CHAPTER II

MEDICAL EVIDENCE GENERALLY

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

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

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

1. DOCUMENTARY

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

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

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

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

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

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

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

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

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

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

=Written Opinions.=--These generally refer to civil questions.

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

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

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

[1] _Monthly Journal of Medical Science_, 1851.

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

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

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

A Medical Report consists of two parts--the _Minute of the Examination_, and the _Reasoned Opinion_ on the first portion of the Report. In the case where the Report is made by two or more persons appointed for the purpose, the latter portion is written in the plural, and signed by each of the parties certifying.

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

FORM OF MEDICAL REPORT

(_Date._)      (_Place of Examination._) (_Names of those who can speak to the Identity of the Body._)

I. MINUTE OF THE EXAMINATION

1. External Inspection

1. General Condition of the Body.--(_a_) _Well or ill nourished._ (_b_) _General colour._ (_c_) _Marks and scars._ (_d_) _Products of disease--Ulcers, hernia, &c._ (_e_) _Injuries._

Caution.--There may be no external marks of injury, and yet death may be due to violence. Extreme difficulty in deciding if injury be inflicted before or after death.

2. Height.--_Determined by measurement._

3. Age.--_This can only be approximately guessed._

4. Sex.--_This is, of course, only difficult when putrefaction is far advanced. Hair found only on the_ MONS VENERIS or PUBES _is characteristic of the female, but if it extend upwards on the abdomen, equally so of the male. No sex can be distinguished in the embryo before the third month of intra-uterine life._

5. Colour of the Eyes.--_Difficult of determination._ Why? (_a_) _Disagreement of observers._ (_b_) _Presence of putrefaction._

6. Colour of the Hair.--_This is necessary, in order to compare hair of deceased with that found on suspected party._

7. Position of the Tongue.--_Normal or abnormal, injured or uninjured._

8. Condition and Number of the Teeth.--(_a_) _Complete._ (_b_) _Incomplete._ (_c_) _Any peculiarity as regards size or form, in order to compare with mark or bite on suspected party, &c._

9. Signs of Death.--_Presence or absence of the_ rigor mortis _or supervening putrefaction_.

10. Condition and Contents of the Hands and Nails.--(_a_) _In the drowned: weeds, sand, and signs of long immersion._ (_b_) _In those shot: scorching or blackening of the hand from powder, or injury from recoil of the weapon._ _Is the weapon grasped firmly in the hand?_ _Cadaveric spasm?_ _Cadaveric rigidity?_

11. Condition of the Natural Openings of the Body--Nose, Mouth, &c.--(_a_) _Presence of sand or weeds in mouth of those found in the water._ (_b_) _Presence of marks of corrosive poisons._ (_c_) _Presence or absence of the signs of virginity, or of recent injury about the parts._

12. Condition of the Neck.--(_a_) _Presence of marks of strangulation._ (_b_) _Condition of the upper cervical vertebræ._ (_c_) _Dangers to be avoided in determining the fracture or dislocation of the cervical vertebræ. Great mobility of neck, sometimes present, not due to injury of the bone._

2. Internal Inspection

_A. Cranial Cavity._

1. Condition of the bones of the skull.

2. Condition of the membranes and sinuses of the brain.

3. Condition and appearances of the brain substance.

4. Contents of the lateral ventricles.

_B. Thoracic Cavity._

1. Position of the organs on opening the chest.

2. Condition of the heart, large blood-vessels, and pericardium.

3. Condition of the larynx, trachea, lungs, pleura, pharynx, tongue, and gullet.

_C. Abdominal Cavity._

1. Position of the abdominal organs.

2. Healthy or diseased condition of the liver, spleen, stomach, intestines, pancreas, bladder and ureters, prostate, kidneys and supra-renal glands, uterus and ovaries, blood-vessels and peritoneum.

3. Contents of the stomach and bladder.--_Should it be necessary to remove the stomach and intestines, two ligatures should be placed at the cardiac extremity of the stomach and also at the pyloric end, and cut between the two ligatures, then the stomach may be removed intact; and other ligatures at the end of small intestines, also the rectum, and the bowels then removed as conditions demand._

4. Condition of the blood-vessels.

5. Condition of bones and joints.

II. THE REASONED OPINION

In this portion of the Report the inspectors state the nature of the conclusion at which they have arrived, and their reasons.

_Recapitulation of the foregoing Rules._--It may be of advantage here to restate, in a tabular form, a few suggestions as to the composition of the Report:

_N.B._--1. Let the Report be as short as possible, but state your views with clearness and distinctness. After stating the nature of the disease in any organ, report “all other organs healthy,” if they have been found so. To specify some organs, omitting others, may lead to a pressing inquiry from counsel as to the condition of the supra-renal capsules, or some other organ, and an unfounded doubt cast on the Report of the examiner.

2. Always avoid the use of technical terms as far as possible, so that you may be saved the annoyance of having to explain your meaning in the witness-box.

3. Express all dates and numbers in writing. Measure all marks, and describe their size and appearance in writing. Carefully write all names of persons to whom reference is made. Take accurate notes, and from them compose your report. Make a list of all articles submitted for inspection and analysis, and label them.

4. State all facts clearly and chronologically. A _fact_ is what is known directly and personally to witness, and not what has been repeated by some other person. Do not report hearsay testimony as matters of fact.

5. Every report should be written under the impression that it may come into court to be read.

6. Always avoid superlatives and all epithets of feeling or impressions on the mind.

7. Always avoid speculative opinions and reference to moral circumstances, unless specially required to do so.

8. State your conclusions at the end of the Report in as few sentences as possible.

9. Keep a rough draft of all your Reports, for future reference.

10. Transmit Report, signed and dated, without unnecessary delay, to the proper authorities.

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

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

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

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

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

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

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

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

2. ORAL OR PAROL

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

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

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

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

[2] _Edinburgh Medical Journal_, February 1876.

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

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

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

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

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

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

3. EXPERIMENTAL

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

Identity

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Examination of a Person said to have been Assaulted

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

Identity of the Dead

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COOLING OF THE BODY

{ Covered by bed-clothes, or otherwise (1) External { unexposed, when cooling will be dry circumstances. { slower than in cold air quickly moving.

(2) Condition of the } body itself. } Slow, if fat.

{ 1. Wasting diseases. Quick. { 2. Suffocation. Slow. (3) Kind of death. { 3. Cholera, yellow fever, } Increase { rheumatic fever, and } of heat cerebro-spinal meningitis. } after death.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Table of the Eruption of the Teeth

Age--Eruption of teeth. Lower central incisors, 7 months. } Upper “ “ 8 “ } “ lateral incisors, 7-10 “ } Lower “ “ 10-12 “ } Temporary. First molars, 12-14 “ } Canine teeth, 18 “ } Second molars, 22-24 “ }

First molars, 6 years. } Middle incisors, 7 “ } Lateral incisors, 8 “ } First bicuspids, 9 “ } Second bicuspids, 10 “ } Permanent. Canines, 11-12 “ } Second molars, 12-13 “ } Wisdom teeth, 18-25 “ }

Examine the lower jaw. The ramus forms an obtuse angle in full-grown fœtus, a right angle in adult life, obtuse in old age from loss of teeth.

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

Years of Life. Bones in which Centres of Ossification appear. 1. Fourth piece of the body of the sternum; coracoid process of scapula; head of humerus; os magnum (carpus); head of femur; upper end of tibia; external cuneiform (tarsus). 2. Lower end of radius; unciform (carpus); lower end of tibia; lower end of fibula. 3. Great tuberosity of humerus; patella; internal cuneiform (tarsus). 3-4. Upper end of fibula. 4. Great trochanter (femur); middle cuneiform (tarsus). 4-5. Scaphoid (tarsus); lower end of ulna. 5. Lesser tuberosity (humerus); internal condyle (humerus); trapezium and semi-lunar (carpus). 5-6. Upper end of radius. 6. Scaphoid (carpus). 7. Trapezoid (carpus). 10. Upper end of ulna. 12. Pisiform (carpus). 13-14. External condyle (humerus); small trochanter (femur).

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

Years of Life. 1-2. Symphysis of lower jaw. 2. Frontal suture; unites from below upwards; it may persist. Anterior fontanelle filled up. 7-8. Rami of ischium and pubes. 17. Epiphyses of upper end of ulna; small trochanter (femur). 17-18. Epiphyses of condyles (humerus); upper end of radius. 18. Epiphyses of great trochanter of femur; lower end of tibia; lower sacral vertebræ; portions of acetabulum united. 19. Epiphyses of the head of the femur. 20. Epiphyses of the head of the humerus; lower end of radius and ulna. 21. Epiphyses of the upper end of tibia; lower end of fibula. 24. Epiphyses of upper end of fibula. 25. Second and third pieces of sternum; first and second sacral vertebræ; epiphyses of clavicle, lower end of femur. 40. Manubrium, with body of sternum.

Table showing the Development of the Embryo according to the Lunar Months ----------+----------+------------+---------------------------------- Month. | Length. | Weight. | Observations. ----------+----------+------------+---------------------------------- _First_. | | | (3rd or | Four to | Twenty |The embryo is curved; the mouth on 4th week.)|six lines.| grains. |the cephalic extremity appears as | | |a cleft, and the eyes as two | | |black points. Nipple-like | | |protuberances mark the position of | | |the extremities. The heart can be | | |seen, and the liver is | | |disproportionably large. ----------+----------+------------+---------------------------------- _Second_. | | | (End of |Fifteen to| Two to |The head disproportionably large. 8th week.)| eighteen | five |Nose, lips, and external parts of | lines. | drachms. |generation visible, but sex | | |doubtful. Anus appears as a dark | | |point. Abdomen encloses the | | |internal organs. Extremities | | |project slightly from the trunk. | | |_Ossification_ in _clavicle_ and | | |_lower jaw_ about end of_ seventh | | |week_; in _frontal bone_ and | | |_ribs_ towards end of _eighth | | |week_. ----------+----------+------------+---------------------------------- _Third_. | | | (End of | Two to |One to two |Eyes and mouth closed. Fingers well 12th week.)| two and | ounces. |separated; nails recognisable. The | a half | |sex can be detected by the aid of | inches. | |a lens. Suprarenal capsules and | | |thymus gland are formed. The | | |cavities of the heart and divisions | | |of the brain distinct. The placenta | | |isolated; the umbilical vesicle, | | |allantois, &c., have disappeared. ----------+----------+------------+---------------------------------- _Fourth_. | | | (End of | Five to | Two and |The skin rosy and tolerably dense. 16th week.)| six | a half |Sex seen without aid from lens. | inches. | to three |The mouth is large and open; the | | ounces. |umbilicus is near the pubes. | | |Meconium of a greyish-white | | |colour in the large intestines. ----------+----------+------------+---------------------------------- _Fifth_. | | | (End of | Ten to | Seven |From the fifth month the length of 20th week.)| eleven | to ten |the fœtus in inches is almost | inches. | ounces. |_exactly double the number of the | |varying in |lunar months_. The nails are | |individuals.|distinct. The head, liver, heart, | | |and kidneys are disproportionately | | |large. The hair appears as a light | | |down. The meconium is of a | | |yellowish-green colour. Points of | | |ossification, pubes and os calcis. ----------+----------+------------+---------------------------------- _Sixth_. | | | (End of |Twelve to | One to two |Down and sebaceous matter cover 24th week.)| thirteen | pounds. |the skin. The colour of the body | inches. | |is a cinnabar-red, and the | | |umbilicus is farther from the | | |pubes. The meconium is darker | | |in colour; and the scrotum is | | |empty, the testes being close | | |to the kidneys. The pupillary | | |membrane is still present. ----------+----------+------------+---------------------------------- _Seventh_. | | | (End of | Fourteen | Three or |The skin is of a dirty-red colour; 28th week.)|to fifteen|four pounds.|the hair about half an inch long, | inches . | |and plentiful. Membrana pupillaris | | |disappearing; eyelids non-adherent. | | |The large intestine quite full of | | |dark olive-green meconium. | | |Fontanelles distinctly felt. | | |Liver still large, of a | | |dark-brownish colour. ----------+----------+------------+---------------------------------- _Eighth_ | | | (End of |Fifteen |Three to |The skin, covered with soft hair, 32nd week.)|to sixteen|five pounds.|is more of a rosy flesh-colour. |inches. | |Disappearance of the pupillary | | |membrane, and descent of the | | |testicles into the scrotum. The | | |open vulva exposes the clitoris to | | |view. The nails almost reach the | | |tips of the fingers. ----------+----------+------------+---------------------------------- _Ninth_. | | | (End of |Sixteen to|Six pounds. |The head covered with hair; 36th week.)| eighteen | |the down on the body closing. |inches. | | ----------+----------+------------+---------------------------------- _Tenth_. | | | (End of | Eighteen | Seven to | Well-known signs of maturity. 40th week.)|to twenty | nine | | inches. | pounds. | ----------+----------+------------+---------------------------------------------------------------------

Table giving the Measurements, according to the Months, of the Extremities of the Fœtus in the Order of their Development +-------+-----------+----------+------------+---------+------------+ | | Third. | Fourth. | Fifth. | Sixth. | Seventh. | +-------+-----------+----------+------------+---------+------------+ |Humerus| 3½ lines.| 8 lines.|13-15 lines.|16 lines.|20-22 lines.| |Radius | 2½ “ | 8 “ | 12 “ |16 “ | 17 “ | |Ulna | 3 “ | 8 “ | 13 “ |17 “ | 18 “ | |Femur |2-3 “ |4-5 “ | 12 “ |17 “ |19-21 “ | |Tibia |2-3 “ |4-5 “ | 12 “ |17 “ |19-21 “ | |Fibula | 2½ “ | . . . | 12 “ |17 “ |19-21 “ | +-------+-----------+----------+------------+---------+------------+

+-------+------------+------------------+ | | Eighth. | Full Period. | +-------+------------+------------------+ |Humerus|23-24 lines.|3 inches. | |Radius |18-19 “ |2 “ 8 lines.| |Ulna |22-23 “ |2 “ 10 “ | |Femur | 24 “ |3 “ 6 “ | |Tibia |21-23 “ |3 “ 2 “ | |Fibula |21-23 “ |3 “ 1 “ | +-------+------------+------------------+

Table showing the Maximum and Minimum Dimensions of the Osseous Nucleus of the Inferior Femoral Epiphysis from the Seventh Month of Intra-Uterine Life to Two Years after Birth +------------+-------------+------+-----------------------------------------+ | |INTRA-UTERINE| | EXTRA-UTERINE. | | | | | +-------------------+ | | | | | | | | | | | | Days. Months. | | +-------+-----+ +-----------------+-----------------------+ | |Seventh|Ninth|Mature| 1-8 9-15 16-28| 1 3-6 7-12 12-24| | +-------+-----+------+-----+-----+-----+-----+-----+-----+-----+ | | |lines| lines|lines|lines|lines|lines|lines|lines|lines| +------------+-------+-----+------+-----+-----+-----+-----+-----+-----+-----+ |Maximum | | 2 | 4 | 3½ | 3½ | 2½ | 5 | 4 | 8 | 7 | |Minimum | | “ | ¾ | 1 | ¾ | 1½ | 2 | 2 | 3 | 5 | | | | | | | | | | | | | | No. of } | | | | | | | | | | | |Children}125| 31 | 9 | 52 | 8 | 3 | 2 | 9 | 3 | 6 | 2 | |examined} | | | | | | | | | | | +------------+-------+-----+------+-----+-----+-----+-----+-----+-----+-----+

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