66. _Rauscher: Friedreich’s Blat., 1886, xxxvii., pp. 324-330._—Woman,

age 71, suffocated by a cloth over nose and mouth. See Tidy, “Med. Jur.,” Cases 1 to 11. DEATH FROM SUBMERSION IN ITS MEDICO-LEGAL RELATIONS. BY IRVING C. ROSSE, A.M., M.D., F.R.G.S. (ENG.), _Professor of Nervous Diseases, Georgetown University; Membre du Congrès International d’Anthropologie Criminelle, etc._ DEATH BY SUBMERSION OR DROWNING. GENERAL CONSIDERATIONS. THE frequence and importance of drowning having arrested attention from the days of Noah’s Ark and those of Hippocrates down to the present time, it is quite possible to array in chronological order the fictitious, transitory, and positive periods that mark the sequence of ideas touching the subject. Mooted questions relative to drowning have been debated since the fourteenth century; and modern statistics show the great development of this class of emergency, than which none is of more startling character. In France between four and five thousand cases of this kind of accident are officially recognized each year, which is about one-third of all the accidental deaths, and the number appears to increase yearly. Nearly the same figures apply to the inland waters of England and Wales, not including the coast. The Board of Trade Return shows that out of 86,695 seamen who died in English ships abroad, 53,673 were drowned, and a late report of the Fisherman’s Federation places the number drowned in the inland waters and upon the immediate coasts of the United Kingdom and its adjacent islands as 6,268 annually. The many hundreds drowned in the late _Victoria_ disaster and in the great storm that swept the British Isles are matters of current knowledge. In our own country accounts of drowning are of daily occurrence, and help to the drowning forms the greater part of the work done by that noble governmental branch, the Life Saving Service. Not only does the sea claim its numerous victims, but the great floods and cyclones have destroyed thousands, while on the lakes and rivers drowning accidents are lamentably frequent. If the statistics of such accidents were as available as those of the late war, for instance, the exhibit would doubtless be surprising. Where the aggregation of killed in action is shown to be 67,058, there were drowned 106 officers and 4,838 men. The small regular army lost 5 officers and 89 men from this cause; the negro troops, 6 officers and 289 men; and the volunteers furnished a large contingent, the State of Ohio alone having lost 14 officers and 770 men from drowning.[935] Aside from the point of view of public hygiene and that of pathology, further evidence is not wanting to show the medico-legal value of the phenomena of drowning, and the frequency and importance of the judicial questions that may arise in this class of accidents. DEFINITION AND PHENOMENA OF DROWNING. Late studies as to the cause and mechanism of _asphyxia by submersion_ or drowning warrant our speaking of submersion as immersion complete enough to menace or to extinguish life. When an animated body or a part only of the body is immersed a sufficient time in water or any liquid medium whatever in such a way as to exclude fresh air from the respiratory orifices, suffocation follows, and death by submersion or drowning takes place. The phenomena occurring in such instances are mostly those common to imperfect aeration or non-aeration of the blood, and for this reason the majority of medical writers describe asphyxia or apnœa, that is, death beginning at the lungs, as the determining cause of death by drowning. It must not be thought that asphyxia is always the mode of death in those submerged, although it is commonly present in a certain number of cases. Other causes may often modify the circumstances of the death or directly produce it, as congestion of the brain and syncope, or the cause of death may be a mixed one. Occasionally one reads accounts of persons resuscitated from drowning who, on recovering from the primary effects of the asphyxia, die suddenly without apparent cause after a lapse of a few minutes or several days. Such cases are explained as the secondary results of the arrested interstitial nutrition that took place during the period while breathing was temporarily arrested. Another secondary cause is physical injury to the lungs from water penetration, which may result in a fatal pneumonia. A case related in England last summer is that of a drowning boy who, on being resuscitated after submersion in contaminated water, suddenly died of cholera. MODE OF DEATH IN DROWNING. Since various lesions may be found, accordingly as the death from drowning has taken place from one or more of the foregoing modes, it is necessary to have a clear notion of asphyxia and to study in detail the mechanism of arrest of the thoracic movements and of the hindrance to hæmatosis. Broadly speaking, there will be asphyxia when any obstacle hinders air from entering the pulmonary vesicles, or when the fluid that penetrates them is of any other nature than the medium in which the animal is destined to live. Consequently the name asphyxia is applied generically to all accidental conditions in which life is threatened by any intervention whatever of the respiration. (See MECHANICAL SUFFOCATION, Vol. I., p. 705 _et seq._, and ASPHYXIATING GASES, Vol. IV.) Submersion in any liquid medium causes asphyxia. This condition may be caused on being surrounded by a medium devoid of oxygen and improper to support sufficient hæmatosis, as hydrogen, nitrogen, and the protoxide of nitrogen, gases not toxic properly speaking, but considered irrespirable. Diminished respiration from deficiency of oxygen is the true cause of asphyxia. No animal can maintain the respiratory process in an atmosphere devoid of oxygen or in one that does not contain at least ten per cent of this gas, and such quadrupeds as whales, hippopotami, and seals or the pygopodous birds would drown in the same manner as a dog if kept submerged long enough. The suppression of the gaseous exchange by submersion is also fatal to such aquatic insects as hydrophiles, dytiscidæ, and the like, which drown in the same manner as the hymenoptera, coleoptera, diptera, or other terrestrial insects. Ants drown in less than a minute when the body is wet, and the disappearance of apparent vitality is accompanied by convulsive movements indicating functional trouble of the nervous apparatus. Sir John Lubbock found that after eight hours of immersion they could be restored to life, and several ants after two days and five days were restored to momentary life with feeble motions, followed by death in two hours. Even a terrestrial plant when submerged drowns like a terrestrial animal, the mechanism of asphyxia by submersion being the same in plants and aerian animals, and due to closure of the principal way of gaseous exchange. Notwithstanding the interruption of the gaseous exchange necessary to support life, there is long persistence of vitality after submersion of some creatures in which an intra-molecular respiration or gaseous dialysis with aerated water takes place, as in ants who have not been wetted before submersion. The resistance of new-born animals to this mode of asphyxiation is especially noted in the greater time required to drown a pup than an adult dog. One minute and a half usually suffices to drown a dog, while a new-born pup often requires as much as fifty minutes. This great difference is owing to the less active change of tissue and the smaller consumption of oxygen in the young animal. The more active the vital combustion and the greater the demand upon the general store of oxygen in the blood, the quicker the young animal perishes when the respiration is obstructed. It is observed in a general way that all kinds of death caused by the privation of respirable air have between themselves the greatest resemblance. Whatever be the obstacle that intercepts the connection of the lungs with the atmosphere, the apparent differences are only secondary and the essential symptoms are identical, because all act in suppressing the functions of the blood and hæmatosis. In fact, the phenomena of asphyxia are constant and related to disturbances in the respiration, innervation, and circulation, which vary according as the asphyxia is the result of submersion or of the absence of oxygen in the surrounding medium, according as asphyxia is immediate or slow. The fatal result of asphyxia is owing to the introductory arrest of the pulmonary circulation, the capillaries of the lungs being incapable of conveying venous blood. The stagnation of the blood in the lungs is followed by paresis of the respiratory centre and stoppage of the heart. STAGES AND SYMPTOMS OF DEATH BY DROWNING. The authorities are that an individual who dies asphyxiated by submersion passes through three stages. At first he experiences a violent shock, followed by an inspiration of surprise, which results from the contact of water with the lungs causing a reflex cough. Then for some seconds there is a voluntary suspension of respiration, giving rise to other forcible involuntary expirations. In this dyspnœic second period the face and brain become congested, owing to slowing of the encephalic circulation. Loss of consciousness soon follows, when the drowning person enters the third stage, which is that of asphyxia. In this period the individual gasps deeply, the pupils are dilated, the sphincters paralyzed, and the limbs are agitated by clonic convulsions. This is followed by complete insensibility and speedy death. When a fatal termination in drowning results from that form of neuro-paralysis known as _syncope_, in which death begins at the heart, we infer from experiments that the sudden loss of consciousness arises from the violent impressions that the sensitive nerves convey to the bulb. Such a result is more likely to occur in persons with weak heart and languid circulation, who are more susceptible to fright and shock or to the sudden collapse from intense cold. It is also shown that stammerers, who have a defective innervation of the phrenic and of the pneumogastric, succumb more rapidly than others. The importance of syncope as a cause of death in drowning is much restricted when we consider the fact that the circulation is the last of the functions extinguished in an animal that for purposes of experiment has been subjected to submersion. This has been shown in a sensuous way by experiment, aided by the resources of the graphic method, which registers the respiratory modifications as shown by the pneumograph and also the condition of the femoral artery in connection with a kymographion. The heart continues to beat as much as three minutes after the animal has succumbed, and recent autopsy gives almost constant proof of asphyxia. In fact, it is held that syncope takes but small part in this form of death, the general agreement of opinion being that nothing short of a syncope that would be fatal either in or out of the liquid medium can account for the entire absence of some of the signs of death from asphyxia. Among the symptoms often present in drowning persons, many relate to nervous phenomena and the mental state, which may vary with individual presence of mind and moral force. Persons who have escaped this kind of death have observed auditory and visual hallucinations, as flashes of light, the ringing of distant bells, and the like. Just before the outset of the asphyxiation a rather curious functioning of the brain known as hypermnesia[936] takes place, in which the revivescence of ideas, of objects, or of facts relates to anterior impressions long past that seem to have been forgotten. According to the narratives of many drowning persons who have escaped the last consequences of asphyxia, this condition was attended by general exaltation of the memory of such a nature that their whole previous conscious existence seemed, in an incredibly short period and with great clearness and precision, to pass before them in panoramic review. In Admiral Beaufort’s letter to Dr. Wollaston, the memory impressions are said to have occurred in retrograde succession. A medical man resuscitated from drowning reports that just before losing consciousness this particular cerebral activity, in his case, took on a most realizing sense of the situation and of the consequences to his family. This cerebral superexcitement is not, however, a constant thing, nor do all subjects experience the ineffable agony of drowning. Persons have been taken from the water apparently dead who, on regaining consciousness, declared that they experienced neither oppression nor suffering and had no recollection of what had passed. A very intelligent woman of my acquaintance, having such an experience a few years since at Newport, quotes herself as and really believes that she is an instance of a person once dead and afterward restored to life. This peculiar vividness of mind has been observed in other kinds of death than drowning, notably in chronic insanity. A priest with extended experience at the Government Hospital for the Insane tells me that he has often noticed the _vaticinatio morientium_ in the form of so-called lucid interval of the insane when called on to administer the last rites of the Church. The condition is explainable from the stoppage of the pulmonary artery and the stimulus caused by circulation of non-oxygenated blood in the brain. The condition known as asynesia, or amnesia, sometimes follows the return to consciousness in persons asphyxiated and apparently dead from drowning. Dr. F. A. Burrell reports the case of a boy of eighteen, submerged for six minutes and resuscitated after four and three-quarter hours, in whom the memory of everything that had occurred from half an hour previous to the accident up to return of consciousness had been entirely obliterated. When last heard from the lapse of memory still remained.[937] The statement that death from submersion results from true asphyxia or from asphyxia in a more or less modified form rests on the authority of a large number of facts. Indeed, recent investigators make the proportion so much greater than formerly as to warrant the statement that asphyxia is the generic cause of death by drowning. Dr. S. Coull Mackenzie[938] reports 305 cases of drowning, in which 297, or 93.37 per cent, died from asphyxiation; 1, or .32 per cent, from syncope; 1, or .32 per cent, from apoplexy and asphyxia; and in 6, or 1.96 per cent, the mode of death could not be determined because of advanced putrefaction. As the post-mortem signs of drowning are known to vary according to a number of circumstances, it is difficult to deal with the subject unless certain fundamental points be kept in mind. These relate more particularly to the external signs and to the different lesions that follow the mode of death, although they are not constant. Surgeon-Major E. G. Russell[939] illustrates how widely the post-mortem appearances may vary in cases of drowning, even when the outward circumstances of the period of death are identical and the bodies have been subjected to precisely similar conditions as regards duration of immersion, subsequent exposure to air, and times of necropsy. He relates that five persons were drowned while proceeding to a ship in the Hooghley River. Three died the same death; and at the same time the bodies were recovered together after the same period of immersion, and were examined together; thus from beginning to end they had been under exactly similar conditions, yet there were very marked differences in the state of preservation of the bodies and in the post-mortem appearances. After five hours’ exposure in air at 88° F., one body, in which the tissues were extremely fatty, showed beginning decomposition; in the other two there were no signs. Decomposition in the scalp, face, and neck indicative of drowning had begun under water, although in ordinary cases it first invades the abdomen, genitals, breasts, etc. Rigor mortis present in one case was absent in the other. The penis was semi-erect in one case, flaccid in the other, retracted and shrunken in the third. Emission of semen and expulsion of fæces were also noted. Tongue not swollen or protruded in any case, and _cutis anserina_ absent in all three, which may have been owing to the high temperature. Water was inspired into the lungs in two cases. The larynx, trachea, and bronchi had regular congestion and scarlet ecchymoses in one case characteristic of asphyxia, and there was muddy water in the stomach. The first question likely to arise when a drowned body has been found is the one of identity. All the circumstances in which the body was observed before its removal to the place where it lies for examination should therefore be minutely detailed, and all lethal injuries and the like should be noted with care, since the smallest accessories often lead to identification. The locality in which a drowned body is found may be a fact of considerable importance that may help to complete the chain of evidence in which the matter of crime or of accident turns upon the question of identity. It must be remembered that bodies often drift many miles away from the spot where the drowning occurred, owing to tides or currents. Such a circumstance I noted a few years ago at Brownsville, Texas, where it was a common sight to see bloated cadavers going down the Rio Grande. Time and putrefactive changes are also elements that enter into the matter of recognizing the drowned cadaver. To resolve this question with desirable precision, the reader is referred to more detailed instruction in the chapter on Identity. TREATMENT OF THE APPARENTLY DROWNED. Help to the drowned does not properly come within the province of judiciary medicine, being rather a humane question that belongs to public hygiene. Systematic writers, however, treat the subject at considerable length, and the statistics of institutions for helping the drowned give such marvellous results that it would manifestly not be out of place to cite briefly some of the means employed for restoring life to persons taken from the water asphyxiated and apparently dead. The prime object in resuscitating the drowned is the introduction of air into the pulmonary vesicles, which is best accomplished by artificial respiration, and the employment of such means as excite the nervous system with a view to reanimate sensibility and develop the reflex movements that contribute to the re-establishment of the respiratory function. The exigencies of drowning also call for special means to restore the animal heat and the circulation, as well as the precaution of removing mucus and fluids from the obstructed air-passages. As the knowledge of securing patency of the air-passages by artificial respiration is generally diffused among medical students and is taught in some schools, it would be superfluous to repeat in detail the procedures of Hall, Sylvester, and others. Laborde’s method of resuscitating those apparently dead has lately gained some notoriety. It consists in stimulating the respiratory reflex by regular rhythmical traction of the tongue, which should be vigorously pulled forward fifteen or eighteen times a minute, to correspond in frequency to the normal respiration. Another method, alleged to have marvellous effects over the respiration, is that of anal dilatation. Its advocates claim that irritation of the anus is a much more effective measure in resuscitating the drowning or narcotized.[940] Respiration may be further promoted by alternate dashes of hot and cold water on the face and chest, by smelling-salts, tickling the throat and nares with a feather, and by electrization of the diaphragm and inspiratory muscles. Protracted galvanism may, however, prove dangerous. When signs of life appear, a warm tonic stimulating drink should be given. A hypodermic injection of caffeine is also recommended. Whatever means are employed should be used on the spot in the open air and without a moment’s delay. Restorative efforts may be kept up for two or three hours, although in the majority of cases life is extinct in the human subject after two minutes’ submersion or even less, and the chance of restoration after five minutes’ complete submersion is doubtful. To be sure, trained tank performers remain under water longer than two minutes, and exceptional instances occur of recovery after twenty minutes’ submersion in individuals in a state of syncope or with catalepsy. CADAVERIC SIGNS IN CASES OF DROWNING. The signs alleged to be common to death by drowning and characteristic of it are difficult to deal with, for the reason that there are no sure signs of drowning and the lesions furnished by necropsy are of feeble importance. There is consequently a divergence of opinion on this subject. EXTERNAL SIGNS. Among the external diagnostic signs consistent with the supposition of death by drowning, the presence of froth at the mouth and nostrils is of first importance. Cadaveric rigidity, pallor, goose-skin, rosy or violet discolorations on various parts of the body, retraction of the penis and scrotum, fish-like expression of the eye, peculiar position of the tongue, maceration of the palmar and plantar epidermis, and convulsive contraction of the limbs, particularly of the hands, which may be clinched after the manner that marks death by asphyxia, are all signs which when united form strong presumption in favor of submersion. These typical and classic signs may, however, be varied by many circumstances. Hence the dissidence of authors. Dr. F. W. Draper states that after inspecting 149 drowned bodies, he has never observed that important sign of death, the presence of substances grasped in the hands.[941] Sand or mud in the hollow of the nails and excoriations of the fingers are also regarded as probable, not certain, signs, since each of these might have occurred either before or after death. The peculiar clinched condition of the hand is not pathognomonic, though strongly suggestive of drowning, as it may appear in asphyxiation from other causes. I have lately noticed this among the external appearances of the bodies taken from the Pompeiian excavations. The further index of drowning known as washer-woman’s or cholera hand, with non-adherent tendency of the epidermis, is an effect that may be produced upon the living after a prolonged bath, notably in the aged and habitually unclean. Nor is the position of the tongue a special and distinctive characteristic of drowning. Only a few months ago I observed its presence in some of the victims of mechanical suffocation in the Ford’s Theatre disaster in Washington. The shrunken state of the genital organs is apparently of little positive value as a thanatological sign, since the negative and opposite state of erection has been often observed, and Dr. Ogston states that he met semi-erection in twenty-two cases. The value of “goose-flesh” as a link in the chain of evidence is also weakened when we consider that it frequently occurs after other violent modes of death. Anserine skin is often met with during life, and cases of drowning are recorded where this appearance has been absent. The aspect of the face and the general position of a drowned cadaver may likewise vary according to the mode of death. Immobility of the body in the attitude of agony, the horrible grimaces of asphyxia, the pale, calm features of syncope, and putrefactive changes are further circumstances of medico-legal detail that may complicate the problem and render an autopsy necessary in order to invalidate or confirm the uncertain conclusions furnished by the external signs. INTERNAL LESIONS. Autopsies on the drowned are remarkable owing to their negative signs. But as an extension of diagnostic means, the autopsy may show the vertical (though not invariable) position of the epiglottis; the presence of water and foreign matter in the bronchi; swelling and emphysema of the lungs; hydræmic engorgement of the liver; fulness of the right heart and emptiness of the left; fluidity of the blood; water in the stomach and middle ear; and a characteristic frothy mucus or lather more or less bloody, which most observers and writers consider the only constant post-mortem appearance of drowning. Examination of the respiratory apparatus is of extreme importance in a question of this kind, for it is contended that the presence of foreign bodies is a proof of submersion.[942] This opinion is in part erroneous, since it has been observed that when a body is submerged after death water will penetrate the larynx, trachea, and remote bronchi, as well as the stomach and middle ear. Moreover, Dr. Ogston states that in 48.7 per cent of cases of drowning no water was found in the lungs. The emphysematous condition of the lungs, which are said to force their way out of the chest on removing the sternum, is difficult to distinguish from the result of putrefaction. Dr. Gilberti shows that in the drowned the lungs disintegrate rapidly, while the heart, in which putrefaction begins chronologically, is relatively in a good state of preservation.[943] Since many cases have been observed in which both sides of the heart may be partly filled or both be empty and flaccid, or the left side distended more than the right, we are obliged to regard the exceptions concerning this post-mortem sign of drowning as co-extensive with the rule. Excessive fluidity of the blood depends upon the rapidity with which the drowning took place. Slight hydræmia occurs in rapid submersion, but when the drowning has taken place slowly a large amount of water passes into the blood. In certain poisonings by opium this fluidity also exists; but it is claimed that analysis and the spectroscope may clear up the diagnosis. Hydræmic engorgement of the liver is regarded as a characteristic fact by Lacassagne, who claims to be able to diagnosticate drowning from a single examination of this organ.[944] It is now generally admitted that the presence in the stomach of a certain quantity of liquid in which the body was found immersed may be considered as a sign almost certain of asphyxia by submersion. Dr. Fagerlund concludes from his experiments that liquids do not penetrate after death either the stomach or anus unless strong pressure be made. But when asphyxia occurs in water the liquid is found in the stomach and the intestines, where it is helped on by peristaltic movements. The pylorus is an obstacle to the passage of this water, the movement of which is easier when the stomach is empty and the submersion prolonged.[945] The quantity and quality of the water may constitute important evidence; but to be of full value the water or other fluid found in the stomach ought to be the same as that in which the immersion has taken place. The liquid, which may have been taken just before drowning, should not be noticed unless it exceeds half a pint; but anything peculiar in the fluids, either of the lungs or stomach, should be subjected to microscopic or other examination. Presence of water in the middle ear is regarded as a thanatological sign of great value. Dr. Bourgier claims as the result of his examination that 23 cases out of 27 had water in the middle ear. Several German observers pretend to have found amniotic liquid in cases of fœtal asphyxia. The fluid may be aspired by a small pipette. Many of the foregoing signs and lesions disappear or undergo variable alterations after sojourn in water, putrefaction, etc. They may, as they have done in the past, give rise to many controversies, so that presumptions only can be established. Hence the necessity for careful and detailed necropsy in such cases, with a view not only to minimize conjecture and uncertainty, but to prevent opposing counsel from entering the plea of negligence and incompleteness. WAS THE DROWNING ACCIDENTAL, SUICIDAL, OR CRIMINAL? Assuming the probabilities to be in favor of death by submersion, the question next turns upon the character of the event. In the absence of lesions it is almost impossible to say whether the individual fell in, jumped in, or was pushed in the submerging fluid. The person’s antecedents should be inquired into—whether subject to epilepsy, vertigo, intemperance, or mental aberration. Alcoholism is an important factor in accidental drowning, and a person intoxicated may be drowned in very shallow water. A few years ago a young man over six feet tall, while bathing in a tributary of the Potomac River, near Washington, was drowned in only three feet of water. On considering all these circumstances, it may not be possible, even after careful inspection of the body and minute exploration of all the organs, to declare the drowning the consequence of an accident. The existence of traces of violence or of injury which may have occasioned death or disability, of such a nature as to render the person unable to defend himself, would seem to merit particular attention. But their presence leads to further consideration—were the marks of injury caused by the water itself, by some object in the water, or were they self-inflicted? Dislocations, fractures, and other injuries have been caused by jumping or falling into the water from a great height. I know an instance of a professional who, on jumping from a height of ninety feet, split his upper lip on striking the water with his mouth open. The autopsy in the case of Odlum, the Brooklyn Bridge jumper, is said to have shown rupture of the liver. On the other hand, many persons jump from great heights into water with perfect impunity. For many weeks at the London Aquarium a performer has nightly jumped into a tank from an elevation of 127 feet, and several persons have successfully jumped from bridges much higher. Objects in the water that may account for cadaveric lesions are numerous. I have known a soldier, a good swimmer, to break his neck on diving from a river bank.[946] Other traumatic lesions may occur in a rapid current, from the breaking up of ice, from the screw or paddle-wheel of a passing steamer, or from aquatic animals. A matter much discussed in connection with this subject—that of shark-bites—may enter into the question of survivorship where it is alleged that several persons during shipwreck or other disasters at sea have been devoured by sharks. Though an occasional accident, such bites are more a figment of the mind than a reality, as the concurrent testimony of disinterested observers will show. After years of investigation among nautical people and much experience as a swimmer in widely different parts of the world, I have no personal knowledge of such injuries, and have met but two persons that had any actual personal knowledge of shark-bites. Documentary evidence as to shark-bites is also very scanty. During the last fifty years soldiers by the tens of thousands have swum at Fort Monroe, Virginia, yet there is no record of one having been bitten by a shark; nor have I been able to ascertain that any accident of the kind has occurred at Malta or at Gibraltar. There does not appear to be a record of any one ever having been bitten off the British Isles. I have been unable to ascertain that a single bite of the kind is reported among the medical records of our War or Navy Department or those of the Marine Hospital. In the West Indies but few facts are reported indicating danger from sharks, and these are not well authenticated. The same may be said as to newspaper accounts, which deserve about as much credence as the reports concerning sea-serpents. A few years ago a public journal gave an account of a boy who was bitten while swimming near New York and afterward died in a hospital. But medical literature has a few reports of shark-bites. After ten years’ diligent search I have found seven references, the earliest in the _London Medical Gazette_, 1823, and the latest in the _London Lancet_, 1886. The bites occurred in Australia, South Africa, and India. The Hooghley and Ganges Rivers are the worst place in the world for sharks and alligators. A particular kind of shark, the _Carcharras Gangeticus_, which is very fierce and bold, sometimes dashes among the crowds at the bathing ghâts, and has been known to bite a boy in two feet of water. All persons bitten at these places generally die from the bite, for the reason that the shark, living on carrion, portions of which stick between the teeth, carries infection to those whom it may afterward bite. The former habit of throwing the dead in the river is supposed to account for the boldness of these particular sharks in attacking the human species. Self-inflicted wounds rather suggest _suicide_, as numerous instances attest, where one or two kinds of death were intended to make assurance doubly sure. I once saw an Eskimo stab himself and then jump overboard from a ship off the Siberian coast. But as a rule suicidal drowning is unaccompanied by traumatic lesions, unless it be those produced by falls. Hence the absence of lesions leads to the presumption that the individual while living fell into the water or other fluid accidentally or voluntarily. Exception may be made in the case of infanticide and _homicidal_ submersion as the result of surprise, where a person taken unawares is suddenly and unexpectedly pushed or thrown into the water. A case in point is that of a man suddenly robbed and seized by three persons, who threw him into the river. Another is that of a man who, wishing to get rid of his wife, gave her arsenic. The effects of the poison being slow he induced her to take a walk along the river, and when her back was turned he pushed her rapidly off the bank into the stream, where she drowned. Death by submersion is rarely the result of murderous intent, and in the case of adults it is suddenly resorted to in order to paralyze resistance and facilitate the success of crime. Submersion is oftener intended to hide a crime. A body may be taken from the water after murder or rape. Whether the cadaver is recent or one that has lain in the water a long time, the expert is confronted with a question of the differences that he may expect to find in a body drowned and one thrown into the water after death. This difficulty can only be resolved by considering all the signs and lesions furnished by the autopsy. No single sign or post-mortem appearance is characteristic of drowning, and none enables us surely to diagnosticate death by submersion either in putrid or fresh cadavers. Nor do we have any significant infallible signs that may serve as a parallel between the immerged post mortem and the submerged. The exterior signs being nearly the same in the two, the diagnosis must necessarily depend upon assembled circumstances, and these are liable to vary. CIRCUMSTANCES THAT MAY AFFECT THE TIME OF SUBMERSION. Putrid decomposition is the chief obstacle to diagnosis in a body that has been drowned. This presents great differences. The death happening in winter or summer, in a temperate or intertropical country, and sojourn of the cadaver in salt or fresh water, are each and all important details to be considered in studying the submergence of a body.[947] It is only by studying the events in this order, along with the immediate signs of death, that the duration of the submergence may be conjectured. With anatomical appearances as the only guide it is impossible to fix the time of immersion. Many elements combined may affect even the gaseous putrefaction that takes place in submerged bodies. Summer heat and shallow or stagnant water hasten the development of putrid gas and subcutaneous emphysema which bring the cadaver to the surface, and that, too, sometimes in spite of precautions taken to insure the submersion. A case in point is the body of the Italian admiral, Caraccioli, mentioned in Southey’s “Life of Nelson.” Bodies weighted with lead or other heavy substance for the purpose of hiding crime have also been known to float in consequence of the putrefactive phenomena. At Evansville, Ind., unsuccessful efforts were made to raise a sunken steamer with thirty head of cattle between decks. A few days after the attempt was abandoned the steamer was suddenly seen to float. The carcasses of the putrefying animals, swollen by gas, had sufficed to bring the wreck to the surface. A great development of gas is very noticeable in what is known as a “blasted” whale, the stomach of which assumes balloon-like proportions. A few summers ago, at Provincetown, Mass., it was my rare fortune to be within a few feet of an enormously distended putrid whale, which suddenly exploded. In cold countries drowned bodies are longer in coming to the surface. In Russia, for instance, in spring after the rivers and lakes have thawed, the bodies of numerous victims of alcoholism and accidental drowning of the previous winter are taken from the water. Last summer, at Quebec, I was present when the body of a man drowned the winter before came to the surface of the St. Lawrence River. On a visit to the northern lakes many persons connected with the navigation of Lake Superior told me that bodies drowned in its waters seldom or never came to the surface. Specific gravity of the water itself may be an additional cause for the body coming to the surface. Dr. Tidy says that every structure of the human body floats in the water of the Dead Sea. The same cannot be said about the buoyancy of the water of Great Salt Lake, the accounts of which have been greatly exaggerated. It does not “support a bather as if he were sitting in an arm-chair and float him like a fresh egg.” Experience shows that there is no difficulty either in swimming or in sinking in its waters, the solid constituents of which are estimated to be about six and a half times more than that of sea-water. Analysis of Dead Sea water places the solid constituents at 24.580, while that of Salt Lake is 22.282. Another strong natural brine in the United States is said to be that of Syracuse Saline, New York, which contains 17.35 per cent of sodium chloride. It is evident from what has been stated that no positive assertion can be made as to how soon a drowned body will rise to the surface, and at best any conclusion as to the date of submersion is so unsatisfactory that it may be said to be an unscrupulous use of guessing privileges. Errors in legal medicine are sadder in their consequences than those of medical diagnosis. The medical legist would therefore do well to preserve the frame of mind that often doubts and rarely affirms, and he should be circumspect enough to avoid dogmatic assertions about matters of uncertainty. DEATH FROM STARVATION. IN ITS MEDICO-LEGAL ASPECT. BY ENOCH V. STODDARD, A.M., M.D., _Emeritus Professor of Materia Medica and Hygiene in the University of Buffalo; Member of the Medical Society of the State of New York and of the Central New York Medical Association; Fellow of the New York Academy of Medicine and of the American Academy of Medicine; Late Surgeon 65th Regt. N. Y. Vols.; Late Health Commissioner, Rochester, N. Y.; etc., etc._ STARVATION. GENERAL CONSIDERATIONS. PHYSIOLOGY teaches that life can only be maintained in the living organism by a constant equilibrium between its waste and repair. =Nutrition= is a term by which we describe this double movement of renewal of the molecular structure of the body, and in this general sense only, that nutrition is synonymous with the maintenance of the organism in a stable condition, is it employed here. This condition of equilibrium is maintained by a regular and constant supply of _food_. =A food= may be defined to be a substance which, after introduction into the body, supplies material for the renewal of its tissues or sustains some of its vital processes. Foods vary greatly in their properties as restorative or constructive agencies, some containing but few essential properties, while others combine almost all of the elements required. As some foods contribute elements for tissue restoration, others are specially concerned in the calorifacient activities of the organism,[948] while others are marked in their tendency to take part, almost exclusively, in special chemical processes.[949] The various articles used as foods contain nutritive elements combined with innutritious substances. They have been variously classified, but are conveniently divided into I. Organic foods, {_a._ Nitrogenous (C.H.O.N.). {_b._ Non-nitrogenous (C.H.O.), {Oleaginous {Carbohydrates. II. Inorganic foods, {_a._ Water, H_{2}O. {_b._ Saline substances. Nitrogen enters largely into the composition of the body, and hence must be abundantly supplied and in combination. Of the non-nitrogenous elements the most important are _fat_, _sugar_, and _starch_. The _inorganic_ principles are essential to the process of nutrition. _Water_, constituting 87 per cent of the bulk of the body, is demanded in constant supply; while the _saline substances_ are necessary for the perfect performance of many of its chemical processes. It is apparent that no single element can alone carry on the nutrition of the body, and hence _variety_ in the supply of food, as well as sufficiency in its quantity, is essential to normal nutrition. Nor are these the only factors in this complex problem. Proper preparation of food, its supply at necessary temperatures,[950] and other requirements enter into the question of normal or sufficient alimentation.[951] Alimentation is sufficient when it is so regulated that all the functions of the body are performed in a complete and regular manner. Insufficient alimentation induces a series of phenomena and a result which have been designated “_inanition_,” or “starvation.” The exact amount of aliment required by each individual can only be stated in a general way. In the circumstances in which he is placed, the supply must be of such character and quantity as shall be proportionate to the constructive and reparative needs of his body. It is possible, however, to state a mean for the various ages and occupations of life. Physiologists generally agree that in ordinary conditions of exercise the following represents the amounts of the several food elements necessary for the adult individual daily: Albuminous substances 120 gms. = 4 oz. Fatty substances 60 ” = 2 ” Carbohydrates 360 ” =12 ” Taking the fatty matters as the unit, the daily allowance would bear the following proportions: Fats, 1; albuminoids, 2; carbohydrates, 6. These quantities and especially the fats and carbohydrates, in conditions of hard muscular labor, must be increased; and the proportion would then stand: Fats, 1; albuminoids, 1.7; carbohydrates, 7. The division of this amount of food elements into proper portions during twenty-four hours is important. This must be regulated by the habits and other circumstances of the individual.[952] The occurrence of death solely from privation of food is comparatively rare; yet it is sufficiently frequent to be considered as one of the causes of violent death and to demand investigation, since circumstances may be such as to constitute a homicide from criminal neglect or a suicide from intentional abstinence from food. “=Starvation=,” or “=inanition=,” may be considered as being _acute_ or _chronic_ according as the requisite food has been suddenly and completely or gradually withheld. ACUTE STARVATION. The complete deprivation of food induces a series of modifications of the functions of the body, differing somewhat from those developed by a partial and prolonged deprivation. The length of time during which complete absence of food can be endured varies with circumstances. In absolute stoppage of the food supply the acute sensations of hunger pass away after the first one or two days, and are succeeded by profound functional disturbances with weakness and depressing sensations over the epigastric region, accompanied by distressing thirst.[953] The mouth is dry and the tongue heavily coated; the breath is fetid; the skin is harsh, dry, and exhales a disagreeable odor; the feces become more and more scanty until the latter days of life, when diarrhœa usually supervenes; the face and extremities become rapidly emaciated; the person walks with a weak and tottering gait;[954] the urine is small in quantity and very acid; muscular feebleness gradually reaches complete inability to move; ringing in the ears, insomnia and, in some cases, hallucinations[955] with delirium and convulsions precede death, though these latter symptoms are not uniformly observed.[956] “CHRONIC STARVATION,” “CHRONIC INANITION.” This form of starvation, met with most extensively during the prevalence of famine, also occurs in conditions demanding legal investigation. =The symptoms= are sufficiently constant and characteristic. Emaciation becomes extreme, the skin dry and rough, exhaling a disagreeable odor and often covered with a coating not entirely attributable to filth; the breath is fetid and offensive. With some exceptions, the victim retains his consciousness and ability to move about, muscular efforts becoming more and more feeble; the voice becomes faint; the evacuations infrequent, dry and dark; the urine scanty and high-colored, death occurring suddenly at the end, with delirium in some cases. The length of time during which these symptoms are developed and their intensity depend mainly upon the amount and character of the aliment actually supplied during the period before death. Upon the PULSE and CIRCULATION the effects of starvation are manifest in increased frequency and feebleness of the cardiac contractions and lessened force of the cardiac impulse; this is more and more marked as the anæmic condition becomes profound. In some cases the pulse is greatly reduced in frequency, as well as in force, dropping as low as thirty-seven beats in the minute,[957] and auscultation reveals the existence of cardiac bruits. In connection with enfeeblement of the circulation, a tendency to hemorrhagic conditions is common, with purpuric and petechial eruptions in some cases. TEMPERATURE.—A subnormal temperature is frequently noted in the progress of chronic wasting disease. In inanition, which in some respects induces a similarly profound disturbance of the functions of nutrition, an analogous lowering of the body temperature occurs. Chossat clearly shows in his experiments the influence of starvation in depressing the body temperature. This abasement of temperature does not remain constant, but daily oscillations appear, differing from those occurring in conditions of normal alimentation. While the normal diurnal variation in the fully nourished is about 0.3° to 1.0° C. (0.5° to 1.7° F.), in the starving this variation reaches 3.28­­° C. (5.4° F.). This rises to nearly double this amount during the latter days of life, and is greatly increased above this figure during the day preceding death. The temperature at the close falls to a mean of 24.9° C. (76° F.), and at the moment of death has been noted at 18.5° C. (66° F.). EMACIATION.—Loss of weight is the most striking and constant symptom of starvation. The rapidity of its production and its extent are modified by circumstances. A very considerable loss of weight can be sustained by the ordinary individual without a fatal result. Chossat[958] fully demonstrated the effects of inanition upon the various functions and organs of the body in animals, and has drawn the conclusion that a loss of weight exceeding four-tenths of the entire weight of the body is productive of a fatal result. These deductions may be adopted as applicable to the human species. This statement must be accepted as a mean, as it is capable of variation by circumstances, such as age, obesity, etc. Death may occur before so great a loss has been reached in some cases, and in the obese the fat may disappear entirely and cause a loss reaching five per cent of the entire weight of the body, in a very fat animal, without a fatal result. Bouchardat[959] considers that the important question is the extent to which the blood and organs of the body contribute to this loss of weight. Impoverishment of the blood by inanition, which at the time of death has been found to amount to six-tenths of its solid constituents, is one of the most vitally serious elements of this loss; and a relative increase of its watery portion appears, without regard to the employment of water as a beverage. It must be remembered that in wasting diseases extreme emaciation may occur under a liberal diet, and may continue for a considerable time before death.[960] _The muscular system_ becomes greatly enfeebled, atrophied, and unable to perform its functions; the loss sustained by the muscles least used being most marked. The extent of muscular power possible in starvation varies in different individuals and in various circumstances. The vigorous and healthy adult, as a rule, retains muscular power to a greater extent and for a longer period than the child or aged person, under similar circumstances. Exposure to a rigorous climate, prolonged fatigue, etc., rapidly reduce capacity for muscular effort in conditions of inanition. THE PERIOD AT WHICH DEATH OCCURS. This is influenced by many circumstances. It is difficult to fix an exact period for the duration of life in complete deprivation of food, or acute starvation, and it is certainly more so in chronic inanition, when the modifying circumstances are increased in number and complexity. A large number of cases of prolongation of life during a period of absolute deprivation of food which has been stated to extend over weeks and even months, cannot be accepted as free from error, and hence are not considered here. A sufficient number, accurately observed and well attested by unimpeachable authorities, have led to the conclusion that the healthy adult, in a total deprivation of food, can exist for a period not exceeding ten to twelve days. On one of the Inman line of steamers, a young man, aged twenty years, endured absolute deprivation of all food and water during eleven days, recovery following.[961] Sarah Jacobs, a child of thirteen years (“the Welsh fasting girl”), had been exhibited by her parents as a miraculous being under the pretence that she had eaten nothing during _two years_. The child being placed under complete surveillance by four nurses from Guy’s Hospital for eight days, during which period no food was taken, died on the ninth day. The post-mortem examination showed all organs of the body to be in a healthy condition. The stomach was empty, with the exception of three teaspoonfuls of a thin acid fluid. The intestines were also empty and their walls were not thinned. A layer of fat, half an inch or more in thickness, was found under the skin of the chest and abdomen. The liver was in a healthy condition, as also the kidneys and spleen. The bladder was empty. The parents were tried on a charge of manslaughter and were convicted of causing death by criminal negligence.[962] Caspar gives the details of a case observed by him of a man aged thirty-six years, who endured total abstinence from all food for eleven days, recovery following.[963] Cases are reported of miners who have been imprisoned by accidents in mines for eight, nine, and nine and one-half days, with recovery following rescue at the end of this time.[964] While the period stated may serve as a maximum limit to which life may be extended in acute starvation, there are circumstances which must be considered as modifying this. =Body Condition.=—It need hardly be stated that the individual in perfect health can sustain complete inanition longer than the enfeebled or diseased. The presence or absence of _fat_ modifies considerably the power of endurance. =Age.=—Infants bear starvation badly and succumb more quickly than the adult. The aged, while they bear a moderate amount of food better than the young adult, do not endure a complete deprivation for so long a time. =Cold.=—The depressing influence of cold upon the vital functions, especially in the young and feeble, renders it a powerful factor in shortening the duration of life in starvation. =The Supply of Water.=—When all food is withheld, free use of water as a drink tends to increase the length of the interval before death. In several cases of protracted fasting, the use of water in moderate amount has been resorted to with the apparent result of amelioration of some of the distressing symptoms and lengthening the period of endurance. Dr. Tanner, a physician, attempted in July and August, 1880, at New York, a complete fast of forty days’ duration, with the exception of the free use of water. In this case absolute abstinence from all nourishment is questioned, as no strict medical surveillance was maintained. The Italian Succi, at New York, in 1890, undertook a voluntary abstinence from food for forty days, under surveillance, with the use of simple liquids and of some narcotic substance. He completed the fast, but beyond this fact the case is without scientific value. =Catalepsy.=—Certain abnormal conditions of the nervous system are met where the activity of the vital functions is very considerably lowered and the various processes of the economy are in a condition of semi-suspension. Cases of this character have been observed where the supply of food has been almost entirely suspended for a period of several days, with but little emaciation and other symptoms characteristic of inanition. WAS STARVATION ACCOMPANIED BY OTHER ILL TREATMENT? This question may arise where evidences of starvation are apparent. Such cases are met among young children neglected or abused by parents or those in whose care they may have been placed, or among the alienated or sick in the care of cruel or unsympathetic attendants. Infants placed with “wet-nurses” or found in the so-called “baby farms” also furnish cases which fall under this head. A careful examination into the collateral circumstances of the case, together with the results of a careful post-mortem examination, usually render a positive answer to this question possible. POST-MORTEM EXAMINATION. The dead body exhibits appearances quite characteristic. =Emaciation= is very marked and sometimes reaches an extraordinary degree, surpassing that of prolonged and wasting diseases. In extreme cases the fat entirely disappears throughout the body; the omentum and mesentery are entirely devoid of it, as well as the subcutaneous and intermuscular cellular tissue. The muscles are atrophied and the _heart_ is sometimes considerably reduced in size; the liver and kidneys in some cases show great reduction of volume. The spleen also is small and often softened. The =stomach= and =intestines= usually display an extensive thinning of their walls, so much so that their contents may be distinguished through them; their calibre also is frequently found to be diminished, though occasionally they may be distended with gas. Usually they are empty, or contain only a small quantity of bile and fecal matter. In some cases various foreign substances which have been swallowed by the victims to appease hunger have been found in them. The thinning of the walls, so constantly noted, has been considered as a specially characteristic symptom of starvation.[965] The congestion, softening, and ulcerations which have been observed in some cases cannot be considered as evidences of starvation or as its results, but rather as being due to an enteritis induced by the ingestion of improper substances. The =gall bladder= is usually found filled with dark and inspissated bile. In death by starvation the entire organs of the body exhibit no specific form of disease. Evidences of the existence of an organic affection observed in the post-mortem examination at once raise the question: WAS DEATH CAUSED BY STARVATION OR DISEASE? Was the original disease aggravated by a failure to supply the patient with food, or are the lesions observed the result of starvation? A positive conclusion can be reached in such cases by carefully considering the results of a post-mortem examination together with other facts elicited by the inquiry. Harriet Staunton,[966] a young girl, had been kept in close confinement by four interested persons, and removed in great haste, when in a condition of extreme prostration, to Penge, where she died, on the day succeeding her removal, in a state of extreme exhaustion and emaciation. Fat was absent from every part of the body; the stomach and intestines were empty, contracted, and their walls were greatly thinned. A small deposit of tubercle was found at the summit of the left lung and a recent deposit of miliary tubercle beneath the arachnoid, upon the surface of one of the cerebral hemispheres. No other tuberculous deposits were found. The opinion given by the physicians making the post-mortem examination was that death resulted from starvation. This opinion was shared by Professor Virchow, of Berlin, who stated that the tuberculous deposits found could not explain the cause of death. In this case the extreme emaciation, entire absence of fat, thinning of the intestinal walls, etc., were the determining conditions. While extreme emaciation alone is not sufficient to decide the case to be one of starvation, its existence, taken in connection with some of the conditions found constantly in persons known to have died of starvation, is a strongly corroborative fact. Nor can its absence be taken as conclusive evidence that death occurred from other cause than starvation, since in some cases of death from inanition emaciation has not been extreme and in a few cases not at all marked.[967] Instances of this character are reported by Taylor and others. DISEASES PRODUCED BY STARVATION. The effect of insufficient alimentation in the production of disease has long been recognized. It is understood that this result follows the deficiency in either quality or quantity. The so-called “famine fever,” prevalent in times of dearth, has afforded extensive opportunity for observation of the effects produced. The symptoms developed are those directly referable to impoverishment of the blood. Pallor, emaciation, nervous depression, derangement of the digestive organs, and muscular enfeeblement appear in every case. The development of strumous, herpetic, and cutaneous diseases generally is marked. Of the secondary effects, the cachectic condition induced expresses itself in pulmonary phthisis largely, while in infants and very young children intestinal disorders are specially frequent. Organic diseases already existing are seriously aggravated; wounds fail to heal, become ulcerative and sometimes gangrenous; while all degenerative processes are rapidly hastened to a fatal issue.[968] INDEX. ABDOMEN, contusions of, 580 post-mortem examination of, 370 wounds of, 580 ABDOMINAL VISCERA, rupture of, 582 wounds of, 582 ABSCESS of brain, 563 ACTIONS TO RECOVER FOR SERVICES (see Privileged Communications), 26 amount of recovery in, 45 elements to be proved in, 47 evidence in, 22-48 ACTIONS FOR MALPRACTICE, 73-87 ADIPOCERE, 451 AGE, determination of, 399 ALCOHOLISM, 564 ANTHROPOMETRY, 432 APNŒA, 709, 796 ARTERIES, wounds of, 578 ASPHYXIA, 708 by submersion, 796, 797 external appearances due to, 715 internal appearances due to, 718 AUTOPSIES, 301, 349 in cases of poisoning, 356, 371 late, 378 of fragments, 380 order of, 356 BILLS FOR SERVICES, effect of, 43 BLADDER, rupture of, 585 wounds of, 585 BLANK CHARGES, wounds by, 617 BLOOD, coagulation of, 488, 701 condition of, after burns, 653 extravasation of, in brain, 565 on weapons, 535 stains, 350 BODY (see Dead Body), examination of, 537 temperature of, 629 BONES, identification of, 390 old or recent? 391 BOOKS, medical, when and where used in court, 64 of original entry, when admissible as evidence, 48 of physician, see Privileged Communications BRAIN, abscess of, 563 concussion of, 561 congestion of, in drowning, 796 extravasation of blood in, 565 post-mortem examination of, 362 wounds of, 569 BULLETS, 595 loss of weight of, 601 track of, 595 BURKING, 775 BURNS, 360, 639 by acids, 641 burning oil, 640 corrosives, 641 electrical currents, 664, 676 flame, 640 fused metals, 640 lightning, 694 petroleum, 641 cases of, 657 causes of death by, 645 classification of, 642 constitutional effects of, 644 local effects of, 643 period of death from, 649 post-mortem appearances of, 647 whether ante- or post-mortem, 649 CADAVERIC CHANGES (see Post-mortem), 441 CADAVERIC SAPONIFICATION, 451 CASES of burns, 657 of hanging, 760 of strangulation, 726 of suffocation, 787 CATALEPSY, 822 CAUSE OF DEATH, see Coroners from burns, 645 severe mechanical injury, 499 submersion, 797 wounds, 496, 497 CAUSE OF DEATH, hemorrhage as, 497 latent disease as, 503 shock as, 499 was it natural? 503 wounds as secondary, 509 CLOTHING, examination of, 352, 537 COLD, effects of extreme, 630 COMBUSTION, spontaneous, 647 COMMUNICATIONS, privileged (see Privileged Communications), 33 COMPENSATION, see Physician and Patient; Expert Witness; Coroners; Medical Examiners CONCUSSION, 472 of brain, 561 spinal cord, 573 CONGENITAL PECULIARITIES, identity from, 403 CONSTITUTIONALITY of statutes regulating practice of medicine and surgery, 7-11 CONTRACTS between physician and patient (see Physician and Patient), 25 CONTRE-COUP, 559, 611 CONTUSIONS, 358, 467, 470, 523 by lightning, 695 of abdomen, 580 of head, 558 of neck, 570 CORONER (see Post-mortem Examinations), 331 is _virtute electionis_ in America, 332 duties of, are both judicial and ministerial, 332 judicial authority of, relates to inquiries into cases of death, 332 jurisdiction of, 332 kinds of, at common law, 331 presumption that he has acted in good faith, 332 protected under same principles which protect judicial officers, 333 Effect of evidence and verdict, 343 at common law was equivalent to indictment by grand jury, 343 not so now, yet inquisition has same power until grand jury passes upon the case, 343 Evidence before, when admissible upon a subsequent trial, 344 Inquest, all evidence must be presented to jury, 342 coroner cannot hold a second inquest while the first is undischarged, 334 coroner has power to hold, 332, 334 is a judicial investigation, 333 must be held in view of the body, 335 separate inquests must be held over each of several bodies, 333 Jury and inquest, coroner may compel attendance of witnesses, 341 Jury and inquest, jurors must be from jurisdiction wherein coroner is empowered to act, 341 jurors must be sworn by coroner, 341 jurors must investigate and determine the facts, 341 jurors must view the body, 341 jurors not challengeable, 341 witnesses must be sworn by the coroner, 342 Massachusetts, see Medical Examiners office abolished by statute in, 338 statutory provisions in, 338 who may hold an inquest, 338 New York, coroner may issue warrant of arrest of person charged with the death, 341 must, after examination of charges, hold defendant to answer or discharge him, 341 must proceed to examine charges against accused upon his arrest, 341 inquisition and testimony must be filed, 340 jurors must inspect the body and hear the testimony, 340 jury must render verdict and certify it by an inquisition, 340 six or more jurors must be sworn, 340 statutory provisions, 339 testimony must be reduced to writing, 340 when inquest may be held, 339 Powers of, cannot delegate authority or appoint deputy, 333 contract will bind county for payment of reasonable compensation, 336 may employ professional skill to aid him, 335 may have body disinterred, 335 may issue process of apprehension, 343 Return of inquisition, 342 inquisition should be signed by the coroner and jury, 343 should certify that witnesses before the coroner were sworn, 343 verdict of the jury is final, 342 Rights of accused party before, 342 has not the right to be represented by counsel or to cross-examine witnesses, 342 is not permitted to produce witnesses to show himself innocent, 342 privilege of prisoner upon arrest, 344 testimony may be taken by the coroner in his absence, 342 under New York criminal code defendant is entitled to a hearing before a magistrate, 344 CRANIOMETRY, 394 CREMATION, 389 CUSTOM of physicians to serve each other gratuitously, 52 DEAD BODY, autopsies, 301, 349 changes in, 441 chemical examination of, 303 cooling of, 441 coroners’ duties concerning (see Legal Status of, Appendix), 301 crimes against (see Legal Status of, Appendix), 299 disposal of, 298 dissection, when permitted (see Legal Status of, Appendix), 302 district attorney’s powers concerning, 303 duty of burial, 298 examination of gunshot wounds, 610 exhumation of, 300 external examination of, 358 flaccidity of, 442 internal examination of, 360 legal status of, 297 Appendix, giving statutes concerning, 304 physical examination of (see Autopsies), 302 post-mortem examination of (see Autopsies; Post-mortem Examiners), 303 putrefaction of, 445 right of burial or removal, 301 saponification of, 451 seizure for debt forbidden, 299 statutes regulating interment or exhumation, etc., generally, 304 Alabama, 309 Arizona, 309 Arkansas, 309 California, 310 Colorado, 311 Connecticut, 311 Delaware, 312 Florida, 312 Georgia, 312 Idaho, 313 Illinois, 313 Indiana, 313 Iowa, 314 Kansas, 314 Kentucky, 314 Louisiana, 315 Maine, 315 Maryland, 315 Massachusetts, 316 Michigan, 316 Minnesota, 317 Mississippi, 317 Missouri, 318 Montana, 318 Nebraska, 318 Nevada, 319 New Hampshire, 319 New Jersey, 320 New Mexico, 320 New York, 320 North Carolina, 321 North Dakota, 321 Ohio, 322 Oklahoma, 322 Oregon, 323 Pennsylvania, 323 Rhode Island, 324 South Carolina, 324 Tennessee, 324 Texas, 325 Vermont, 325 Virginia, 325 Washington, 326 West Virginia, 326 Wisconsin, 326 temperature of, 441, 453 DEATH, apparent, 439 from anæsthetics, 516 burns, causes of, 645 period of, 649 whether accidental, suicidal, or homicidal? 657 cold, 633 post-mortem appearances in, 634 electrical currents, 683 hanging, proof of, 757 latent disease, 503 natural causes, 503 slight injuries, 507 starvation, 813 strangulation, proof of, 721 submersion, 794, 798 suffocation, proof of, 784 surgical operations, 515, 624 wounds, causes of, 496, 497 signs of, 440 time of, 437 DEFORMITIES, identity from, 403 DELIRIUM TREMENS, 514, 624 DIAPHRAGM, rupture of, 579 wounds of, 579 DIPLOMA OR LICENSE, how proved in court, 20 DISLOCATIONS, 476 DROWNING (see Submersion), 793 ECCHYMOSES, 467 ante-mortem, 444 post-mortem, 443, 444, 485 ELECTRIC CARS, 668 ELECTRIC LIGHT, effects of, on eyes, 676 ELECTRICAL APPARATUS, injuries from, 664 ELECTRICAL CURRENTS, burns from, 664, 676 direct injuries from, 671 direct symptoms of injury from, 676 fatal, 682 high tension, 666 indirect injuries from, 670 injury from, 664 internal symptoms caused by, 678 mechanical effects of, 675 mental symptoms from, 689 muscular contraction from, 677 ELECTRICAL RESISTANCE, 673 ELECTRICITY, 661 medical, 664 static, 673 ELECTROCUTION, 683 EROSION, 471 ERYSIPELAS, 511 EXAMINATION of body, 537 of clothing, 537 of surroundings, 541 EXCORIATION, 471 EXPERIMENTS, testing powder-marks, 613 with cadavers, 607 EXPERT WITNESS (see Privileged Communications), 49-72 compensation of, 60 competency of, 61 conduct of, in court, 65 definition of, 53 examination of, scope of, 65, 68 impeachment of, 64 in civil and criminal cases, 61 medical books, how may be used in examining, 64 practical suggestions, 70 summons of court must be obeyed, 60 system in Germany and France compared with that in United States, 54 EXPOSURE, effects of, 630 EXTREMITIES, wounds of, 589 FACE, wounds of, 569 FALLS, 549 FARADISM, 672 FIREARMS, evidence from, 600 examination of, 612 FLASH, identity by, 619 FOOTPRINTS, 427 FRACTURES, 359, 474, 491, 553 by gunshot wounds, 610 of ribs, 574 skull, 559 spine, 571 spontaneous, 474 GALL-BLADDER, wounds and rupture of, 584 GARROTTING, 571, 707 GENITAL ORGANS, post-mortem examination of, 376 wounds of, 588 GUNSHOT WOUNDS, see Wounds, Gunshot HÆMATOMATA, 468 HAIR, identity from, 406 on weapons, 535 HANDWRITING, 434 HANGING, 707, 735 accidental, cases of, 774 cases of, 760 homicidal, 759 cases of, 767 judicial, cases of, 770 post-mortem appearances, 746 proof of death by, 757 suicidal, 758 cases of, 760 symptoms in, 740 treatment in, 744 HEALTH, BOARDS OF, see Practice of Medicine and Surgery physicians reporting contagious diseases to, not liable for mistaken reports, 23 powers, how governed, 23, 24 HEAD, post-mortem examination of, 361 wounds of, 557 HEART, in strangulation, 719 post-mortem examination of, 366 rupture of, 578 wounds of, 575 HEAT, effects of extreme, 635 HEMORRHAGE, 483, 497, 716 HYPOSTASES, 443, 716 internal, 444 IDENTIFICATION, 383 by flash of gunpowder, 619 from congenital peculiarities, 403 deformities, 403, 430 entire skeleton, 392 imprints, 427 injuries, 403 scars, 419 stigmata, 426 tattooings, 421 teeth, 401 in death from submersion, 802 of burnt remains, 389 human bones, 390 mutilated remains, 408 recently dead, entire cadaver, 415 surface signs for, 419 IMPRINTS, 427, 542 INCISED WOUNDS, see Wounds INFANTS, liability of, for medical services, 37 INFORMATION, duty of patient as to (see Physician and Patient), 33 INJURIES, coagulation of blood in, 488 fatal, acts performed after, 493 identification from, 403 medical inspection of, 101 of abdominal walls, 580 viscera, 580 spinal cord, 571 spine, 571 slight, death from, 507 whether ante- or post-mortem, 482 INQUEST, see Coroners INSANE PERSONS, liability of, for medical services, 39 INSOLATION, 636 INSULATION of electrical conductors, 667 INTESTINES, post-mortem examination of, 371 wounds of, 586 KIDNEYS, post-mortem examination of, 370 rupture of, 584 wounds of, 584 LARYNX, in death from hanging, 754 strangulation, 718 post-mortem examination of, 369 LICENSE (see Practice of Medicine and Surgery), 7 (or diploma), how proved in court, 20 licensed physician presumed competent as an expert witness, 58 licensed practitioner, pretending to be, when not a misdemeanor, 22 statutes requiring, constitutional, 7 suits cannot be maintained by persons without, 18 unlicensed practitioner not presumed competent as expert witness, 62 when may be compelled by courts, 14 when presumed, 19 LIGHTNING, 690 burns from, 694 contusions by, 695 effects on internal organs, 702 loss of consciousness from, 696 memory from, 696 paralysis from, 697 pathology of, stroke of, 700 staining of skin by, 696 symptoms produced by, 693, 696 wounds by, 695 LIVER, post-mortem examination of, 375 rupture of, 582, 808 wounds of, 582 LUNGS, in death from strangulation, 719 submersion, 805 post-mortem examination of, 368 wounds of, 575 LYMPHORRHAGIA, 470 MALPRACTICE, 73-87 abortion is, 74 civil cases concerning, 80 contributory negligence in, 87 criminal cases concerning, 73 damages for, 83 definition of, 73 degree of care and skill in, 80 evidence in, 84 inspection before trial in, 85 partners liable for, 84 MANNLICHER RIFLE, effects of, 619 MARKS OF POWDER, 608 MARRIED WOMEN, liability of, for medical services, 37 MASTER, liability of, for services rendered servant, 39 MASSAGE, not practising medicine or surgery, 28 MEDICAL EXAMINERS, see Coroners contract of coroner with, binds county to payment of reasonable compensation, 336 coroners may employ, 335 In Massachusetts: cannot hold autopsy unless authorized, 338 cannot hold an inquest, 338 in place of coroners, 338 MEDICAL SOCIETIES, by-laws of, 15 fee bill, 22 MEDICINE AND SURGERY, see Physician and Patient; and Practice of Medicine and Surgery MUSCULAR CONTRACTION, from electrical current, 677 MUTILATED REMAINS, identification of, 408 NAILS, identification from, 406 NECK, contusions of, 570 wounds of, 569 ŒSOPHAGUS, post-mortem examination of, 369 OVERLYING, 774 PANCREAS, post-mortem examination of, 375 PATIENT, rights of, concerning confidential communications, 96 PHYSICIAN, action for professional services, 133 his books containing confidential entries, 110 his rights and duties concerning confidential communications, 132 receiver not entitled to his books of account, 110 what is a professional capacity? 123 PHYSICIAN AND PATIENT, contracts between, compensation for services, 37 conditional and unconditional, 34 consulting physicians, 44 duties of patient, 29, 30 physician, 28 employment, how terminated, 26, 28, 30 may be declined, 24 estates of deceased persons, when liable for, 43 express or implied, 26 express, 27 implied, elements of, 28 infants, liability of, 43 insane persons, when liable, 45 married women, generally not liable, 43 masters, liable for services rendered servants, 45 measure of recovery for, 45 patient presumed liable, 37 person calling in physician not presumed liable, 36, 41 physicians treating each other, when they may recover, 47 railway company, when liable for, in case of accident, 42 railway physicians, authority of, 42 relation of physician and patient, 119 compensation for services, right to sue for in United States, 26 how lost, 19 students’ services, 44 skill and care required of (see Malpractice), 28, 31, 32, 33 schools of medicine not recognized by courts, 15 standard of school professed must be attained, 31 stranger may not be called in without patient’s consent, 29 PITHING, 572 POISONING, 597 POSITION OF VICTIM, 541, 546 POST-MORTEM APPEARANCES, in death from burns, 647 cold, 634 hanging, 746 starvation, 822 strangulation, 713 submersion, 801, 804 sunstroke, 638 POST-MORTEM CHANGES, 441 ecchymoses, 443, 485 hypostasis, 443 lividity, 443 rigidity, 442, 453 POST-MORTEM EXAMINATIONS (see Autopsies, Coroners), 354 when and ow made by coroner, 337 POST-MORTEM WOUNDS, 355 POWDER-MARKS, 608, 612 PRACTICE OF MEDICINE AND SURGERY (see Physician and Patient), 7-25 acquirement of right, regulated by statutes, 7 constitutionality of, statutes regulating, 8 criminal cases, proof of, 19, 22 license for, may be compelled, 14 how proved, 20 medical societies and by-laws of, 14 fee bills, 15 massage not, 22 patent medicines, 14 statutory regulations concerning, in: Alabama, 137 Arizona, 139 Arkansas, 140 California, 141 Colorado, 144 Connecticut, 145 Delaware, 148 Dist. of Columbia, 149 Florida, 150 Georgia, 151 Idaho, 152 Illinois, 153 Indiana, 155 Iowa, 157 Kansas, 160 Kentucky, 160 Louisiana, 162 Maine, 164 Maryland, 165 Massachusetts, 167 Michigan, 167 Minnesota, 168 Mississippi, 169 Missouri, 171 Montana, 173 Nebraska, 175 Nevada, 177 New Jersey, 178 New Hampshire, 181 New Mexico, 181 New York, 183 North Carolina, 189 North Dakota, 191 Ohio, 193 Oklahoma, 193 Oregon, 194 Pennsylvania, 197 Rhode Island, 203 South Carolina, 203 South Dakota, 204 Tennessee, 205 Texas, 207 Utah, 209 Vermont, 211 Virginia, 212 Washington, 215 West Virginia, 219 Wisconsin, 222 Wyoming, 223 Great Britain, 224 Scotland, 224 England, 224 Ireland, 224 Brit. Columbia, 238 Manitoba, 242 N. Brunswick, 248 Newfoundland, 255 N. W. Terr., 258 Nova Scotia, 262 Ontario, 268 Prince Edw. Is., 278 Quebec, 284 PRIVILEGED COMMUNICATIONS, 91 cause of death, 111 communications to physician not privileged at common law, 91 “confidential communications,” 115, 118 between physician and patient, when privileged, 94 dependent upon professional capacity, 98 effect of excluding privileged evidence, 130 evidence admitted not to be commented on, 111 in criminal actions, 101 in lunacy proceedings, 103 of abortion, 102 of adultery, 102 of crime in civil actions, 101 of criminal intimacy, 102 of habitual drunkenness, 103 of value of physician’s services, 133 to establish privilege, 106 function of the court, 128 ground of privilege, 91 harmless admission no ground for exception, 111 how evidence of physician taken in New York, 97 how privilege established, 131 in actions for divorce, 102 in criminal actions, 101 “information,” 97, 115 “matters confided,” 99 “matter committed,” 97, 118 “matter necessary to enable a physician to prescribe or a surgeon to act,” 124 mental condition of patient, 103 necessity, 98 objections to evidence, 109 when made, 110 objection once made need not be repeated, 111 partner of physician, as privileged witness, 122 patient’s ignorance immaterial, 110 rights concerning confidential communications, 96 physician defined, 105 “duly authorized,” 105 as witness to establish privilege, 131 physician’s advice, 98 books, 110 cannot refuse to disclose when patient waives privilege, 99 knowledge, 98 presumption from failure to give privileged evidence, 130 privilege is patient’s, not physician’s, 107 “professional capacity,” 123 purpose of statutes prohibiting disclosures, 96 relation of physician and patient, 119, 122 result of legislation, 134 rights and duties of physician, 132 statutory privileges concerning confidential communications, 93 statutory privileges for waiver of privilege, 96 surgeon defined, 105 testamentary causes, 103 waiver after death of patient, in New York, 98 waiver of privilege after patient’s death, 108 by application for insurance, 111 by proof of death to insurance company, 111 by contract, 112 by infant, 108 by patient’s attorney, 107 by representative of deceased patient, 103 by requesting physician to witness will, 113 certificate of death, 115 effect of, 107, 110 infant’s, 113 taking physician’s deposition, 112 testimony of patient, 111 what constitutes, 111 what evidence is excluded, 97 what is privileged, 115 when patient may be contradicted by physician, 112 who may waive, 106 whose testimony is privileged, 105 witness, 97 PROJECTILE, course of, 615 evidence from, 600 PUNCTURED WOUNDS, see Wounds PUTREFACTION, 445, 453 circumstances favoring, 447 retarding, 448 of immersed bodies, 450, 810 PYÆMIA, 511 RACE, determination of, from hair, 393 skeleton, 393 RAILWAY COMPANIES, when liable for medical services, 41 RAILWAY PHYSICIANS, authority as to employing nurses, 42 REPORTS, medico-legal, 381 RESISTANCE, electrical, 673 RESPIRATION, suspended, 439 RIBS, fracture of, 574 RIFLE, Mannlicher, 619 RIGOR MORTIS, 442, 453, 701 RUPTURE of abdominal organs, 582 bladder, 585 gall-bladder, 584 of heart, 578 internal organs, 553 kidneys, 584 liver, 582, 808 spleen, 584 stomach, 586 SAPONIFICATION, 451 SCALDS, 639 SCARS, in relation to identity, 419 SCHOOLS OF MEDICINE not recognized by courts, 15 SEPTICÆMIA, 510 SEX, determination of, 400 SHARKS, bites of, 808 SHOCK, 499 SHOT-GUNS, wounds by, 607 SIGNS OF DEATH, 440 SKIN, marks on, 419 SKULL, fracture of, 559 measurements of, 394 SMALL SHOT, wounds by, 617 SMOTHERING, 774 SPINAL CORD, concussion of, 573 post-mortem examination of, 377 wounds of, 571 SPINE, dislocation of, 572 fracture of, 571 wounds of, 571 SPLEEN, post-mortem examination of, 371 rupture of, 584 wounds of, 584 SPONTANEOUS COMBUSTION, 647 STABS, 463 STAINS, could assailant have escaped without? 538 STARVATION, acute, 817 chronic, 818 death from, 813 diseases produced by, 824 or disease, which was cause of death? 823 period of death from, 820 post-mortem appearances in, 822 whether accompanied by other ill-treatment, 822 STATURE, determination of, 398 STERNUM, fracture of, 574 STIGMATA, 426 STOMACH, post-mortem examination of, 373 rupture of, 586 wounds of, 586 STRANGULATION, 707, 708 accidental, 724 cases of, 734 cases of, 726 external appearances due to, 713 homicidal, 725 cases of, 726 internal appearances due to, 727 post-mortem appearances, 713 proof of death by, 721 simulated, 725 stages of, 710 suicidal, 724 cases of, 732 symptoms of, 708 treatment of, 712 STRUGGLE, signs of, 536 SUBMERSION, 793 asphyxia by, 796 cadaveric signs in death by, 804 circumstances modifying time of, 810 definition of, 796 mode of death by, 797 post-mortem appearances, 801 stages and symptoms of death by, 798 treatment of apparently drowned, 802 whether accidental, suicidal, or homicidal, 807 SUFFOCATION, 707, 774 accidental, 785 cases of, 787 by submersion, 796 cases of, 787 external causes of, 774 homicidal, 785 cases of, 790 internal causes of, 775 mechanical, 705 post-mortem appearances, 781 proof of death by, 784 suicidal, 785 cases of, 790 symptoms of, 777 treatment, 779 SUNSTROKE, 636 SURGEON, definition of term, 56 duties of, see Physician and Patient SURGICAL OPERATIONS, death from, 515 SURVIVAL, 556 SYNCOPE, 796, 799 TATTOOING, 421 TEETH, determination of identity from, 401 TEMPERATURE of body, 629 of dead body, 441, 453 TETANUS, 513 THORAX, post-mortem examination of, 365 wounds of, 573 TIME OF DEATH, 437 how determined, 452 VEINS, air in, 579 wounds of, 578 WEAPONS, 353, 524 evidence from, 600 as to origin of wounds, 533, 549 examination of, 612 presence of blood and hair on, 535 was it fired from a distance or near? 612 WITNESS, see Expert Witness; Privileged Communications physician as expert and ordinary witness, 50 when must testify as, 60 WOUNDS, 358, 457 as directly cause of death, 497 as secondary cause of death, 509 by what instrument made? 517, 524 cause of death from, 496, 497 coagulation of blood in, 488 consequences of non-fatal, 556 contused, 467, 470, 523 death from, after long periods, 508 definitions of, 459 description of, 482 direction of, 529 eversion of lips of, 489 evidence from weapon, 533, 549, 600 examination of, 476 from crushing, 553 falling, 549 lightning, 695 gunshot, 593 by blank charges, 617 by shot-guns, 607 gunshot, by small shot, 617 complications of, 624 course of projectile, 615 death from surgical operations in, 624 description of, 594 dimensions of perforations, 609 direction of, 599 examination of, 594 of body in, 610 of entrance, 614 of exit, 614 situation of, 598 treatment of, 620 imputed, 544 incised, 460, 517, 557 diagnosis of, 462 kinds of, 459 lacerated, 471, 523 mortal, 460 nature of, 548 number and extent of, 531 of abdominal viscera, 580 walls, 580 arteries and veins, 578 bladder, 585 brain, 569 diaphragm, 579 extremities, 589 face, 569 gall-bladder, 584 genital organs, 588 head, 557, 558 heart, 575 intestines, 586 kidneys, 584 liver, 582 lungs, 575 neck, 569 spinal cord, 571 spine, 571 spleen, 584 stomach, 586 thoracic viscera, 573 thorax, 573 throat, incised, 526 origin of, evidence from weapons, 533, 549 punctured, 463, 518, 557 regionally considered, 557 retraction of sides of, 490 severe, 460 situation and position of, 527, 548 slight, 460 whether accidental, 547 ante-mortem or post-mortem, 482 necessarily the cause of death, 500 self-inflicted or by another, 525, 544, 548 which of several was first inflicted? 544 two was cause of death? 500 FOOTNOTES: [1] The distinction made in the text and in the title of this work is not new. It was recognized by the father of medico-legal science, Zacchias, in his two prefaces, one to the “lector medicus,” the other to the “lector legumperitus” (“Quæst. Med. Leg.,” Ed. Venet., 1727, fol.). In a note to the introduction of the “Medical Jurisprudence” of Dr. Paris and Mr. Fonblanque (the first work produced by joint authorship of a physician and a lawyer, in 1823) is the following (p. i.): “Some authors have objected to the term _Medical Jurisprudence_ as implying a knowledge of the laws relating to medical topics, rather than an acquaintance with the medical science necessary for the elucidation of legal subjects. As it is our peculiar object to unite the sciences and to show their mutual relevance, the title becomes most applicable to this, although it may have been improperly affixed to former works.” The title of one of two existing French works in whose authorship a lawyer is associated is: “Traité de Médecine légale, de Jurisprudence médicale et de Toxicologie,” par Le Grand du Saulle, Geo. Berryer et Gab. Pouchet, 2d ed., 8vo, Paris, 1886. [2] “Bibl. Hist.,” I., ii., 77; Miot’s transl., Paris, 1834, i., 157. [3] _L. c._, I., ii., 82; transl., i., 165. [4] _L. c._, I., ii., 75, 76; transl., i., 152. [5] The “Papyros Ebers,” in the University of Leipzig, the most ancient medical text known, was written about 1550 B.C., and is probably one of the books referred to by Diodorus. It contains no statement bearing upon our subject. It is, however, simply a collection of descriptions of remedies, and their uses, including the incantations to be used with them. (See “Papyros Ebers,” H. Joachim, Berlin. 1890.) The same is true of the Berlin and Leyden papyri. The Bibl. Nat. (Tf. 2) possesses a Chinese manuscript on legal medicine. The catalogue does not, however, state to what period it belongs. [6] For an account of early Indian medicine, see Th. A. Wise, “Review of the Hist. of Med.,” Lond., 1867, i., 272 _et passim_; “Hindu System of Medicine,” 1845, by the same author; Haeser, “Lehrb. d. Gesch. d. Med.,” 3. ed., i., 5-40. [7] Hippocr.: “De Superfœtatione,” ed. Littré, viii., 472. [8] Hippocr.: “De Septimestri partu;” _ibid._, “De Octimestri partu,” ed. Littré, viii., 432, 436, 452. [9] “Aphorismi,” vi., 18, 24; “De Morbis,” ed. Littré, vi., 144. [10] Petit, S.: “Leges Atticæ,” Lugd. Bat., 1742, lib. iii., tit. 8. [11] “Od.,” iv., 229; xvii., 384. [12] For an excellent account of Attic criminal procedure, see Kennedy, C. R.: “Demosthenes’ Orations,” ed. Bohn, iii., 326-372. [13] “Var. Hist.,” iii., 38. [14] Kennedy’s transl., ed. Bohn, v., 95. [15] What the contents of these depositions were and by whom made is unknown, as the papers referred to by the orator are not given. In the Attic courts the testimony was taken at a preliminary trial, and referred to at the trial by the orator. [16] “Oratores Attici,” C. Müller, Paris, 1877, i., 20. [17] “Oratores Attici,” C. Müller, ed. Didot, Paris, 1877, i., 200-203. [18] In a doubtful fragment of Lysias the expression “as physicians andmidwives declare” (_ὡσπερ οὶ ἰατροὶ καὶ αὶ μαῑαι ἁπερηναντο_) is used in connection with the question whether a fœtus has life and may be murdered. _Cf._ “Orat. Attici,” Müller and Hunziker, Paris, Didot, 1858, ii., 257. [19] “Jul. Cæs.,” 82. [20] “Hist. Nat.,” xi., 71. [21] “Hist. Nat.,” vii., 4. [22] A. Gellius: “Noct. Att.,” 1. 3, c. 16: “requisitis veterum philosophorum et medicorum sententiis.” The word “_veterum_” seems to indicate that the emperor consulted books, not living physicians. [23] “Medici non sunt proprie testes, sed majis est judicium quam testimonium.” [24] For accounts of the medico-legal provisions of the Justinian enactments, see: G. A. v. d. Pfordten, “Beiträge z. Gesch. d. ger. Med. aus d. Justin. Rechtssam.,” Würzburg, 1838: M. F. Eller, Bull. Med. Leg. Soc. N. Y., 1879, i., 226-237; and Friedreich, Blt. f. ger. Anthr., Nürnberg, 1850, I., iii., 1-64; 1862, xiii., 188-215. [25] See Mende: “Handb. d. ger. Med.,” Leipzig. 1819, i., 83-87. [26] “Etablissements et Coûtumes, Assises et Arrêts de l’Echiquier de Normandie au xiii. Siècle,” A. J. Marnier, Par., 1839: “veue d’homme en langueur, veue de méfaits, veue d’homme occis et veue de femme despucelée.” [27] “Ut peritorum judicio medicorum talis percussio asseveretur non fuisse letalis,” Mende, “Handb. d. ger. Med.,” i., 91. [28] Hensschel, in “Janus,” Breslau, 1847, ii., 135. [29] Assises de Jérusalem,” Beugnot, Paris, 1841-43, quoted by Ortolan, _l.c._, _infra_. [30] Ortolan: “Débuts d. l. Méd. lég.,” Ann. d’Hyg., Par., 1872, 2 s., xxxviii., 361. [31] “Registre Criminel du Châtelet de Paris,” Par., 1861, i., 255. [32] _Ibid._, i., 313. [33] _Ibid._, i., 375, 409. [34] “Quæst. Medico-legales,” t. ii., lib. vi., tit. ii.: vol. ii., pp. 33-49, ed. Venet., fol., 1737. [35] See also “Reg. Crim. Chât. de Paris.,” i., 204, ii., 429; Desmaze: “Hist. Méd. Lég.,” 11-20, 33-41. [36] Isensee: “Gesch. d. Med.,” i., 216. [37] “Constitutio criminalis Carolina.” The first edition was printed at Mayence, 1533, fol., by J. Schöffer. See also Kopp, “Jahrb. d. Staatsarznk.,” Frankf., 1808, i., 183. [38] “Con. cr. Car.,” art. 147. [39] _Ibid._, art. 149. [40] _Ibid._, arts. 35, 36, 131, 133; “Bambergische Halssgerichts-Ordenung.” Bamb., 1507, art. 44. [41] “Con. cr. Car.,” art. 37. [42] _Ibid._, art. 134. [43] _Ibid._, arts. 135, 179, 219. [44] “Non per quoslibet, nec per insipidos et imperitos, sed tantum per peritos ac doctos medicos aut chirurgos,” p. 245. [45] “Praxis Rerum Criminalium,” Antw., 1554 (the dedicatory epistle is dated 1551), pp. 245-252, 223-228. [46] Wildberg, “Bibl. Med.-for.,” Berl., 1819, Nos. 553, 554, 1,124, 1,125, 1,126, 1,304, 1,835, 1,836, 2,342, cites nine works earlier than 1575. These are, however, monographs on the period of gestation, witchcraft, fasting girls, drunkenness, and wounds of the head. Works on toxicology were written at a much earlier date: the _Θηριακά_ and _Αλεξιφάρμᾶκα_, of Nicander, _ca._ B.C. 135; _θeπερὶ δηλητηρίων φαρμάκων_, of Dioscorides, _ca._ A.D. 50; the treatises, “De Venenis,” of Petrus de Abbano (_ca._ A.D. 1250), first printed Mantua, 1472; of Arnoldus da Villanova (_ca._ A.D. 1300), first printed (_sine loc. et an._) _ca._ 1470; of Santes de Ardoynis, Venice, 1492, and of F. Ponzetti, Venice, 1492, are among the earliest. Works on toxicology are not considered in this Introduction, the historical sketch of that science being reserved for a later volume. [47] Ed. Malgaigne, 1840, t. iii., l. xxvii., pp. 651-658; ed. princ., Paris, 1575, fol., pp. 931-944. On the title-page of an earlier work, printed in 1562, Paré is referred to as “chirurgien ordinaire du Roi, et Juré à Paris.” Ploucquet, “Lib. Med. dig.,” Tüb., 1809, iv., 349, mentions a monograph by “Tygeon, Th.,” printed at Lyons, 1575. [48] S. Pineau: “De notis Integritatis et Corruptionis Virginum,” Paris, 1598; A. Hotman: “De la Dissolution du Mariage par l’Impuissance,” etc., Paris, 1581; de la Corde, “Ergo Virgo ... lac in mammis habere potest,” Paris, 1580. Wildberg, _l. c._, Nos. 555, 1,308, 1,309, are not properly medico-legal. [49] In his “De Vitiis Vocis,” etc., Frankf., 1597. He had previously published a treatise, “De morbis veneficis ac veneficiis,” Venet., 1595. [50] “De relationibus medicorum ... in quibus ea omnia quæ in forensibus ac publicis causis medici referre solent,” etc., Panormi,