Text-book of medical jurisprudence and toxicology

Front matter

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Class (^Kv& gt- Book_ ,'^_

Copyright N'

Preface To Seventh Edition

The continued popularity of this work, as shown by its steady sale, is the best evidence of its adaptation to the purpose for which it was originally written. Its distinguished author was a man of unusually wide experience in the field of Medical Jurisprudence and Toxicology, and at the same time of high scientific attainments and much experience as a teacher. He was therefore able to produce a work rich in illustrative materials and to present them in a clear and yet concise form.

In the present revision the principal purposes of the book have, as in former revisions, been kept prominently in mind. It is essentially a text-book for the student and a manual for the attorney and general expert.

As regards the additions and amendments in the present revision, it need only be said that the revisor has endeavored to keep the work up to date. Among the new matters may be mentioned the application of ;ir-rays to the study of development of the skeleton, a method that has direct bearing on the question of identification.

Much progress is constantly making in toxicology. New methods of treatment are being proposed and applied, and the rapidly growing list of synthetic organic remedies has led to many new forms of poisoning both acute and chronic. Among recently reported cases included in this revision are to be noted : Chronic poisoning by potassium chlorate, acetanilid and carbon monoxid ; acute poisoning by boric acid, resorcinol, wormseed and formaldehyde.

Vlll PREFACE.

In these and other recent toxicologic reports, a considerable advance is evident in the precision and fullness of clinical history and tests of the conditions of blood and urine and in symptomatology. This is the result of the modern extensions of laboratory methods in medical teaching and shows the value of such work in aiding diagnosis and pathology. As exemplification of these matters, some of the reports introduced into the present revision have been given in considerable detail. The literary precision in these reports is often not up to the level of the scientific precision, carelessness in terms and phrases being often evident. The modern system of education is defective on the side of literary and linguistic training.

December, 1905.

Contents

Introduction i- ii

Phenomena and Signs of Death 12- 42

Medico-legal Investigations — The Post-mortem 43- 54

Chapter I

Medical Jurisprudence, Legal or Forensic Medicine, may be defined to be the science which appHes the knowledge of Medicine to the requirements of Law. In the discovery of truth, the great purpose of Law, every department of human knowledge should be made to assist. Cases affecting life, reputation, or property, and requiring for elucidation and appeal to medicinal knowledge, are termed medico-legal cases, and the science of the application of medicine to them is named Medical Jurisprudence.

The students of Medicine and Law are equally interested in a knowledge of this science, and it should require no argument to show its importance to members of these professions.

Many cases brought before a court can only, be settled by an appeal to medical knowledge ; sometimes it is to one department of medicine, and sometimes to another; and it not infrequently happens that several branches of the science may be called into requisition in order to aid in arriving at a proper decision.

It is more particularly when the physician appears upon the witness stand, and assumes the functions of the medical witness, that medico-legal knowledge is of the most importance. After he has accomplished the investigation of some case there remains the duty of giving the results of his investigations to the court in the form of evidence. This will be more manifest as we detail the mode of proceeding in a criminal case.

The Coroner's Inquest. — The first public duty usually imposed upon the physician who has been in attendance, or has investigated a case of violent death, is to testify at the coroner's inquest. In many civilized countries, especially English-speaking communities, a special officer, the coroner, is appointed to investigate the unknown or unexplained causes of sudden death. For example, a body is discovered with or without marks of external violence, or dragged out of the river ; the body of a new-born child has been found in a well or cess-pool, or floating in the water ; a person is discovered dead at some hotel, far distant from his home ; or a person in apparent health suddenly drops dead in the street. In these and in analogous cases the law provides for an investigation to ascertain the cause and circumstances of the death ; and, if due to violence, then the nature of it — i. e., whether from a wound (gunshot or otherwise), from a bludgeon, an axe, hammer, or other blunt weapon ; or whether occasioned by a fall. In the absence of all external marks of violence, then, might the death not have been produced by poison? In each one of these cases a further question must be solved — was the death homicidal, suicidal, or accidental?

THE CORONER S INQUEST. 3

The coroner's jury consists of a few men (the number varies in different places), mostly selected from the district in which the inquest is held. Their duty consists in (i) viewing the body and establishing its identity and (2) in holding the inquest, which is a sort of petty court, wherein inquiry is made as to the cause of death, and (in case of homicide) to ascertain, if possible, the guilty person. Witnesses are examined, and the person who has performed the post-mortem examination makes a report and gives his opinion as to the cause of death. The jury consult and render a verdict. In some cases, particularly in cities, where the coroner has one or more specially appointed physicians, it is not considered necessary that the jury should personally view the body ; it is regarded as sufficient if the body has been identified by the examining physician, and the autopsy reported.

The special duty of the coroner's inquest is to discover the cause of death; it does not fall within his province to discover the individual who caused it. Nevertheless, it often happens that, in the course of the investigation, suspicion may so strongly point to some one as to warrant the coroner committing the suspect to prison to await further investigation. The usual verdict in cases of violent death (shown to have been neither suicidal nor accidental) is that of murder or manslaughter, against some person or persons, known or unknown.

The office of coroner, as at present constituted in many places, exhibits antiquated and inconvenient methods. In Massachusetts the office has been abolished, the investigation of sudden or suspicious deaths being carried out by physicians, called '' Medical Examiners," who do not refer evidence to a special jury, but can place any suspected criminal in the charge of the courts.

The post-mortem examination is an inseparable part of the coroner's inquiry in a case of this character, and constitutes its most important factor. It should be performed carefully and thoroughly. The autopsy should be performed deliberately, and by daylight if possible. It will always be an advantage if the examination be performed by two experts.

In giving evidence before the coroner's jury, the medical witness must not undervalue the importance of the situation ; nor forget that the testimony is generally recorded, and will be available at a subsequent trial. This fact shows the importance of drawing up the report with due care and accuracy.

The Criminal Court. — If the coroner's jury or other preliminary method if inquiry indicates the probability that a crime has been committed, the matter is referred to the prosecuting officer, generally called in the United States, the District Attorney, who prepares a bill of indictment that is a document which sets forth the nature of the crime as far as known and the name of any suspected person. This bill is submitted to a special body of persons, called the grand jury, which deliberates in secret, usually calling only such witnesses as the authorities indicate, though it may be given power to send for other persons. If the grand jury decides that the evidence justifies a trial in open court, the document is returned marked " true bill," but if not deemed so, the bill is " ignored." A true bill leads to a trial. The indictment is read in open court and the accused is required to plead guilty or not guilty. To this trial the medical witness is summoned to appear by a subpena, which must be obeyed. He will undergo a strict and severe examination as to his opinions and observations on the case.

JUDICIAL PROCEDURE. 5

He will be cross-examined as to his professional knowledge and acquirements, the extent of his opportunities for making such investigations as the one pending, the accuracy of his post-mortem or toxicologic examination, and other matters which may annoy and confuse him to no small degree, unless he be prepared beforehand by medico-legal knowledge and training. A witness properly fortified need have no fear for himself: for, as he goes upon the stand honestly to testify to the truth, he need only, to apply the language of the late Dr. Taylor, bear in mind two considerations : first, that he should be prepared on the subject on which he is to give evidence ; and, secondly, that his demeanor should be that of an educated gentleman, and suited to the serious occasion on which he appears.

In regard to medical evidence several points require brief notice. After opening the case before the court, the prosecuting attorney calls witnesses and examines them " according to the rules of evidence " ; this is technically called the examination in chief. The cross-examination follows ; this is conducted by the counsel for the defense, and may be aimed at contradicting and overthrowing, if possible, the previous testimony. Attorneys are allowed considerable latitude in cross-examination, and it will be necessary for the witness to exercise self-control, since in this way a brow-beating attorney can be parried. The witness must also remember that there are technical methods in the law which are not comprehended by others, and it is especially advisable that if objection be made by either attorney to any question, the witness should pause until the matter is decided by the judge. It is inadvisable for a witness to appeal to the judge for protection against a line of questions. An honest and properly informed physician has nothing to fear from any lawyer. Reexamination sometimes follows the cross-examination of the witness, when it becomes necessary to clear up or explain any matter that may have been obscured by the cross-examination.

After the examinations of the witnesses called by the prosecuting- officers, the witnesses for the defense are heard. The same general line of examination is pursued. When expert witnesses for the defense are called, unpleasant exhibitions frequently take place, one expert directly contradicting another. Such professional tilting is sometimes sneeringly designated as the " war of the experts," and is certainly deeply to be regretted, as it tends greatly to prejudice both the court and the public against expert testimony in general.

It is well to understand the difference between an ordinary and an expert witness. The former testiiles only to facts which he has seen, or heard, or learned from personal observation. The " expert " or skilled witness does not necessarily testify to facts, but gives his opinion on facts observed by himself or testified to by others. An expert witness is supposed to be specially skilled in the matter on which he is to testify. It is just here that much difficulty arises in cases involving expert evidence. The so-called " experts " are often selected with the intention that they shall advocate particular views or belittle in every possible way the ability or work of the experts on the opposite side.

The expert witness has his rights as well as his duties and responsibilities. One of these rights is his compensation. It has often been made a subject of just complaint that an expert witness is placed upon the stand and his professional opinions, which may be of the utmost value in the pending case, extorted from him piecemeal by the questionings of

MEDICAL EVIDENCE EXPERTS. 7

counsel, and yet he receives as his compensation merely the pay of an ordinary witness. Some legal authorities admit that the expert is not bound to submit to this imposition, and that he is entitled to a special fee for his services. In this country the practice of the courts in relation to the compensation of medical experts is not settled. In many states the law allows no additional compensation to the expert, and it is not an infrequent practice to subpena him as an ordinary witness, and when in the witness box to use him as an expert. What shall the expert do in such a case? How shall he conduct himself consistently with his own dignity and proper rights? Certainly the court would not use a man's private property — the work of his hands, his skilled manual labor, or the product of his farm or merchandise — without adequate compensation ; why, then, should they exact from him that which is the result of the labor /of his brain, than which nothing can be more exclusively and definitely a man's own private property? It is to be regretted that so few of our American courts and legislatures have appeared to recognize the true bearings of this subject so that with us the old practice still prevails of affording no legal protection to the medical expert in the matter of fees.

It rarely happens in important criminal cases, especially in poison cases, that either the prosecution or the defense would venture to trust their interests to a reluctant witness ; and certainly he would be a reluctant witness who had been dragged perhaps hundreds of miles from his home and business by a subpena which the law forces him to obey, and who, after spending, it may be, days in attendance upon the court, is compelled to give, for the paltry pittance of the wages of a day-laborer, that which has cost him years of labor and study to acquire, in the shape of an opinion, on which may turn the question of Ufe or death to the prisoner. In all such cases the ordinary practice is to arrange beforehand with the expert for his proper fee, and the witness should be admonished to look carefully about his interests in this matter. Let him remember that the district attorney, who usually directs the affair, may have no authority to pay the fee ; neither does this authority always lie with the court. The responsible parties in the case are often the county commissioners, or some equivalent county authority. With these alone ought the expert to make his arrangements, and always previously to undertaking the case ; and to these alone can he look, legally, for his fee.

As regards the obligation of a witness to obey a subpena when he is to be questioned only as to his opinion, the mandate of the court in this country is obligatory ; the witness's duty is to obey it, and then endeavor to arrange about compensation, if this has not been done, before giving his evidence.

The subject of expert testimony has engaged the attention of some of the ablest minds in the professions of law and medicine, but with no very definite results. No doubt, our present system of volunteer medical experts is open to objections, which, under our present laws, cannot be remedied. A system is much advocated of each State appointing one or more experts, who shall be State officers, physicians of thorough education and experience and trainings^' this particular line, who shall devote their time and attention exclusively to this duty, and for which they shall receive an adequate compensation. Such an office, properly filled, and kept aloof from all political considerations, might

REMUNERATION TO EXPERTS. 9

be of real benefit ; but it would not, necessarily, abolish the unseemly contention of the experts in the court room, for in the United States the clause in the Constitution providing that in every criminal trial the accused shall have the power to call witnesses in his favor and be confronted by the witnesses against him will permit of the same contentions between experts that now occur. Moreover, it is not likely that in our present political system a satisfactory selection of " State experts " will be made. Social as well as political influences will operate to control such appointments, and the former as well as the latter are capable of promoting unfit persons. The system of State experts is in vogue in some countries in continental Europe ; but the method of criminal procedure is different in such places, and does not exhibit the care of the rights of the accused which is the principle of English jurisprudence. It is worthy of note that some eminent authorities in continental Europe are advocating the adoption of some phases of the English system.

There are a few practical rules relating to the giving of evidence which it is well the medical expert should observe. He should prepare himself upon all the points bearing on the case in which he is called to give evidence. This he should do in order to further the ends of justice, and also' to avoid personal censure. He should be accurate as to weights, measures, distances, size, relationship of objects, etc., never guessing, but testifying with certainty and precision.

He should maintain a quiet, dignified, and composed demeanor on the stand, not exhibiting any irritability of temper, however much he may feel provoked by the rudelO MEDICAL JURISPRUDENCE.

ness of the opposing counsel. He should beware of any display of arrogance or assumption of manner, or of stubbornness or testiness of behavior, which are sure to make him appear to disadvantage in the court room.

The witness should give his answers in a clear and audible tone, and these replies, together with his explanations, should always be given in the simplest possible language ; and they should be free from all ambiguity, otherwise they will require explanation, which is apt rather to weaken the testimony. It will be better, also, for him to avoid all voluntary remarks, and confine himself closely to answering the questions put to him..

He should never be afraid frankly to confess his ignorance. Nothing is more dangerous than for a witness to attempt to guess, for fear of being thought ignorant.

He should particularly avoid the use of all technical expressions and learned formulae in giving his descriptions. Pomposity and pedantry should, of course, be avoided by every sensible and well-bred witness, since they are certain to expose him to ridicule and contempt.

Dying Declarations. — By this term is understood such declarations as are made by a dying person, who believes that he is in actual danger of death, and that his recovery is impossible. Such declarations are received in evidence without being sworn to. The law presumes that declarations made at so solemn a crisis as at a dying moment must be sincere. They may not, however, necessarily be true, although sincere — i. e., believed in, at the time, by the deceased. Dr. Taylor quotes an instance of a dying woman in St. Thomas' Hospital who accused a man of assaulting her. He was found guilty and executed. A year after the execution his innocence was established, the real murderers

EXPERT EVIDENCE. I I

having been discovered. These declarations, moreover, must relate to the actual circumstances of the death, and to nothing else.

A magistrate or other official authorized to take deposition in important cases, if such can be had, is the proper person to take down dying declarations, the physician in attendance merely giving opinion as to the hopelessness of the case and the soundness of the person's mind. In the absence of an official, the medical man is the best substitute, and he should content himself by simply writing down the exact words of the dying person, without adding his own interpretation of them. If possible, the dying person should sign the declaration after having it read over.

Chapter II. Phenomena And Signs Of Death

Among the numerous and diversified cases claiming medico-legal attention, perhaps the most frequent are those of violent death. A knowledge of the Signs of Death becomes of the utmost importance, since cases not infrequently present themselves in which there is considerable doubt and uncertainty as to the reality of the death.

For a proper comprehension of this subject, attention should first be directed to the distinction between molecular and somatic death. By the former term is to be understood the incessant disintegration of tissue which is^'going on in the body during the active processes of life ; the waste of material thus produced being compensated by the reparation. In youth, the supply is in excess of the waste, and growth is the result ; in advanced age, the reverse is the case. Somatic death is the cessation of all the vital functions of the body, or the death of the whole body. The latter is the popular idea of death, and the time when it takes place is generally recognizable. The precise period when universal molecular death occurs cannot be accurately determined. No doubt, molecular life may continue some time after somatic death, as is evidenced by post-mortem temperature and muscular irritability, by the post-mortem beating of the heart, and by certain acts of nutrition and secretion.

Although the outlets of human life are so numerous and varied, and the phenomena of death are diversified, the im-

PHENOMENA AND SIGNS OF DEATH. 1 3

mediate or actual cause must in every instance be referred to an arrest of the function of one or otlier of the three great centers of Hfe — the heart, the kings, and the brain. And so intimately are the functions of these three ''centers " connected together, that when one ceases to act, the actions of the others speedily cease. Each one of these three varieties has its own special phenomena or signs ; and each exhibits its own peculiar or characteristic post-mortem appearances. The following is Bichat's classification : ( i ) death beginning at the brain, (2) death beginning at the heart, and (3) death beginning at the lungs.

I. Death Beginning at the Brain — Coma. Symptoms. — Stupor, more or less profound; insensibiHty to external impressions ; loss of consciousness ; breathing slow, stertorous, and irregular ; respiration gradually failing, and ceases as the medulla oblongata begins to be affected. The chest ceases to expand ; the blood is no longer aerated ; the pulmonary circulation is arrested ; the lungs cease to act, and finally the heart's pulsations are brought to a stop.

Post-mortem Appearances. — (i) Effusion of blood or serum in the brain or cavities, caused by (a) apoplexy, (b) rupture of vessels from injury or fracture of the skull, or in disease of the arteries, under excitement. (2) Pressure caused by (a) embolism, (b) abscess, tumor, or other organic disturbance ; (c) congestion of the vessels of the brain. (3) Concussion from a blow or fall.

II. Death Beginning at the Heart — Syncope. — The heart may cease to act from two distinct causes : ( i ) from a deficiency in the quantity of blood — its normal stimulant (anemia) ; and (2) from a defect in the quality of the blood, or from a loss of heart power (asthenia).

Anemia is produced by sudden loss of blood in disease, as in rupture of an aneurysm ; uterine and other hemorrhage ; or by violence, as from wounds of heart and large vessels, causing fatal hemorrhage.

Symptoms. — Paleness of face ; lividity of lips ; vertigo ; cold sweat ; slow, weak, and fluttering pulse ; gradual insensibility. There may also be nausea and vomiting, hallucinations, delirium, jactitations, irregular breathing, sighing, and convulsions before death. The nervous symptoms are due to want of brain power, in consequence of a deficient supply of blood.

Post-mortem Appearances. — Heart contracted and empty (if inspected early). If life has been protracted for several hours, a heart clot may be found. General paleness of the organs and tissues.

Asthenia. — Here, the cause of the cessation of the heart's action is either a defect in the quality of the blood or some disorder of the organs producing a loss of heart power : ( i ) by disease, as (a) various cardiac disorders, such as fatty degeneration, diseases of the valves, etc. ; (b) all exhausting diseases, as phthisis, cholera, cancer, etc.; (2) starvation; (3) certain injuries, as blows on epigastrium; (4) certain poisons. Cases of heart failure are popularly termed paralysis of the heart.

Symptoms. — Coldness of hands and feet ; lividity of lips ; fingers, toes, nose, and ears ; extreme muscular weakness ; feeble pulse ; sense and intellect not affected, but preserved to the last. This latter is well seen in the collapse of Asiatic cholera.

Post-mortem Appearances. — The heart not contracted ; its cavities contain more or less blood, or else are dilated and flabby. Blood in all large vessels, but no congestion of lungs or brain.

PHENOMENA AND SIGNS OF DEATH. I 5

III. Death Beginning in the Lungs — Apnea — (Asphyxia) . — Respiration may be arrested ( i ) by any mechanical impediment to the ingress of air into the hmgs, as (a) pressure of the thorax; (b) tetanic spasm of the muscles of respiration; (c) paralysis of the pneumogastric or phrenic nerves; (d) exhaustion of muscular power; (e) foreign bodies in the air passages; (/) compression of the throat; (g) suffocation; (h) drowning. (2) By disease, as pneumonia, phthisis, etc., spasm of the glottis, edema of the glottis, pharyngeal abscess, embolism of the pulmonary artery, and the accumulation of serum, blood, or pus in the pleural cavities. (Strictly speaking, most of these diseases cause death through mechanical interference with breath-

Symptoms. — Great dyspnea, lividity of the face, loss of consciousness, vertigo, and occasionally convulsions.

Post-mortem Appearances. — The right side of the heart and the whole venous system are usually filled with dark blood ; the left side, together with the arteries, is generally empty. Cases are, however, reported where the right cavities of the heart were found empty. The lungs themselves are nearly always gorged with dark blood ; but there are some exceptions to this, which will be noticed hereafter.

By keeping in mind the foregoing varieties of somatic death, together with the characteristic post-mortem appearances attendant on each, the examiner will be considerably aided in arriving at a definite conclusion as to the real cause of death in any particular case.

In every inquest over a dead body Hve important questions will present themselves for solution : ( i ) The reality of the death. (2) The cause of the death. (3) Was the death instantaneous, sudden, or was the death agony prolonged?

(4) The time that has elapsed since the death. (5) In the case of the body of a new-born infant — Was it born aUve ? The first of these questions comprises the phenomena and signs of death. How can a case of real death be distinguished from apparent death? In the great majority of instances, of course, no practical difficulty arises ; but exceptional cases do, at times, occur, in which the corpse retains so much the appearance of life as to occasion doubts. The horror of being buried alive also suggests caution in the matter, although cases of premature burial rarely, if ever, occur in civilized countries ; yet such may have occurred when fatal pestilence has prevailed to such a degree as to produce a panic and demoralize the community. Dr. Tidy reports that Nussbaum states " that he believes many to have b^en buried during the Franco-Prussian war who were merely in lethargy from loss of blood, exhaustion, hunger, cold and fear."

The following may be regarded as the Signs of Death; but no one sign should be relied upon exclusively :

I. The Complete and Continuous Cessation of the Functions of Circulation and Respiration. — In some cases of apparent death — syncope, trance, catalepsy — these two functions seem to be suspended for a time; but the suspension is apparent, not absolute. The absence of the pulse at the wrist is not proof of the suspension of the circulation, as this may be going on so feebly as only to be detected by a very close stethoscopic examination of the heart, which should never be omitted in cases of doubt. The condition of both the circulation and respiration, in such cases of apparent death, simply resembles that of

SIGNS OF DEATH. 1/

certain animals in the state of hibernation. Thus, M. Bouchut informs us that in the marmot the heart beats during its state of activity amount to 80 or 90 a minute, but are reduced to 8 or 9 very feeble pulsations during the period of hibernation. Instances are recorded (like that of Colonel Townshend, by Dr. Cheyne) of a voluntary suspension of the heart's action; but as these cases occurred many years ago, before the discovery of auscultation, it is highly probable that the suspension was not absolute, but only reduced so as to have escaped ordinary notice. It is certainly contrary to scientific reasoning that life can continue many minutes without the circulation of the blood; therefore one need have no hesitation as to the reality of death, if the heart's action has been arrested completely for an hour. The converse of this proposition, however, is not always true; that is, the pulsation of the heart may continue for a brief time after actual death. Duval m'^nt'ons having seen the heart of a criminal beat fifteen tir.ici: afte decapitation, the left auricle pulsating for an hour. Tl .s is corroborated by some observations made in Paris upon the body of a decapitated criminal. This same phenomenon, as it is well known, is witnessed still more remarkably in the heart of the sturgeon, frog, and snapping turtle, which will continue to pulsate many hours after removal from the body. This fact, as also the post-mortem contraction of the muscles under galvanic stimulus, proves the continuance of molecular life after somatic death.