CHAPTER V.

MEDICO-LEGAL QUESTIONS.

1. Method of Conducting a Medico-Legal Autopsy.

In making medico-legal examinations of human bodies, the greatest care must be taken not to omit the examination and recording of any of the appearances presented; since a point trifling in itself, may, in the course of the subsequent legal process, prove of great importance.

It may sometimes be necessary for the physician to examine the exact spot and the locality in which the body has been found, to ascertain the position in which it was discovered, etc., and also to inspect the clothing.

In cases of suspected poisoning, the utmost precautions are to be used in making the autopsy. All the viscera are to be carefully examined, and the stomach and intestines, with their contents, are to be removed in the manner already described. They are then to be opened, examined in separate vessels, either entirely new, or thoroughly cleansed immediately before being made use of. After a careful examination, they are to be placed in perfectly clean or new glass jars, without the addition of any foreign substance; the jars are then to be securely corked and labelled, and handed over to the chemist for analysis. Should the jars have to remain any time in the hands of the physician, they are to be kept under lock and key, in some place to which none but himself has access. Portions of other organs, especially of the liver, spleen, kidneys and brain, should also be preserved with the same care for future analysis.

The results of the examination are to be taken down on the spot, by an assistant, in ink, and after having been read through by the physician at the close of the examination, are to be signed by him.

All these precautions will be found of great value, in saving from innumerable petty annoyances, at the hands of the “learned members of the bar,” if the case should be brought before court.

In the _external_ inspection of the body, we should notice:

1. _The Sex._ Even after the external parts of generation have been completely destroyed, the sex may still be ascertained by a reference to the growth of hair around these parts. A circumscribed arc of hair on the _mons veneris_, is distinctive of the female, while its prolongation, however slight, from this point towards the umbilicus, marks the male.

2. _The Age._ In the case of known bodies this is not of any importance, in unknown bodies it is, however, necessary. The physician can only conjecture from appearances, which, even in the living body, are very deceptive, and he will do well, therefore, to allow tolerably wide limits to this conjecture.

3. _The Size._ The length of the body must be ascertained by actual measurement in a straight line, from the crown of the head to the sole of the heel.

4. _The General Condition of the Body._ Lean or fat, etc.

5. _Color and Condition of the Hair._

6. _Color of the Eyes_, if still recognizable.

7. _Number and Condition of the Teeth._ In the case of unknown bodies, an accurate description is always advisable, with a view to future identification.

8. _Special Marks or Deformities._ Scars, tattoo-marks, excess or defects of limbs, marks of disease, as ulcers, etc., should all be accurately noted.

9. _Injuries or Wounds_, which appear to have been the cause of death, should be carefully described. In the case of wounds, their position and direction with reference to the neighboring fixed points of the body, and their exact length and breadth, must be recorded.

10. _Of the Body itself_, the parts deserving of particular examination are the natural openings of the ears, nose, mouth, anus and female genitals; the neck and the hands.

In the _internal_ examination or dissection, the three great cavities—the head, thorax and abdomen—should all be opened. In some cases, it may be important to open also the spinal canal.

The first thing to be observed on opening each of these cavities, is the position of the organs they contain; next, whether there be any fluid effusions present; and lastly, the external and internal appearance of each separate organ. In every case, that cavity should be opened first, in which there is the greatest probability of finding the cause of death. In the case of new-born children, however, the abdomen must be first opened in order that the natural position of the diaphragm may be observed undisturbed.

In examining the base of the skull for injuries, we must not omit to remove the periosteum, which might otherwise conceal small fissures.

In examining the thoracic organs, if it be particularly desired to observe the amount of blood contained in them, and we do not wish to apply ligatures, we examine the heart first, leaving it in its natural horizontal position, and opening it by a lateral longitudinal incision on both sides. This gives us a distinct idea of the actual amount of blood in all the cardiac cavities. The lungs are next cut into, and last of all the large blood-vessels. This procedure is to be followed, _e. g._, in cases of suffocation, where it is of particular importance to determine the amount of blood in these organs, and where the blood is peculiarly fluid.

In determining the amount of blood in the venous trunks, it will be sufficient to examine the _vena cava ascendens_.

In penetrating wounds, the wound is of course to be examined as far as possible before disturbing any of the organs.

The result of the external and internal examinations, thus thoroughly conducted, are to be noted down at the time, and are not to be trusted to memory. It is of the utmost importance that this rule be observed.

In presenting a written or verbal report before court, the physician should be careful to furnish merely a description of the post-mortem appearances, and not to give an opinion as to their probable or possible cause or causes, unless called upon to do so. He should also avoid prolixity and, as much as possible, the use of technical terms, unintelligible to nonprofessionals.

His answers to direct questions should be concise and decided if possible, but where this is not possible, he should not hesitate to state that the dissection has not afforded him any facts which could enable him to give a positive answer.

2. Questions relating to New-Born Children.

The body of a dead infant is found, and the physician may be called upon to answer the following questions, one or all:—Was the child mature? Was it born alive? If so, what was the cause of its death?

_Was the child mature?_ Among the various signs of fœtal maturity, such as the firm, tense skin, of the usual pale corpse-color, the hair upon the head, the weight and length of the body, the diameters of the head, shoulders and hips, the horny nails reaching to the tips of the fingers, the absence of the pupillary membrane, etc., the most infallible, is the presence of the centre of ossification of the inferior femoral epiphysis. “The easiest way to find this, is to make a horizontal incision through the skin and superficial tissues over the knee-joint down to the cartilages. The patella is then to be removed, and the end of the femur made to protrude through the incision. Thin horizontal sections are then to be removed from the cartilaginous epiphysis, at first more boldly, but so soon as a colored point is observed in the last section, then very carefully, layer by layer, till the greatest diameter of the osseous nucleus is attained. This appears to the naked eye as a more or less circular bright blood-red spot in the midst of the milk white cartilage, in which vascular convolutions can be distinctly recognized.” When there is no visible trace of this centre of ossification, the fœtus can be no more than from thirty-six to thirty-seven weeks old.

In still-born children, the commencement of this nucleus indicates a fœtal age of thirty-seven to thirty-eight weeks; when it possesses a diameter of from three-quarters to three lines, it shows the fœtus must have attained a uterine age of forty weeks. When the osseous nucleus measures more than three lines, we may conclude that the child has lived after birth.

Isolated exceptions are occasionally met with, when, however, concomitant appearances, such as, in the one case, defective ossification of the skull, or in the other, peculiarly advanced development, will guard us against mistakes.

_Was the child born alive?_ or, _Did it live during and after its birth?_ and, _If so, how long?_

These questions are intimately connected, and in order to be able to answer them, we must in our examination note the following points:

_The position of the diaphragm_, is a good diagnostic sign. The diaphragm will necessarily be higher where there has been no respiration, natural or artificial, than where the child has actually breathed. “Its position is most easily ascertained by making a longitudinal incision through the skin and superficial cellular tissue, from the chin to the pubis, in the mesial line, dissecting these from the thorax on both sides, next carefully opening the abdominal cavity, introducing the finger of one hand into it, and pressing it up to the highest point of the concavity of the diaphragm, and then with one finger of the other hand reckoning off the intercostal spaces from above downwards till both fingers correspond. The rule is, that the highest point of the concavity of the diaphragm in children born dead, is between the fourth and fifth ribs, and in those born alive, between the fifth and sixth.” Where respiration has been but transitory, the diaphragm will remain very nearly in its fœtal position.

_The lungs_, from lying quite posteriorly in the fœtus, come to fill the cavity of the chest, the more perfectly respiration has been established. In the fœtus, the left lung is never found even partially covering the heart. Where respiration has been but transitory and imperfect, the volume of the lungs will not be much increased.

The presence of dark bluish-red, insular patches in the lungs, no matter what may be their ground color, proves that respiration has taken place.

The crepitant spongy consistence of the lungs of a live-born child, is readily distinguished from the compact, resistent liver-like lungs of one still-born.

The hydrostatic test for the presence of air in the lungs, is of all, the surest for deciding whether respiration has taken place. The vessel used should be at least one foot in depth, eight or ten inches in diameter, and filled with pure cold water. The buoyancy of the lungs depends upon the greater or less completeness with which the pulmonary tissue is permeated by the air. Only one lung may float, generally the right one, or only single lobes, or only a few pieces into which the lung has been and must be divided, in order accurately to apply the test. Artificially inflated fœtal lungs, may be distinguished from those lungs which have respired, by the presence, in the case of the latter, of the bluish-red mottling above referred to, and the escape of bloody froth when the substance of the lungs is cut into, and slight pressure applied.

The general appearance of putrescence in the lungs, will serve to distinguish the buoyancy arising from the gaseous products of putrefaction, from that due to respiration.

Careful attention to the foregoing points, will enable us to answer with certainty whether the child was born alive.

_How long did the child live after its birth?_ The question can be approximately answered with reference to the first few days, by attention to the following points:

If there are no traces of blood, or of that peculiar unctious substance, the _vernix caseosa_, on the body, sufficient time must have elapsed since its birth, to have afforded leisure and opportunity for cleansing it.

The contraction of the umbilical arteries in living children, does not occur sooner than after eight or ten hours. The mummification of the cord commences after two, three, or even four days, and the putrefaction only after a much longer time. Mummification of the cord takes place as well after death as before, but not in water, nor in the liquor amnii. If the umbilicus has already cicatrized, the child must be at least five days old.

The stomach immediately after birth, contains a small quantity of quite white, transparent, seldom somewhat bloody, inodorous mucus, very tough, or a trifling quantity of the colorless liquor amnii. If milk be found, it shows that some time must have elapsed since the birth.

In the large intestines meconium is still to be found, two, three, or even four days after birth.

The age of a child, evidently older than five or six days, can only be determined by general appearances.

_What was the cause of death?_ We will here refer only to those injuries and kinds of death as can only occur in new-born children, and to those _post-mortem_ appearances which might lead to error in regard to them.

During labor, death to the child may result from cerebral hyperæmia, or from injuries to the cranium, which are then unattended by traces of violence on the body, and are frequently due to imperfect ossification of the bones, detected by holding the bones up to the light after removal of the periosteum.

Prolapse and pressure of the cord, and coiling of the cord around the neck, may produce all the appearances of death by suffocation.

The mark of the cord runs uninterruptedly round the neck, is broad, circularly depressed, grooved, never excoriated, and everywhere quite soft. A mummified, parchmentlike, unecchymosed depression, with or without excoriations, points to intentional strangulation.

Subsequent to birth, the child may have been killed by falling on its head on the floor, if the birth has been very rapid. The probable results of such a fall, would be rupture of the cord; premature separation of the placenta, with its consequences; concussion of the brain and hyperæmia, or actual hæmorrhage within the skull; and fracture of the skull bones. The fractures are almost exclusively confined to the parietal bones, one or both, chiefly in the region of the vertex.

Comminuted fracture of several bones of the skull, speak against an accidental death by a fall. The absence of any signs of violent usage on other parts of the body, or about the head, with simple fracture of the skull, speaks for an accidental death.

The child may also have been suffocated by the mother in violent attempts at self-delivery. The visible signs of this will consist merely of scratches and nail-marks upon the face or neck. Very severe injuries are never produced in this way.

We must be careful not to mistake the common blood-coagulum usually found under the aponeurosis on the child’s head for the result of violence; nor the folds of the skin, in fat children particularly in winter, produced by the movements of the head, and which remain strongly marked in the solidified fat, for the mark left by the cord in a case of actual strangulation.

3. Supposed Period of Death.

The answer to the question as to the probable time of death, is often of the utmost importance. To be able to determine this, we must have regard to the various appearances following death, previous to putrefaction, and to the chronological succession of the phenomena of external and internal putrescence.

=A.= _Signs of Death previous to Putrefaction._

Respiration and circulation have entirely ceased.

The eyes have lost their lustre.

There is no vital reaction to stimulants.

The body grows ashy-white. A particularly florid complexion may retain its color for some days after death.

Neither the red or livid edges of ulcers, nor red, black or blue tattoo-marks disappear after death.

An icteric hue existing at death never becomes white, and ecchymoses retain in every case, the hue they had at the time of death.

Most bodies become quite cold in from eight to twelve hours. Fat bodies and those of persons killed by lightning, or by suffocation, retain the heat longer than others; in water, bodies cool rapidly.

A general relaxation of the muscular system occurs immediately after death.

A body presenting only the above signs, has been dead from eight to twelve hours at the longest.

In from twelve to eighteen hours the eye-balls become soft and inelastic, and feel flaccid.

The muscles on those parts of the body on which it lies, become flattened by the weight of the body.

In from eight to twelve hours after death, hypostases resulting from the gravitation of the blood in the capillaries, begin to form on all the depending parts of the body.

The most important are the external hypostases—for they are liable to be confounded with ecchymoses, and consequently with traces of violence committed previous to death. An incision into the discolored spot should always be made, when, if it be an hypostasis—a post-mortem stain—there will be no escape of effused fluid or coagulated blood, as there will be if it be an ecchymosis, the result of violence previous to death.

The color of these post-mortem stains varies from a livid or coppery-red to a reddish blue. They are extremely irregular in form, and are never elevated above the surrounding skin. They are formed after every kind of death.

Internal hypostases occur in the brain, in the sinuses and veins of the pia mater of the posterior hemispheres, even after death from hæmorrhage. They must not be confounded with cerebral hyperæmia.

In the lungs, hypostases are of constant occurrence, and are carefully to be distinguished from the signs of ante-mortem pulmonary congestion and pneumonia.

In the intestines and kidneys, hypostases are also noticed.

In the heart we find no hypostasis, but clots, or “cardiac polypi,” which are the coagulated fibrine of the blood, formed in most cases after death. Their presence proves that coagulation of the blood may take place after death.

The last sign of the earliest stage of death is the _rigor mortis_. It passes from above downwards, beginning on the back of the neck and lower jaw, passing on into the facial muscles, the front of the neck, the chest, the upper extremities, and last of all, the lower extremities. It begins variously after eight, ten, or twenty hours, and may last from one to nine days. In the mature new-born infant it is feeble and very transitory. A low temperature, and the existence of alcoholization, favor the long duration of cadaveric rigidity. A frozen body is stiff as a board from head to foot, whereas in rigor mortis the extremities, particularly at the elbows and knees, preserves a certain amount of mobility. A body in which only the signs thus far mentioned are present, may be presumed to have been dead from two to three days at the longest.

=B.= _The Process of Putrefaction._ The progress of putrefaction is modified by the following conditions:

By age. The bodies of new-born children putrefy more rapidly than others; those of very aged persons much more slowly.

By the condition of the body. Fat, flabby and lymphatic corpses putrefy more quickly than lean ones, for an abundance of fluid is very favorable to decomposition.

By the kind of death. The process is rapid after death from exhausting diseases, from injuries attended with much mutilation, from suffocation, from narcotic poisons. It is slower after sudden death in healthy persons, after death from poisoning with phosphorus, sulphuric acid and alcohol.

By the access of atmospheric air. Whatever prevents this, retards decomposition. Thus, bodies buried in the earth, or lying in water, or clothed, putrefy less rapidly than those exposed to the direct influence of the air.

By the quantity of moisture, which in addition to its own, can and does reach the body from without. The more moisture, the more rapid the process.

By the temperature of the air, or of the water in which the body is lying. “At a tolerably similar average of temperature, the degree of putrefaction present in a body after lying in the open air, for one week (or month), corresponds to that found in a body after lying in the water for two weeks (or months), or after lying in the earth in the usual manner for eight weeks (or months.”) (Caspar.)

In bodies lying in the air, external putrefaction begins with a greenish coloration of the abdominal coverings, in from twenty-four to seventy-two hours after death, according to the modifying conditions just noticed. (In bodies lying in water, the process of putrefaction begins in the face, head as far as the ears, and the upper part of the neck, with a livid, bluish tinge, rapidly becoming a brick-red, and proceeds downwards in the same relative manner as about to be described.) Within the same period, the eye-ball becomes soft, yielding to the pressure of the finger.

After three to five days from the period of death, the discoloration has spread over the whole abdomen and external genitals, and spots make their appearance on other parts.

In from eight to ten days the discoloration has spread over the whole body, and the peculiar odor is developed. The abdomen is distended with gas; the cornea has fallen in and become concave. The nails are still firm.

In fourteen to twenty days after death, the whole body is of a bright-green, mixed with red and brown. The epidermis is raised here and there in blisters, and in other parts patches of it are quite stripped off. Maggots cover the body. From the continued development of gas, the whole body is bloated, and has a gigantic appearance. The nails are detached at their roots and lie loose, and are easily separable. The hair is loose and easily pulled out.

Since this stage may continue many weeks or even months, we cannot distinguish a body in this state after one month, from one in the same condition after from three to five months.

After from four to six months, or sooner in the case of bodies that have lain in warm and moist media, the cavities of the body are opened by the continued development of gas; the skull has separated from the neck, and the brain has run out; the orbital cavities are empty; all the soft parts have commenced to break down into a soft pulp, or are partly already broken down and dissolved, leaving entire bones exposed. The bones of the extremities are often separated by the destruction of the fasciæ and ligaments. No trace of a physiognomy is discernible. The doubtful sex of the deceased can only be determined from the external peculiarities of form, or the hair about the pubis, or by the presence of a uterus, which withstands decomposition longer than any other soft organ of the body.

_Internally_, the process of putrefaction begins in the trachea and larynx. The brain in children up to the end of the first year, is next attacked. Next the stomach, intestines and spleen, and then the omentum and mesentery. The liver is usually compact and firm, even some weeks after death. Putrefaction commences on its convex surface. The brain of the adult follows next in the succession of putrefying organs. Several months usually elapse before putrefaction of the heart has advanced very far. In the lungs decomposition begins about the same time as in the heart, sometimes earlier. The kidneys, urinary bladder, œsophagus, pancreas, diaphragm and larger arterial trunks then succumb, and last of all the uterus.

4. The Probable Cause of Death.

Although in general, a careful examination of a body found dead, will readily reveal the true cause of death, yet instances frequently occur where attempts at concealing it, or peculiar circumstances in connection with the death, may render the task more difficult.

We confine ourselves here to a brief notice of some of the more important points to be kept in view, in rightly estimating the relative value of post-mortem appearances, and in guarding against possible mistakes.

Rough handling, falls and blows, occurring a short time after death, may produce excoriations and pseudo-ecchymoses, which cannot by sight be distinguished from such as are the result of violence inflicted during life.

_Wounds_ inflicted during life are distinguished from those inflicted after death, by the entire absence in the case of the latter, of any signs of vital reaction, as inflammation, hæmorrhage, suppuration, swelling or cicatrization of the edges of the wound, etc. But in the case of very sudden death from wounding of an important organ, these traces of vital reaction may also be wholly wanting. Again, injuries are often produced on dead bodies, by the instruments used to recover them from the places in which they have been discovered.

_Contused wounds_ seldom represent the exact dimensions of the weapon employed.

Blunt weapons may merely contuse and disfigure, or lacerate, or fracture bones, or produce rupture of internal organs. Healthy organs never rupture spontaneously, and can only be ruptured by external violence.

The inspection of the position, direction, depth, breadth, and number of wounds, compared with the weapon with which they have been inflicted, often furnish the means of approximately judging of the position of the perpetrator when he committed the deed, and even his object and bodily strength.

In judging whether _fractures_ have been produced before or after death, we must remember that it is very difficult to fracture the bones of a dead body. Hence, for example, considerable injuries of the cranial bones, particularly of the base of the skull, have most probably been produced during life. A fracture of the ribs in the dead body is never splintered.

In deciding whether a case is one of _suicide_ or _homicide_, besides the previous state of mind of the deceased, the posture and position of the body, hands, etc., the appearance of the clothing, and the character of the wounds or injuries, are the points to be particularly noted, as well as the absence or presence of evidences of robbery.

_Gunshot wounds_ produced upon dead bodies, are never as deep as similar ones would be in a living body; the track of the bullet can be distinctly traced; and the edges of the wound show no appearance of vital reaction. Hence they can readily be distinguished from such as have been produced during life.

_Burning_ of a dead body does not in general produce vesication; by exceedingly intense heat it may, however, be produced. The bullæ, however, last but a few minutes, never contain serum, but only watery vapor, and never exhibit any trace of the bounding line of redness, nor any trace of color on their basis. They are, therefore, easily distinguished from burns inflicted during life.

In distinguishing between spontaneous apoplexy and _cerebral hæmorrhage_ the result of injuries, it will be sufficient to note that, in the former case, but a very small amount of blood is effused, so that the discovery of very extensive and considerable extravasation of blood within the cranial cavity, can be regarded as a proof of the application of external violence.

In the case of a dead body found _hanging_, it is in most instances to be regarded as a case of suicide, unless the examination of the body should show external marks of violence, or internal signs of death from another cause.

_Where a body has been found in the water_, the question may arise whether it was alive or dead when it entered the water. The investigation of the body will reveal the cause of death. The surest sign that the body was alive when it was thrown or fell into the water, is the presence in the stomach of some of the fluid in which it was lying, if this fluid be such as is never voluntarily drank. Whether the drowning was a case of suicide or homicide, it is sometimes impossible to determine. All the various circumstances of time and place, and concomitant appearances, must be minutely investigated, in order to hope to arrive at a probable conclusion.

In the case of _supposed poisoning_, where the fact of the administration of poison has been proved, and the person has died with symptoms attributable to poisoning, and the post-mortem appearances reveal no other cause of death—then the death is to be regarded as the actual results of the poison, whether its existence in the body can be proved by chemical analysis or not. Only such poisons are used by suicides as a general thing, as are known to be _certain_ poisons, and such as have a very disagreeable taste are, from this fact, hardly ever used for the purpose of murder, except in the case of very small children, or persons rendered insensible by any means. (Caspar.)