Aids To Forensic Medicine And Toxicology Part 2

11. Diabetic coma; uraemia.

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

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

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

VI.--SIGNS OF DEATH

(1) Cadaveric appearance; ashy white colour. (2) Cessation of the circulation and respiration, no sound being heard by the stethoscope.

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

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

Still, the body, other things being equal, may be said to be _quite cold_ in about _twelve hours_.

=Hypostasis= or =post-mortem staining= is due to the settling down of the blood in the most dependent parts of the body while the body is cooling. It is a sure sign of death, and occurs in all forms of death, even in that due to haemorrhage, although not so marked in degree.

Post-mortem staining (_cadaveric lividity_) begins to appear in from eight to twelve hours after death, and its position on the body will help to determine the length of time the body has lain in the position in which it was found. The staining is of a dull red or slaty blue colour. It must be distinguished from ecchymosis the result of a bruise, by making an incision into the part; in the case of hypostasis a few small b.l.o.o.d.y points of divided arteries will be seen, in the case of ecchymosis the subcutaneous tissues are infiltrated with blood-clot.

Internally, hypostasis must not be mistaken for congestion of the brain or lungs, or the results of inflammation of the intestines. If the intestine is pulled straight, inflammatory redness is continuous, hypostasis is disconnected. About the neck hypostasis must not be mistaken for the mark of a cord or other ligature. When the blood is of a bright red colour after death (as happens in poisoning by CO or HCN, or in death from cold), the hypostasis is bright red also.

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

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

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

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

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

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

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

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

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

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

VII.--DEATH FROM ANaeSTHETICS, ETC.

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

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

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

The chloroformist ought always to use the best chloroform.

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

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

Before a major operation is performed, it is well to get a written agreement.

VIII.--PRESUMPTION OF DEATH; SURVIVORSHIP

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

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

IX.--a.s.sAULT, MURDER, MANSLAUGHTER, ETC.

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

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

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

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

X.--WOUNDS AND MECHANICAL INJURIES

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

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

The larger the area of skin burnt, the more grave is the prognosis.

Burns of the abdomen and genital organs are especially dangerous. Young children are specially liable to die after burns.