signs of, 234. ,, ,, hemorrhage, 299. ,, ,, heat-stroke, 236. ,, „ inflammation, 302. _„ ,, lightning, 236. ,, ,, ,, Post-mortem signs of, 240. ,, ,, psychical shock, 301. ,, ,, septic processes, 303. ,, ,, shock, 300. ,, tetanus, 303. ,, Molecular and somatic, 36. „ Signs of, 36. Delirium ebriosum, 334. ,, tremens, 335. Delivery, hasty. Death of infant from, 150. ,, Loss of consciousness during, 150. ,, Prolonged, 148. ,, Signs of, 116. ,, ,, in the dead, 117. ,, ,, remote, 118. Delphinium staphisagria, Poisoning by, 5SS. Delusional insanity, 326, 356. Delusions, 319. ,, and testamentary capacity, 373. Dementia, Acute, 325. ,, Adventitia, 350. ,, from coarse brain lesions, 342. ,, natural is, 350. ,, Secondary, 342. ,, Senile, 341. Desquamation of the skin of new-born infant, 26. Detachment of funis, 27. Development of fcetus after five months,. before 128. INDEX. G27 Development of foetus, Table of, •_'(">. Diagnosis of poisoning, 3S6. Diaphragm, Rupture of, 276. Discharge of lunatics, 3(i4. Dichromate of Potassium, Poisoning by, •174. ,, ,, Treatment of poisoning by, 474. Digitalin, Tests for, 579. Digitalis, Fata] dose of, 578. ,, Poisoning by, .~>77. ,, ,, Treatment of, 578. Dinitrohenzene, Acute poisoning by, 524. ,, Chronic ,, .V2-3. ., Tests for, .~>27. ,, Treatment of poisoning by, 526. Dinitrotoluene, Poisoning by, 527. Dipsomania, 337. Disease as an impediment to procreation, 84. ,, contrasted with the effects of poison, 386. Disposing mind, In testamentary capa- city, 373. Divorce, Duties of medical inspectors in, 184. ,, Incapacity as a plea for, 183. ,, Insanity ,, 18:2. ,, Medico legal bearings of, 182. Documentary evidence, 13. Dodwell, Reg. v., 357. Doubtful sex. 79. Dover's powder, 551. I >rowning, 215. ,, and strangulation, 226. ., wounds from fire-arms, 227. Artificial respiration in, 232. ., Condition of lungs in death from, 219. ., Death after re-commencement of respiration, 232. ,, Epitome of signs of death from, 224. Floatation of body after, 217. hands and feet tied, 229. ,, Importance of external rela- tions in death from, 225. ., Inhibition of respiration in, 215. ,, Injuries produced after death from, 227. ,, ,, befoiv from. 226. ,, in shallow water, 229. ,, post-mortem appearances, 217. ,, Resuscitation from apparent, 230. Statistics of, 224. ,, Water in intestines in, 223. ,, ,, stomach in, 221. Drowning, wounds on body, 22.~>. Drugs used to procure abortion, 121. Drunkards, Restraint of habitual, 378. Drunkenness, Criminal responsibility, plea of, 359. Dry method of destroying organic matter, 405. Duboisine, Poisoning by, •">(3.~>. Duration of '■.< station, 168. Blondlot's test for phosphorus, 484. Dying declarations, 13. Dynamite, Gases produced by detona- tion of, 50 1 . ,, Poisoning by, 512. ,, Suicide by detonation of , 288. EAR, Injuries of, 271. Ecbolics, 121. Ecchjunoses, 257. ,, Colour-changes in, 257. ,, from slight pressure, 237. Edmunds, Reg. v., 355. El iiriuni, Poisoning by, ('>!).">. Electricity, Death from, 242. Elevation of temperature, Post-mortem, 38. Emetics in poisoning, 389. Emmenagogues, 121. Epileptic automaticity, 329. furor, 329. ,, insar.it} - , 32S. Epispadias, 79. Epsom salts, Poisoning by, 420. Ergot, Acute poisoning by, 595. ,, Chronic ,, ."97. ,, Nature and physiological action of, 595. ,, Tests for, 59S. ,, Treatment of acute poisoning by, 596. Ergotism, Gangrenous, 597. ,, Spasmodic, .".97. Esserine, Poisoning by, 601. Ether, ., " 510. Evidence of poisoning from dead body, 396. Ex; i. Poisoning by, 530. Examination of lunatics, .'l( : (>. ,, dead body, 17. ,, ,, in poisoning, 19. ,, women. Precautions necessary in, 103. Examination-in-chief, 7. Excitement as a cause of death, 301. Exhumation, 21. Expert witness . 8. Exposure of person, Indecent, 111. Eyes, Injuries of, 271. FACE, Injuries of, 271. Fasting, Metabolism during, 311. 628 INDEX. Fatty changes in poisoning by antimony, 444. ,, ,, arsenic, 433. ,, ,, copper, 463. ,, ,, ergot, 595. fungi, 611. ,, ,, phosphorus, 479. Fees to medical witnesses, 12. ,, ,, in Scotland, 17. Feigned delivery, 176. ,, homicidal wounds, 308. ,, ,, strangulation, 204. ,, insanit}', 376. Female organs, Abnormalities of, 82. Finger marks, Identification by, 294. Fire-arms, Multiple fatal wounds by, 297. ,, Wounds produced by, 282. ,, ,, Causal relation of, 296. Fish, Poisoning by tinned, 620. Fly-fungus, 609. ,, papers, Use of, as toxic agents, 42S. ., powder, 427. Ftetus at term, 24. ,, Death of, in utero, 175. ,, Development of, after live months, 23. ,, ,, before ,, 128. Food, Symptoms of poisoning after, 386. ,, poisonous. 619. Footprints, 62, 293. Foxglove, Poisoning by, 577. Fractures of bones, 279. ,, ,, in the living and the dead, 282. ,, from muscular contraction, 280. Delayed, 280. ,, Previous, 281. ,, Processes of union in, 281. ,. of the skull, 266. ,, ., spine, 270. Fright, Death from, 301. Fruit, Poisoning by tinned, 470. ,, stains, 72. Fungi, Causes of toxicity of edible, 607. ,, Gastro-enteric symptoms due to, I il)S. ,, Neurotic, ,, ,, 609. „ Poisoning by, 608. ,, ,, Treatment of, 611. ,, Varieties of poisonous, 607. Funis, Accidental injuries to, 159. ,, in relation to live-birth, 144. ,, Mummification of, 26. ,, Neglect of tying, 158. ,, Prolapse of, 146. ,, Separation of, 27. ,, strangulation of infant by, Acci- dental, 147, 157. jj , y Criminal, 158. Fusel oil, Poisoning by, 510. Gangrenous ergotism, 597. Gas, coal, Poisoning by, 49;5. ,, Mater, ,, 495. Gaseous compounds, Poisoning by, 491. Gases produced by explosives, 500. Gasoline-stoves, Poisoning by vapour from, 496. Gathercole, Reg. v., 349. Gaultheria, Poisoning by oil of, 594. Gelsemine and gelsemin, 567. ,, Tests for, 568. Gelsemium, Poisoning by, 567. ,, ., Treatment of, 56S. General paralysis of the insane, 331. ,, ,, ,, Fxceptional forms of, 333. ,, symptoms of corrosive and irri- tant poisoning, 394. ,, treatment of poisoning, 389. „ violence as a cause of abortion, 123. Genitals, Injuries of the, 27S. Gestation, Abnormally prolonged, 169. ,, ,, shortened, 171. ,, normal, Duration of, 168. (Jiving evidence, 10. Glass, Wounds from broken, 258. Godfrey's cordial, 551. Gonococci in cases of rape, 99. Green hellebore, 581. Greened vegetables, 464. Group-reagents for alkaloids, 541. Guaiacum test for blood, 65. Gun-cotton, Gases produced by explosion of, 501. ,, -powder, ,, ,, 501. Gunshot wounds, 282. , , Causal relation of, 296. Habit, Influence of, as regards poisons, 383. Habitual drunkards, Placing under restraint, 378. Hamatin, reduced, Spectrum of, 69. Ha?matoporphyrin in urine in poisoning by sulphonal, 5 IS. Ha?matorrhachis, 269. Haemin crystals, 70. Hematoma auris, 271. Haemoglobin, Spectrum of, 67. Ha?morrhage as cause of death, 299. ,, from iucised wounds, 259. Hair, Alteration in colour of, 61. Hairs, Source of, 62. Hallucinations, 319. Hanbury ?•. Hanbury, 183. Hand, Blackening of, by firearms, 296. , , Weapon in, after death, 292, 298. Hanging, 185. ,, Accidental, 193. INDEX. 629 Hanging, After-effects of threatened death from, 200. ,, Cases of, 107. , , compression of vessels in neck, 190. ; , Distinction of, before and after death, 194. ,, Experimental investigations as to, 186. ,, Experimental investigations as to the condition of the lungs in, 188. ,, Eomicidal, 1!I4. ,, Mark of cord round neck in, 191. ,, Modes of death in, ISO. ,, Post-mortem appearances of death from, 190. ,, Pressure on the vagi in, 189. ,, Sudden loss of consciousness in suicidal, 190. Head, Injuries of, 264, 286, 297. Health, State of, as to the effect of poisons, 383. Heart, Wounds of, 273, 297. Heat-stiffening, 45. ,, stroke, Death from, 236. Hedeoma, Poisoning by, 593. Hellebore, Poisoning by, 588. )) ,, Treatment of, 588. Helleborin, Physiological action of, 587. ,, Tests for, 58S. Hemlock, Poisoning by, 574. Henbane, ,, 564. >> >, Treatment of, 564. Hennah, Reg. v., 3S2. Hermaphrodism, 80. ,, Illustrations of varieties of, 81. Homicidal impulse, 346. Horse-radish compared with aconite root, 5s3. Hunter v. Edney, 182. Hydrochloric acid, Poisoning by, 415. ,, ,, Tests for, 416. Hydrocyanic arid, Fatal dose of, 504. >) ,, Poisoning by, 501-2. ,, ,, Tests for, 506. ;> ,, Treatment of poison- ing by, 505. Hydrostatic t< st, 1-34. >> ,, Inferences from, I In. >> ,, Possible fallacies of, 134. Hymen, Injuries of, 93. Ffyoscine, 564. Hyoscyamine, Poisoning by, 564. Hyoscyamus, ,, ' 564. Hypospadias, 79. Identity of the dead, 72. ,, living, 59. [diocy, 340. Idiosyncrasy as regards poison*, 383. Illusions, 319. Imbecility, 340. Immediate causes of death from wounds, 299. Impotence and sterility. 82. Impulse, Homicidal, 346. ,, Suicidal, :; 17. Impulsive insanity, 345, 356. Incapacity a ground for nullity of marriage, Is.:. Incised wounds, 258. ,, apparent from blunt weapons, 259. ,, of the abdomen, 278. Indecent exposure of the person, 111. Indian hemp, Poisoning by, 566. ,, tobacco ,, 572. Indications of poisoning, 386, :;^s. Infanticide, 130. ,, by drowning. 102. ,, ,, fracture of the skull, 159. ,, ,, strangulation, 155. >i >) ,, with the funis, 158. ,, ,, suffocation, 152. ,, .. wounding, 161. ., causes of death of infant, 145. ,, exposure of infant as a cause of death, 163. ,, hasty parturition ,, 150. ,, prolonged ,, ,, 14S. „ neglect of infant ,, 158. ,, Hydrostatic test in cases of, 134. , , Post-mortem examination in cases of, 164. „ Signs of respiration in cases of, 131. ,, Statistics of, 146. Inflation of lungs of infants. Artificial, 135. Injuries of the abdomen. 275. ,, bladder, 276. ,, cervical spine not imme- diately fatal, 270. ,, chest, 272. j, diaphragm, 276. ear, 271. . 271. ,, genital organs, 278. ,, head. 264. ,, heart. 27 b intestines. 275. ,. kidneys, 270. ,, liver, 275. ,, neck, 272. skull. 261. ,, spine, 269. ,, spleen, 276. ,, stomach, 275. ,, uterus, 279. 630 Inorganic poisons, 407. , , Isolation of, 404. Inquests, Coroner's, 2. Inquisitions in lunacy, 371. Insanity, 31(3. as a plea for divorce, 182. Certificates in, 361, 364. Circular, 325. Classification of forms of, 316. Criminal responsibility in, 350. Delusional, 320, 356. Deprivation of civil rights in, 372. Epileptic, 328. Feigned, 370. from coarse brain-lesion, 342. general paralysis, 331. ,, exceptional forms of, 333. Hallucinations in, 319. Impulsive, 345, 350. Indications of, 317. in relation to child -bearing, 33S. Legal terms used in, 350. Lucid intervals in, 326, 354. Moral, 342, 354. Medico-legal relations of, 350. of lactation, 339. Plea of, in criminal cases, 350. in pregnancy, 33S. Puerperal, 338. Recurrent, 320, 354. Toxic, 334. Instantaneous rigor, 4 / . Insurance, Life, 178. Intervals, Lucid, in insanity. 320, 354. Intestines, Punctured wounds of, 278. ,, Rupture of, 275. ,, Water in, after death from drowning, 223. Inverted sexual desire, 109. Iodine, Poisoning by, 4S5. ,, Solution of, as a reagent for alkaloids, 541. „ Tests for, 4S7. ,, Treatment of poisoning by, 4S7. Iodoform, Poisoning by, 4S0. Iron, Poisoning by, 472. ,, Tests for, 473. ,, Treatment of poisoning by, 472. Irritant poisoning, General symptoms of, 395. ,, Post-mortem siens of, 396. Isolation of alkaloids, 401. ,, inorganic poisons, 404. Jaboeaxdi, Poisoning by, 599. Jasmine, yellow, 567. •Jaw, Changes in, from age, 2S. ,, in old age, 2:). Judicial inquisition as to lunacy, 371. Juniperus sabina, 592. Kidneys, rupture of, 270. Kleptomania, 349. Knives, Blood-stains on, 71, 295. Labour, Hasty, as a cause of infant's death, 150. ,, Prolonged, ,, 148. Laburnum, Poisoning by, 589. ,, ,, Treatment of, 590. Lacerated wounds, 201. Laceration of the lungs, 273. Lactation, Insanity of, 339. Larynx, Death from spasm of, 210. Laudanum, 551, 554. Lead arthralgia, 457. ,, Acute poisoning by, 454. ,, Chronic ,, 455. ,, chromate, Poisoning by, 475. ,, colic, 457. ,, Elimination of, in chronic poison- ing, 459. ,, encephalopathy, 458. ,, paralysis, 457. ., poisoning, Psychoses of chronic, 338. .,, Tests for, 460. ,, Treatment of acute poisoning by', 455. ,, ,, chronic ,, 45S. Legal procedure in Scotland, 15. , , Test of insanity as regards criminal responsibility, 351. Legitimacy, 168. ,, Duration of gestation in relation to, 108. ,, Laws of various countries with regard to, 173. ,, Viability in relation to, 171. Leuciu in the urine in acute phosphorus poisoning, 4S1. Leucorrhcea in alleged rape, 99. Levant nut, Poisoning by, 549. Life assurance, 17S. ,, Form of medical report in, 181. Lightning, Death from, 236. ,, ,, Post-mortem appearances of, 240. Lime-kilns, Vapours from, 494. Limits of age as regards procreative power, S3, 86. Liquids, corrosive, Burns by. 254. Live-birth, Changes in funis as sign of, 144. ,, Definition of, 142. ,, in civil cases, 166. ,, Signs of, 145. Liver, Rupture of, 275. Lobelia, Poisoning by, 572. ,, ,, Treatment of, 572. INDEX. G31 Lobeline, Tests for, 57-. Local violence as a cause of abortion, 124. Locomotion after fatal injuries from lire- arms. 297. ,, ,, ,, of the bladder, 276. ,, bead. 269, 286. „ ,, ,, ,, hi art,273. „ large ves- sels, '290. ,, ,, poisoning by hydro- cyanic acid, 504. ,, immediately after delivery. 155. Lockjaw after injury, 303. ,, from tetanus and strychnine poisoning contrasted, ."i43. Lucid intervals in insanity. 326, 351. Lunacy certificates, 361, 364. ,, ., Legal responsibility as regards. 369. ,, Judicial inquisition as to, 371. Lunatics, Discharge of, 364. ,, Examination of, 366. ,, Testamentary capacity of, 373. Lungs fter death from drowning, 219. ,, amount of blood in, before and after respiration, 133. ,, Artificial inflation of, 132. , , Colour of, before and after respira- tion, 131. ,, Consistence of, ,. 133. ,, Fcetal condition of, in infants that have breathed, 13S. ,, Hydrostatic test for, 134. ,, ,, ,, inferences from, 1-10. ,, ,, ., possible falla- cies of, 134. ,, Laceration of, 273. ,, Specific gravity of, before and after respiration, 134. ,, ,, Effects of disease on, 137. ,, ,, ,, imperfeel ration, 138. ,, ,, ,, putrefaction, 136. M'Gowan, Reg. v., 360. M'Xaughton, Keg. v., 357. Magistrates' court. .5. Magnesium sulphate, Poisoning 1 Majority. Questions relating to attain- ment of, 22. Malapraxis, 306. Male organs. Abnormali tie ,, fern, Danger of taking castor oil with, 571 • ,, ,, Poisoning by, 570. ,, ,, ,, Treatment of, .371. Mania, Acute delirious, 320. ,, ,, ordinary, 321. Mania, Chronic, 322. Mark of funis round child's neck, 148, 156. Marriage, Grounds for nullity of, 183. ,, Impediments to, 182. Marsh's test for antimony. 445. ,, ,, arsenic, 437. Mason v. Marshall and others, 370. Matches, lucifer, Poisoning with, 476. Maturity of infant, Signs of, 24. Maybrick, Reg. v., 430. Meat from diseased animals, Poisoning by, 620. Meconic acid, Tests for, 551 . Meconium, 24. Medical certificates in lunacy, 364. ,, ,, examination of alleged lunatic, :'A)tl ,, evidence, Oral and documen- tary, 7. ,, inspectors in divorce cases, 1S4. ,, responsibility, 304. ,, ,, as to giving evi- dence, 8. ,, ,, ,, professional secrets, 9. ,, ,, in cases of poison- ing, 387. ,, ..in relation to lunacy certificates, 369. ,, ,, ,, examining women, 103. ,, ,, ,, patients with delirium tremens, 379. ., ,, ,, those crimin- ally wounded, 304. ,, test of insanity as regards criminal responsibility, 352. ,, witnesses, Fees to, 12. Medico-legal necropsies, 17. ,, ,, in cases of poison- in-, 19. ,, relations of insanity. 350. ,, ,, suicide-, ;: 1'..'. ,, reports, 14. Melancholia, 32:!. ,, with agitation, 325. ,, ., stupor, 325. Menstruation, Cessation of, 87. ,, ,, as evidence of pregnancy, 112. His. ,, Commencement of, 86. ,, Pregnancy without, S7. Mercuric chloride. Poisoned by. 447. ,, nitrate, ,, 449. Mercury, Acute poisoning by, 447. ,, Chronic ,, 450. Tests for ,, 452. ,, Treatment of acute poisoning by, 449. G32 INDEX. Metabolism during fasting, 311. Metallic poisons, 427. Methamioglobin, Spectrum of, 68. Mezereon, Poisoning by, 590. Middle ear test of live-birth, 143. Milk, Poisoning by, 621. Mirbane, essence of, Poisoning by, 523. Miscarriage, 119. Mitscheriicn's test for phosphorus, 484. Modes of dying, 33. Moist method of destroying organic matter, 404. Molecular death, 36. Moles, 115. Monk's-hood, Poisoning by, 5S3. Monomania, 326. Monorchids, Virility of, 82. Monsters cannot inherit, 78. Moral insanity, 342, 354. Morphine, Acute poisoning by, 552. ,, ,, ,, exceptional symptoms, 553. ,, ,, ,, Treatment of, 554. ,, Chronic ,, 558. ,, ,, ,, Treatment of, 559. ,, Elimination of, 55S. ,, Fatal dose of, 554. ,, Properties of, 551. ,, Solvents for, 556. ,, Tests foi*, 557. Morphinism, 337. Muco-purulent discharge in cases of rape, 98. Multiple suicidal wounding, 291. Mummification, 57. ,, of funis, 26. Muscarine, Properties and physiological action of, 609. Mushrooms, Poisoning by, 607. Mussels, Bacteria in, 619. ,, Cause of toxicity of, 618. ,, Poisoning by, 617. ,, ,, Treatment of, 019. Mydalein (ptomaine), 610. Mytilotoxin ,, 618. Naphthalene, Poisoning by, 531. Neck, Injuries of, 272, 2S9.' Nepenthe, 551. y Neurin (ptomaine), 616. Nicotine, Acute poisoning by, 573. ,, Chronic ,, 574. ,, Properties and physiological action of, 573. Tests for, 574. Nightshade, Deadly, 559. Nitre, Poisoning by, 423. Nitric acid, Poisoning by, 412. ,, fumes, ,, 414. Tests for, 413. Nitrite of amyl, Poisoning by, 511. TVT Nitrobenzene, Properties of, 523. ,, Tests for, 520. ,, Treatment of poisoning by, 524. Nitroglycerine, Gases produced by detonation of, 501. ,, Poisoning by, 511. Non compos mentis, 350. Notes, must be the original copy, 9. ,, Reference to, when giving evi- dence, 9. Noxious substances, 381. Nullity, Suits for, 184. Nutmeg, Poisoning by, 602. Nux vomica, Poisoning by, 548. ( Ibligation of medical witnesses, 8. (Enanthe crocata, Poisoning by, 577. Oil, croton, Poisoning by, 005. ,, of bitter almonds, Poisoning by, 501 , 505. ,, ,, gaultheria, ,, 594. ,, ,, mirbane, ,, 523. ,, ,, pennyroyal, ,, 593. ,, ,, savin, ,, 592. ,, ,, tansy, ,, 594. ,, ,, turpentine, ,, 591. r, ,, vitriol, ,, 407. ,, , , wintergreen, ,, 594. Opium and its alkaloids, 551. ,, Acute poisoniug by, 552. ,, ,, ,, exceptional symptoms of, 553. ,, Chronic ,, 558. ,, eating, 558. ,, fatal dose, 554. ,, Treatment of acute poisoning by, 554. ,, ,, chronic ,, 559. Orders for reception of lunatics, 361. ,, ,, Expiration of, 364 ,, ,. wandering at large, 363. ,, ,, pauper lunatics, 363. ,, Urgency for reception of lunatics, 3(32. Orpiment, Poisoning by, 428, 431. Ossification, Table of points of, 31. Overlaying of infants, 212. Oxalic acid, Poisoning by, 416. Tests for, 418. ,, Treatment of poisoning by, 417. Oxidicolchicine, 579. Oysters, Poisoning by, 619. Palmer, Reg. v., 544. Paraffin oil, Poisoning by, 520. Paraldehyde, 510. Paranoia, 326. Paregoric, 551. 633 Partial insanity. 326. Par ton, Reg. v., 515. Paternity, 168. ,, and affiliation, 176. Peas greened with copper, 464. Pederastia, 109. 1'clvis. Sexual characteristics of. 77. Penis, Malformation of, 85. Pennyroyal, oil of, Poisoning by, 593. Personal identity in the dead. 72. ,, ,, living, 59. Person, Indecent exposure of the, 111. Petroleum oil, Characteristics of, 5*20. ,, Poisoning by, 520. Phallin, Toxic action of, 610. Phenol, Poisoning by, 534. ,, Tests for, 537. ,, Treatment of poisoning by, 536. Phosphomolybdic acid, 541. Phosphorus, Acute poisoning by, 476. ,, ,, „ Treatment of, 478. ,, acute poisoning by, Changes in metabolism in, 481. ,, Chronic poisoning by, 483. ,, Fatal dose of, 478. Tests for, 483. Phosphotungstic acid, 541. Physical condition of poison, Influence of, 384. ,, signs of virginity, 97- Pbysostigmine, Poisoning by, G01. ,, Properties and physio- logical action of, 000. „ Tests for, 602. ,, Treatment of poisoning by, 602. Picric acid, Poisoning by, 538. , , , , Treatment of, 53S. ,, Properties of, 537. ,, Tests for, 539. Picrotoxin, 549. ,, Tests for, 551. Pilocarpine, Poisoning by, 599. ,, ,, Treatment of, 600. ,, Properties and physiological action of, 599. Placing habitual drunkards under re- straint, 378. Plea of insanity in criminal rases. 350. Poisoning by acetylene and the oxides of carbon, 496. ,, aconite. .">st. ,, alcohol amyl, 510. ,, ., ethyl, 507. ,, alniouds, bitter, 506. ,, ,, ,, oil of. 505. ,, amanita muscaria, till. phalloides, (510. ammonia, 420. ,, ., carbonate, 422. ,, amyl nitrite, 511. ,, aniline, 527. Poisoning by antifebrin, 530. ,, antipyrin, 531. ,, antimony, 442. ,, arsenic (acute). 428. ,, ,, (chrome i, 433. ,, atropine, 560. ,, barium, 42">. Battle's vermin-killer, 546. ,, belladonna, 560. ., benzene, 522. ,, bismuth, 471. ,, bisulphide of carbon(acute), 518. ,, .. ,, (chronic), 519. ,, bitter almonds, 506. ,, oil of, 505. bleaching fluid, 490. ,, borax. 4!H. boracic acid, 490. bromine, 4*7. ., cadmium, 470. calabar bean. fioO. ,, camphor, 003. ,, cannabis Indie i. 56G. ,, cantharides, 612. ,, carbolic acid, 535. ,, carbon bisulphide (acute), 5 1 8. ,, ,, .. (chronic), 519. ,, ,, dioxide. 494. ,, ,. monoxide (acute), 496. ,, ,, .. (chronic), 500. „ castor-oil seeds, GOG. ,, cheese, G21. ,, chloral hydrate, 514. ., chlorine, 489. ,, chloroform. 512. ., chrome yellow. 475. ,, chromic acid, 473. ,, coal-gas, 495. ,, cocaine. 568. ,, cocculus Indicus, oV.l colchicum, 579. ,, coloeyill li. 605. ,, conium maculatum, 574. copper (acute). 462. ,, ,, (chronic), 463. ,, corrosive sublimate. ! !7. ,, creasote. 539. ,, croton oil. 605. ,, cyanide of pot tssiuin, .">ii">. ,, daphne mezereon, 590. ,, datura stramonium, 565. ,, delphinium staphisagria, 588. ,, dichromate of potassium, 474. ,, digitalis, ">77. ,, dinitrobenzene (acute), 524. ,, ,, (chronic), 525 ,, dinitrotoluene. ."27. 634 INDEX. Poisoning by duboisine, 5(35. ,, dynamite, 512. ,, elaterium, G05. ., Epsom salts, 426. ,, ergot (acute), 595. ,, ,, (chronic), 597. , esserine, 001. ,, ether, 510. ,, exalgin, 530. fish, 620. ,, fly-fungus, 609. ,, foxglove, 577. ,, fruit, tinned, 470. ,, fungi, 608. ,, fusel oil, 510. ,, gases produced by explo- sives, 500. ,, gaultheria, oil of, 594. ,, gelsemium, 567. ,, hellebore, 5S8. ,, hemlock, 574. ,, henbane, 564. ,, hydrochloric acid, 415. ,, hydrocyanic ,, 502. ,, byoscyamus, 564. ,, Indian hemp, 500. ,, ,, tobacco, 572. ,, iodine, 485. ,, iodoform, 4S6. ,, iron, 472. jaborandi, 599. ,, laburnum, 589. ,, laudanum, 554. ,, lead (acute), 454. ,, ,, (chronic), 455. ,, lobelia, 572. ,, male fern, oil of, 570. ,, meatfrom diseasedanimals. 620. ,, mercury (acute), 447. ,, ,, (chronic), 450. ,, mezereon, 590. milk, 621. ,, mirbane, oil of, 523. ,, morphine (acute), 552. ,, ,, (chronic), 558. , , muscarine, 611. ,, mushrooms, 607. ,, mussels, 617. ,, naphthalene, 531. ,, nicotine, 573. ,, nitric acid, 412. ,, nitrite of amyl, 511. ,, nitrobenzene, 523. ,, nitroglycerine, 511. ,, nutmeg, 602. ,, mix vomica, 548. ,, u'uanthe crocata, 577. ,, oil of bitter almonds, 505. ,, ,, mirbane, 523. ,, ,, pennyroyal, 595. ,, ,, savin, 592. ,, ,, tansy, 594. ,, ,, turpentine, 591. ' Poisoning by oil of vitriol, 407. ,, wintergreen, 594. opium (acute), 552. ,, (chronic), 558. orpiment, 431. oxalic acid, 416. oysters, 619. paraffin oil, 520. paraldehyde, 510. pennyroyal, 593. petroleum, 520. phenol, 534. phosphorus (acute), 476. ,, (chronic), 483. physostigmine, 601. picric acid, 538. picrotoxin, 549. pilocarpine, 599. poisonous foods, 619. potassium bromide, 488. „ chlorate, 423. ,, cyanide, 505. ,, dichromate, 474. ,, hydrate, 419. ,, iodide, 486. ,, nitrate, 423. prussic acid, 502. ptomaines, 617. pyrogallol, 532. rat-paste, 476. red-precipitate, 44S. resorcin, 532. roburite, 526. salicylate of sodium, 533. santonin, 603. sardines, 620. sausages, 620. savin, 592. Sehweinfurt-green, 431. sewer gas, 492. silver, 466. sodium borate, 491. ,, hydrate, 420. ,, salicylate, 533. solanum dulcamara, 570. spotted hemlock, 574. stavesa/cre, 5SS. stramonium, 565. strychnine, 542. sugar of lead, 454. sulphonal, 517. sulphuric acid, 407. sulphuretted hydrogen, 491. tansy, 594. tartar emetic, 442. taxus baccata, 592. tin, 470. tinned fish, 620. ,, foods, 620. „ fruit, 470. tobacco, 573. turpentine, 591. vaseline, 521. veratrine, 581. 635 Poisoning by water-gas, 49(3. ,, white-precipitate, 448. ,, wintergreen, oil of, 594. ,, yew, 592. ,, zinc, 46S. ,, Chemical evidence of, 399." ,, Criminal law of, 382. ., Diagnosis of, 380. ,, Evidence of, from dead body, 396. ,, Examination of the dead body in, 19. ,, General treatment of, 389. , , Systematic chemical analysis in cases of, 400. Poisonous foods, 619. Poisons, Classification of, 385. ,, Effect of, contrasted with those of disease. .MIT. ,, ,, contrasted with post- mortem changes, 398. ,, in their general aspect, 381. Position of the body in death from wounding, 293. ,, ,, diaphragm in the new- born infant, 131. ,, of wounds. 285". Post-mortem coagulation of the blood, 39. ,, cooling, 38. ,, elevation of temperature, 38. ,, examinations, Medico- legal, 17. ,, examination in cases of poisoning, 19. ,, stains, 39. ,, ,, distinguished from bruises, 41. ,, ,, of internal organs, 42. Potash, Poisoning by, 419. ,, Tests for, 420. Treatment of poisoning by, 419, Potassium arsenate, binoxalate, 428. 418. 488. 423. 502, 505. 474. 486. 423. bromide, chlorate, cyanide, dichromate, iodide, ,, nitrate, ,, Precognitions (Scotch Law), 16. Pregnancy, Concealment of (Scotch law). 166. Duration of, 168. Earliest age for, 86. Insanity of, 338. Latest age for, 87. Plea of, as bar to execution, 112. Post-mortem appearances of, 114. Pregnancy, Signs of, 112. Preternatural combustibility of the body, 251. Preternatural combustibility of the body, Medico-legal bearings of, 254. Pritchard, Reg. v., 443. Procreative power, Age for, in the female, 86. ,, ,, ,, male, 83. Professional secrets in the witness-box, 9. Prolapse of the funis, 146. Prolonged gestation, 169. Prostitutes, Rape on, 90. Prussic acid, Fatal dose of, 504. ,, Poisoning by, 502. ,, ,, Treatment of, 505. Tests for, 506. Leal impediment to sexual inter- course in the female, 88. ,, impediment to sexual inter- course in the male, S4. ,, shock as a cause of sudden death, 301. Psychoses of chronic lead poisoning, 338. Ptomaines from the cadaver, 615. ,, in food, 617. ,, Isolation of, 614. ,, Nature of, 614. Puberty in the female, 86. ,, ,, male. 83. Puerperal insanity, 338. Punctured wounds, 259. Putrefaction in air, 50. ,, in water, 52. ,, Internal appearances pro- duced by, 54. ,, Signs of, 51. Pyrogallol, Poisoning by, 532. ,, ,, Treatment of, 533. ,, Tests fur, 533. Quickening as an indication of preg- nancy, 113. Quotations from books in the v, , box, 10. Rape, Blood-stains in cases of, 10S. ,, Death from, 97. ,, during abnormal sleep. 91. ., natural ,, 90. ,, ,, an attack of hysteria. 91. ,, ,, insensibility due to anaes- thetics and narcotics. 92. ,, ,, insensibility due to chloro- form, 93. ., Examination of females iu cases of, 103. ,, ,, males incases of, 105. ,, ,, seminal stains in cases of, 106. ,, ,, the dead body in cases of, 104. G3G INDEX. Rape, False accusations of, 95, 101. ,, Law in relation to, 89. Signs of virginity in relation to, 97. ,, loss of virginity in rela- tion to,^9S. Recurrent insanity, 32(5, 354. IN id -precipitate, Poisoning by, 448. Lie-examination, 7- Reiusch's test for antimony, 445. ,, ,, arsenic, 435. Remote causes of death from wounds, 302. Reports, Medico-legal, 14. Resorcin, Poisoning by, 532. ,, Tests for, 532. Respiration and circulation, Cessation of, 37. ., Artificial, after immersion, 232. ,, before birth, 142. Imperfect, in relation to infanticide, 138. ,, Signs of, 131. Responsibility, Criminal, 350. Medical, 304. J5 ,, as to death from anaesthetics, 305. >9 ,, in relation to lunacy certifi- cates, 369. }J ,, in the examina- tion of women, 103. Restraint, Placing habitual drunkards under, 378. s) ,, lunatics under, 301. Resuscitation from immersion, 230. ,, modes of effecting, 232. Revolver found in hand after death, 29S. ,, Suicidal wounds with, not always blackened, 296. wounds, 284, 298. „ of head and heart not immediately fatal, 297. Rigidity, Cadaveric, 43. Rigor mortis, 43. .,, Causation of, 43, 47. ,, Conditions which hasten, 44. in respect to the heart, 45. ,, Instantaneous, 47. ., causation of, 47. ,, examples of. 48. Robin ite, Acute poisoning by, 526. ,, Chronic ,, 526. ,, (Jases produced by detonation of, 501. Rupture of the bladder, 276. Rupture of the bladder, Spontaneous, 277. ,, diaphragm, 276. ,, intestines, 275. ,, kidneys, 276. ,, spleen, 276. ,, stomach, 275. SACRTJM, Sexual characteristics of, 76. Salicylic acid, Poisoning by, 533. , , Tests for, 534. Salt of sorrel, 418. Saltpetre, Poisoning by, 423. Sanguineous mole, 115. Santonin, Poisoning by, 603. „ ,, Treatment of, 604. Tests for, 604. Sardines, Poisoning by, 620. Sausages, ,, 620. Savin, ,, 592. Scalds, 246. ,, and burns, Death from, 242. Scalp-wounds, 264. Scars, 59. Scherer's test for phosphorus, 484. Schultze's swinging, 133, 135. Schweinfurt green, Poisoning by, 431. Scot v. Wakem, 379. Scotland, Legal procedure in, 15. Secrets, Professional, 9. Self-delivery, Alleged violence produced by, 156, 161. Self-inflicted wounds feigning homicidal violence, 30S. Seminal stains, Examination of, 106. Senile dementia, 341. Separation of funis, 27. Septic causes of death from wounds, 303. Sewer-gas, Poisoning by, 492. Sex, Determination of, 79. ,, Doubtful, 79. Sexual abnormalities, 78. ,, characteristics of the skeleton, 75. ,, defects in females, 86. ,, ,, males, 83. ,, ,, Proof of, in divorce, 183. Shell-fish, Poisoning by, 617. Shock as cause of sudden death, 300. Shortened gestation, 171. Signs of abortion, 127. ,, death, 36. ,, delivery, 116. ,, live-birth, 145. ,, pregnancy, 112. ,, putrefaction, 51. ,, virginity, 97. ,, loss of virginity, 98. Silver, Acute poisoning by, 466. ,, Chronic ,, 467- ,, Tests for, 467. ,, Treatment of poisoning by, 466. Skeleton, Sexual characteristics of, 75. Skull, Fractures of, 266. ,, Injuries of, 264. INDEX. 637 Sleep, Rape during abnormal, 91. ,, ,, natural, 90. Smothering, 213. Six la. Poisoning by. 420. Sodium salicylate, Poisoning by, 533. Sodomy, 109. Splanum dulcamara, Poisoning by, 570. Sorrel, Salt of, 41S. Spanish-flies, Poisoning bj', 612. Spasm, Cadaveric, 47. ,, of the larynx, Death from, 210. Spasmodic ergotism, 597. Spectrum of haematin, Reduced, CO. ,, haemoglobin, 07. ,, methsemoglobin. (is. ,, phosphuretted hydrogen, 4S4. ,, ergot, .Solution of, f)9S. Spermatozoa, 107. Spine. Fractures of, 270. ,, Injuries of, 209. Spleen, Rupture of, 276. Spontaneous combustion, So - called, 251. Spotted hemlock, Poisoning by, 575. ,, ,, Treatment of, 570. Stab-wounds, 259. Stains, Post-mortem, 39. ,, produced by aniline, 72. ,, ,, blond, 63. ,, . , fruits, 72. ,, ,, mineral salts, 72. ,, on weapon, 71, 295. Starvation, 309. ,, Diseases which may cause appearances resembling death from, 313. ,, 1 duration of life in, 314. ,, Effect of drinking Mater in, 314. ,, Metabolism during, 311. ,, Post-mortem appearances of, 312. Stas' process, 400. ,, Stevenson's modification of, 401. .Statistics of deaths of legitimate and illegitimate children, I 15. ,, ,, from drowning, 224. ,, ,, ' ,, suicidal hang- ing. 197. ,, ,, ,, overlaying of infants, 212. Stature, 73. Staunton. Reg. v., 313. Stavesacre, Poisoning by, 5SS. .Sterility, 82. Stomach, Air in, as a sigu of respiration, 141. ,, Contents of. in new-born infant, 145. Stomach, effects of poison, disease and post-mortem changes con- trasted, 397. ,, Redness of, as a sign of poisoning, 390. ,, Ulceration and perforation of, 397. ,, Water in, after death from dro\J niii'j, 221. Stomach-pump, Use of, in poisoning,389. Moms. Wounds from sharp edged, 258. Stramonium, Poisoning by, 565. Strangulation, 201. Accidental, 202. ,, by throttling, 207. ,, ,, Position of marks in, 207. Homicidal, 202. ,, indications from degree of violence, 206. ,, mark of cord, 201. ,, of infant with funis. Acci- dental, 147. „ ,, Criminal. 158. ,, Post-mortem appearances of death from, 201. Suicidal, 205. Strontium, Salts of, not toxic, 426. Strychnine, Fatal dose of, 514. ,, Poisoning by, 542. ,, ,, Treatment of, 545. ,, Properties of, 541. ,, Tests for, 547. Toxic action of, 542. Subjects involving sexual relations, 78. Subpoena, 6. Suffocation, 209. ,, from compression of the chest, 211. ,, ,, covering the mouth and nostrils, 212. ,, ,, foreign bodies in the air-passages, 209. ,, ,, pathological causes, 209. ,, ,, smothering, 213. ,, Occasional absence of indi- cations after death from, 209. ,, Post-mortem signs of death from. 214. Sugar in the urine in poisoning by carbon monoxide, 496. ,, ,, phosphorus, 482. Suicidal impulse, M47. Suicide by cutthroat. 2S9. ,, ,, detonation of dynamite, 288. ,, ,, drowning, 225. ,, ,, electricity. 242. ,, ,, fire-arms, 290. ,, ,, foreign bodies in the air- passages, 211. ,, ,, guillotine. 288. „ hanging, 197. 038 INDEX. Suicide by injuries to the head, 2S6. ,, „ poisoning, see Poisoning. ,, ,, red-hot iron, 288. ,, ,, smothering, 213. ,, ,, stab-wounds, 291. ,, ,, strangulation, 205. ' ,, ,, throttling, 20S. , , , , wounds of the head and heart, 297. ,, Medico-legal relations of, 349. Sulphomolybdic acid, 548. Sulphonal, Poisoning by, 517. Tests for, 518. Sulphuretted hydrogen, Poisoning by, 491. ,, ,, cause of death in 492. ,, ,, treatment of, 493. Sulphuric acid, Poisoning by, 407. ; , ,, Treatment of, 409. Tests for, 411. ,, Throwing of. 254. Summary reception orders in lunacy, 362. Superfcetation, 173. Supposititious children, 170. Survivorship, 177- Symm v. Fraser and Andrews, 380. Syncope, 34. Systematic chemical analysis in poison- ing, 400. Table of development of foetus, 26. ,, points of ossification, 31. ,, union of epiphyses and bones, 32. Tanacetum vulgare, Poisoning by oil of, 594. Tansy, Poisoning by, 594. Tartar emetic, ,, 442. Tattoo-marks, 60. Taxus baccata, Poisoning by, 593. Teeth, Development of, 29. ,, Permanent, 30. ,, Temporary, 29. Tenancy by courtesy, 107- Testamentary capacity, 373. Tetanus as a cause of death from wounds, 303. ,, contrasted with the clonic spasms of strychnine poison- ing, 543. Throat, Wounds of, 2S9. Throttling, 207. Thymus gland, Hyperplasia of, in new- born infants, 149. Tichborne, E-eg. v., 61. Tin, Poisoning by, 470. ,, ,, Treatment of, 471. ,, Tests for, 471. Tinned foods, Poisoning by, 620. ,, fruit, ,, ^ 470. ,, peas, Copper in, 464. Tobacco, Acute poisoning by, 573. ,, ,. Treatment of, 574. ,, Chronic ,, 574. Touite, Gases produced by detonation of, 501. Toogood v. Wilkes, 370. Townley, Peg. v., 357. Toxic insanity, 334. Toxicology, 381. Tribadism, 109. Tricomonas vaginas, 108. Triennial cohabitation, 1S3. Trimethylamine in decayed cheese, 622. Turpentine, oil of, Poisoning by, 591. Ty rosin in the urine in acute phosphorus poisoning, 4S1. Tyrotoxicon, 621. Ulceration and perforation of stomach, 397. Umbilical cord, Hemorrhage from, 15S. ,, in relation to live-birth, 144. ,, Prolapse of, 146. ,, Separation of, 27. ,, Strangulation of infant with, 147, 156. Unnatural sexual offences, 109. Unconsciousness during delivery, 150. ,, >, rape, 91. Urgency orders in lunacy, 362. Urochloral acid in poisoning by chloral hydrate, 517. Uterus, Absence of, 88. ,, Injuries of, 279. Vagina, Injuries of, 278. Vaginismus, 88. Vaseline, Poisoning by, 521. Venereal disease in cases of rape, 105. Veratrine, Properties and physiological action of, 581. ,, Poisoning by, 5S2. ,, Treatment of, 5S2. Tests for, 5S3. Verdigris, 462. Vermin-killers, 542. Vertebras, Injuries of, 269. ,, „ i 11 hanging, 192. Vesicular mole, 115. Viability, 171. Virginity, Physical signs of, 97- ,, Loss of, 98. Virility, Proof of absence of, in divorce cases, 183. Vitriol throwing, 254. Vulva, Injuries of, 27S. Vulval rape, 90. Ware, Reg. v., 351. Water in intestines after death from drowning, 223. stomach ,, 221. Water-gas, Poisoning by, 495. Weak-mindedness, 339. Weapon in the hand after death 292 298. „ Stains on, 71, 295. Weight of child, Increase in, after birth, 27. Weldon v. Winslow, 371. White arsenic, 427. ,, hellebore, 581. ,, precipitate, 44S. Williams, Reg. v., 359. Willis. Reg. v., 121. Wills, Capacity to make. .",7:;. Wintergreen, Poisoning by oil of, 594. Witness, Examination of, 7. ,, Expert, 8. ,, Medical, S. ,, Obligations of, S. Wolf's-bane, Poisoning by, ."s;;. Women. Necessity for consent before examining, 103. Wounds, 258. „ Blackening .of, by fire-arms, j 296. ,, Causes of death from, 299. Extent and direction of, 28S. ,, fatal from anaesthetic during operation, 305. " ,, improper treatment, 305. " >. negligent ,, 305. " >> septic processes, 303. >> ,, tetanus, 303. ,, Feigned homicidal, self-in- flicted, 308. INDEX. 639 Wounds, General causal indicatii as death from, 293. ,, Incised, 258. ,, indications from weapon. 261. in their causal relation. 284. ,, Lacerated, 261. -., made before and after death 262. >j ,> by broken crockerj-- ware, &c, 258. Multiple fatal, 291, 299. ,, Nature of, 287. of the back, 292, 298. ,, chest, 272, 291. fare. 271. •' >> gen - 278, 237. ,, head, 204, 2Sli, 297. ,, heart, 273, 297. >> ,, neck, 272. ,, throat, 289. ., Position of, 285. ,, Post-mortem examination of, 263. ., produced by fire-arms, 282. " » ,, causal relation of, 290. ,, Punctured. 259. Yew, Poisoning by, 592. Youth, in relation to procreative power* 83, SO. Zixc, Acute poisoning by, 4G8. » > s ,, Treatment of, 4G8. ,, Chronic ,, 469. ,, Tests for, 479. la 11. AND BAIN, LIMlihi,, PB.INTE1S, MITCHELL S1KEET, GLASCOW. CATALOGUE OF MEDICAL WORKS PUBLISHED BY CHARLES GRIFFIN & COMPANY. LONDON: 12 EXETER STREET, STRAND. MESSRS. CHARLES GRIFFIN & COMPANY'S PUBLICATIONS may be obtained through any Bookseller in the United Kingdom, or will be sent direct on receipt of a remittance to cover published price. To prevent delay, Orders must be accompanied by a Remittance. Postal Orders and Cheques to be crossed " Smith, Payne & Smiths." 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