586 CAUSES OF DEATH IN NEWBORN CHILDREN. arteriosus furnishes no evidence of a child having been born alive. These parts may become closed and contracted before birth, and therefore be found closed in a child born dead; or they may remain open after birth in a child born living, even subsequently to the establishment of respiration. 6. That the presence of air and of farinaceous or other food in the stomach and bowels proves that a child has been entirely born alive. 7. That the presence in the stomach and air-passages of blood, meconium, vernix caseosa, or the natural discharges, does not prove that a child was born alive. 8. That the presence of an air-cavity in the tympanum, or middle ear, affords additional evidence of live birth. 9. That, irrespective of the above conclusions, there is no certain medical sign which indicates that a child that has died at or about the time of birth has been born alive. CAUSES OF DEATH IN CHAPTER LII. NEWBORN CHILDREN.-PROPORTION OF CHILDREN BORN DEAD.DEATH.-A PROTRACTED DELIVERY.-DEBILITY.—BLEEDING FROM NAVEL-STRING.-COMPRESSION OF THE NAVEL-STRING.-MALFORMATION.-DESTRUCTION OF MONSTROUS BIRTHS.--DEATH FROM CONGENITAL DISEASE. Causes of Death in Newborn Children.-The next important question in a case of infanticide, and that upon which a charge of murder essentially rests, is-What was the cause of death? 1. It is admitted that a child may die during birth or afterwards. 2. In either of these cases it may die from natural or violent causes. The violent causes may have originated in accident or in criminal design. The last condition only involves the question of child-murder. If death has clearly proceeded from natural causes, it is of no importance to settle whether the cause operated during or after birth. All charge of criminality is henceforth at an end. It is well known that of children born under ordinary circumstances a great number die from natural causes either during birth or soon afterwards; and in every case of child-murder death will be assumed to have arisen from some cause of this kind, until the contrary appears from the medical evidence. This throws the onus of proof entirely on the prose cution. Many children die before performing the act of respiration, and thus a large number come into the world dead or stillborn. The proportion of stillborn among legitimate children, as it is derived from statistical tables extending over a series of years, and embracing not fewer than eight millions of births, varies from one in eighteen to one in twenty of all births. (Brit. and For. Med. Rev., No. 7, p. 235.) In immature and illegitimate children, forming the greater number of those which give rise to charges of child-murder, the proportionate mortality is much greater-probably about one in eight or ten. Stillbirths are much more frequent in first than in after-pregnancies; and children are much more frequently born dead among primiparous than among pluriparous women. Males are more often stillborn than females. According to Lawrence's observations, the proportion of deaths is 1 to 11 among the primiparous, and 1 to 31.2 among the pluriparous. (Edin. Med. Jour., March, 1863, p. 814.) In most cases of child-murder, the woman is primiparous. These DEATH FROM NATURAL CAUSES. 587 facts should be borne in mind when we are estimating the probability of the cause of death being natural. Should breathing be established by a protrusion of the child's head from the outlet, or during the birth of the body, the chances of death from natural causes are considerably diminished. Nevertheless, as W. Hunter long ago suggested, a child may breathe and die. Thus, according to this author, "If the child makes but one gasp and instantly dies, the lungs will swim in water as readily as if it had breathed longer and had then been strangled." In general, it would require more than one gasp to cause the lungs to float readily in water; but, waiving this point, the real question is-If the child breathed either during or after birth, what could have caused its death? The number of gasps which a child may make, or which may be required for the lungs to swim in water, is of no moment; the point to be considered is, whether its death was due to causes of an accidental or criminal nature. So again observes Hunter: "We frequently see children born, who, from circumstances in their constitution, or in the nature of the labor, are but barely alive, and after breathing a minute or two, or an hour or two, die, in spite of all our attention. And why may not this misfortune happen to a woman who is brought to bed by herself?" The substance of this remark is that many children may die naturally after having been born alive; and in Hunter's time these cases were not, perhaps, sufficiently attended to. In the present day, however, the case is different; a charge of child-murder is seldom raised, except in those instances where there are the most obvious marks of severe and mortal injuries on the body of a child; and it must be admitted that the discovery of violence of this kind on the body of a newborn infant renders a full inquiry into the circumstances necessary. Among the natural causes of the death of a child may be enumerated the following: : 1. A Protracted Delivery. The death of a child may proceed, in this case, from injury suffered by the head during the violent contractions of the womb, or from an interruption to the circulation in the umbilical cord before the act of breathing can be performed. As it is elsewhere explained (post, pp. 588, 590), each contraction of the womb affects the placental circulation, and a succession of these contractions in a protracted delivery will have the same effect on the child as the arrest of breathing after birth, i. e. non-oxygenated blood will be circulated and may cause the death of the child. For a similar reason, a premature separation of the placenta may lead to its death. A child, if feeble and delicate, or if prematurely born, may die from exhaustion under these circumstances before respiration is established. This cause of death may be suspected when a serous tumor (or caput succedaneum) is found on the head of a child and the head itself is deformed or elongated as a result of pressure; or an effusion of blood (cephalhæmatoma) is found beneath the pericranium. These appearances will be accompanied with a congested state of the vessels of the brain. The existence of deformity in the pelvis of the woman might corroborate this view; but in primiparous women (among whom charges of child-murder chiefly lie) with well-formed pelves delivery is frequently protracted. It is presumed that there are no marks of violence on the body of the child, excepting those which may have reasonably arisen from accident in attempts at self-delivery. 2. Debility. A child may be born either prematurely or at the full period, and not survive its birth, owing to a natural feebleness of system. This is observed among immature children; and it is a condition especially dwelt on by W. Hunter. Such children may continue in existence for 588 BLEEDING FROM LACERATION OF THE NAVEL-STRING. several hours, breathing feebly, and may then die from mere weakness. These cases may be recognized by the immature condition of the body and the appearance of a general want of development. 3. Bleeding from Laceration of the Navel-string.-A child may die from loss of blood, owing to a sudden separation of the placenta, or an accidental rupture of the navel-string. In the latter case, it is said the loss of blood is not likely to prove fatal if breathing has been established; but an instance is reported in which a child died from bleeding even under these circumstances. (Henke's Zeitschrift, 1839, Erg. H., p. 200; also 1840, Bd. 1, p. 347, and Bd. 2, p. 105; Ann. d'Hyg., 1831, t. 2, p. 128.) Bleeding from the cord has been observed to take place at various periods after birth, and to have led to the death of the child. (Edin Month. Jour., July, 1847, p. 70.) Death from bleeding may be commonly recognized by the blanched appearance of the body and a want of blood in the internal organs; but there are several instances on record in which the cord was ruptured close to the abdomen without causing the death of the child. Bleeding from the vessels of the navel-string may prove fatal several days after birth, even when a child has been properly attended to, and the navelstring has separated by the natural process. A case of this kind is reported in which, in spite of every application, the child died from loss of blood six days after the cord had separated. (Med. Times and Gaz., 1854, i. p. 287.) The impossibility of arresting the bleeding in this case appeared to depend upon a great deficiency of fibrin in the blood, and a consequent want of tendency to coagulation. (Wieczorek, Vierteljahrsschr. für Gerichtl. Med., 1873, Bd. 1, p. 385.) It has been believed that the danger arising from bleeding of the cord was chiefly confined to those cases in which it was divided near to the abdomen, and where a cutting instrument had been used; and this is no doubt generally true. Page performed some experiments on this subject, which showed that hemor rhage might take place from the divided navel-string, even when torn through at a length of eighteen inches from the body and to such an extent as to endanger the life of a child. He also found that hemorrhage from the cord might take place without any interference with the respiration; but the arrest of this may lead to hemorrhage which might not otherwise have occurred. If there are severe wounds on the body from which blood has issued, it would be obviously wrong to refer a blanched condition of the body to accidental bleeding from the cord. The fatal bleeding may really have arisen from the wounds. Before a medical expert refers death to this cause, he should be well assured that the cord was really torn through or severed about the time of birth and not from any accident subsequently. A case is reported which shows the necessity for this caution. The body of a newborn child was taken from a river in which it had probably been floating for nearly a fortnight. The placenta and cord were attached to the body, but in removing it from the water the cord was torn through and the placenta carried away by the stream. A medical man examined the body, and, seeing the cord ruptured and observing no marks of violence, he came to the conclusion that the cord had been torn through by the woman at birth and that the child had died from hemorrhage. (Ann. d'Hyg., 1873, t. 2, p. 443.) The medical opinion, however, was disproved by the evidence of witnesses. 4. Compression of the Navel-string.—When a child is born by the feet or buttocks the cord may be so compressed under strong uterine contrac tion that the circulation between the mother and child will be arrested, MALFORMATION-MONSTROSITY. 589 and the latter will die. The same fatal compression may follow when, during delivery, the cord becomes twisted round the neck. A child has been known to die under these circumstances before parturition, the cord having become twisted round its neck in the uterus. (Lond. Med. Gaz., Oct. 1840, p 122; also vol. lxxix. pp. 232, 233.) Davis reported a case where it is probable that the child, which was heard by the mother to cry for some time, was strangled by the mother having moved her body away from the infant after delivery, and thus tightened the navel-string. (Brit. Med. Jour., 1882, ii. p. 1069.) On these occasions the child is sometimes described to have died from strangulation, but it is evident that, before the establishment of respiration, such a mode of expression is improper. There are few or no appearances indicative of the cause of death. There may be lividity about the head and tace, with a mark or furrow on the neck, and congestion of the brain internally; it is, however, necessary to remember that vessels of the brain of a child are always more apparent than those of an adult. Hofmann considers that asphyxia is really the cause of death in children which have not breathed. He looks upon the placental circulation as vicarious to that of the lungs after birth, the arterial blood from the woman supplying the oxygen (derived from respiration) necessary to support the life of the unborn child. The amount of oxygen required for this purpose is exceedingly small, and, according to Schwartz and Pflüger, it is not sufficient to produce any difference of color in the blood of the umbilical vessels. (Vierteljahrsschr. für Gerichtl. Med., 1873, Bd. 2, pp. 219, 224.) Although, under compression of the cord, a child may die before breathing, from the want of a proper supply of oxygen through the blood, yet the appearances presented by the lungs would differ from those which are found in these organs after breathing has been once established. 5. Malformation, Monstrosity.-There may be a deficiency or defect of some vital organ which would at once account for a child dying either during delivery or soon after its birth. Two cases are reported, in one of which the child died from an absolute deficiency of the gullet, the pharynx terminating in a cul-de-sac; in the other the duodenum was obliterated for more than an inch, and this malformation had occasioned the child's death. (Lond. Med. Gaz., vol. xxvi. p. 542.) In a third, a child was suffocated by the retraction of the base of the tongue, owing to defect of the frænum. (North. Jour. Med., 1849, p. 278.) The non-establishment of respiration sometimes arises from the mouth and fauces of the child being filled with mucus. An enlargement of the thyroid gland has occasionally led to the death of a newborn child by suffocation. (Edin. Month. Jour., July, 1847, p. 64.) The epiglottis is sometimes fixed over the glottis so as to prevent the entrance of air. In a case of this kind which occurred to Hicks, a child was saved by the introduction of a finger the air suddenly rushed in, and the child was then enabled to breathe. But a child may be born in this state when no person is at hand to assist the woman: in this case it will die; and the lungs being found in the foetal or unexpanded condition it will be pronounced stillborn. Obstruction of the air-passages is a frequent cause of death among newborn children. The varieties of malformation are very numerous, but there can be no difficulty in determining whether they are such as to account for death. Persons are not allowed to destroy monstrous births; and the presence of any marks of violence in such cases should be regarded with suspicion. It is the more necessary to make this statement, as there is an idea among the vulgar that it is not illegal to destroy a monstrous birth. A 590 SPASMS OF THE LARYNX-CONGENITAL DISEASES. lady was delivered of a hideous two-headed monster. At the earnest solicitations of the friends the nurse destroyed it. The question wasWas this woman guilty of murder? The only case in reference to this point, which is recorded by medico-legal writers, is that of two women who were tried at the York Assizes in 1812 for drowning a child which was born with some malformation of the head, in consequence of which it was not likely that it could survive many hours. It did not appear that there had been any malice or concealment on the part of the prisoners, who were not aware of the illegality of the act. (Paris and Fonblanque, Med. Jur., vol. i. p. 228.) The absence of malicious intention would probably lead to an acquittal on the charge of murder; but such an act would doubtless amount to manslaughter, as the degree of monstrosity or the viability of the offspring cannot be received as an extenuating circumstance. As to the first, if a liberty of judging of what was monstrous and what not were conceded to any ignorant nurse children simply deformed might be put to death on this pretence; as to the second, it is held in law that whoever accelerates death causes it; hence the fact that a child is not likely to live more than a few hours does not justify the act of one who prematurely destroys it. 6. Spasms of the Larynx.-Some children are born alive, and on coming into the world make attempts to breathe, but, owing to spasms of the larynx and retraction of the tongue, the air is unable to enter; the child dies soon after birth, and on inspection no air being found in the lungs, the child is wrongly pronounced to have been born dead. (Guy's Hosp. Rep., 1866, p. 476.) A careful examination of the fauces may show the presence of mucus or meconium, or a condition of the epiglottis which may account for the obstruction to respiration. Hicks has on more than one occasion seen the newborn child make these inspiratory efforts, and by lifting the epiglottis has given free passage to the air, and the child has been saved. 7. Atelectasis.-Atelectasis, as it has been elsewhere explained (ante, p. 567), implies simply an unexpanded state of the lungs. In some cases it is complete, in others partial. It can scarcely be regarded as a diseased condition, as the body of a child may be otherwise healthy; the lungs themselves are in a normal state, and they can be easily expanded by the artificial introduction of air, or by other remedial measures, when assistance is at hand. This imperfect expansion of the lungs is generally due to debility in the child, and it is especially a cause of death in weakly or immature children. But strong and healthy children may die from simple non-inflation of the lungs. Assuming that in utero the child lives by what has been called "placental respiration," i. e. a continuous supply of sufficiently oxygenated blood from the woman, another explanation may be offered. If anything should arrest the placental circulation during labor by interrupting the flow of blood to the child through the umbilical cord, this may cause its death before pulmonary inspiration can be established. The child is born asphyxiated, and this may explain the state of atelectasis. Every contraction of the womb more or less interrupts placental respiration as it is above defined. The child lives inside the womb by the placenta, and outside by the lungs. If the action of the placenta is destroyed before that of the lungs can be set up, this would explain the condition known under the name of atelectasis. (See a paper by Hofmann, Vierteljahrsschr. für Gerichtl. Med., 1873, 2, p. 219.) 8. Congenital Diseases.-It has been elsewhere stated (p. 567, ante) that a child may be born laboring under such a degree of congenital dis |