CHANGES IN THE ARTERIAL DUCT.

359

duct before respiration, and (as the author frequently had occasion to observe) after respiration has been established, and the child has died soon after birth. Fig. 160 shows the state of the duct in a still-born child, and in a child which has breathed imperfectly. Fig. 161 shows its contraction after perfect breathing, and an increase in the size of the pulmonary arteries (3 3). Fig. 162 represents the closure and obliteration of the duct in advanced

Fig. 160.

Fig. 161.

Fig. 162.

འ་ ལས་ ཚིག

The heart, with arterial duct open and contracted.

life. The figures of reference are the same as in figs. 158, 159; but in addition to these, the following references may be pointed out:-5, the situation of the right auricle; 6, the superior vena cava; and 7, the inferior vena cava. Among the exceptional conditions, Bernt remarks that the contraction may be first observed at the cardiac instead of the aortal end. In one instance of a still-born child that was resuscitated and breathed feebly for a short time, and in which the thymus gland was absent, the duct was of the size of a crow-quill, as in children which have lived several days. He also states, on the authority of Schallgrüber, that the duct is sometimes entirely absent. ('Das Verfahren bei der gerichtlich-medicin. Ausmit. zweifelhafter Todesarten der Neugebornen,' von Joseph Bernt, s. 67, Wien, 1826: also, 'Systemat. Handbuch der gerichtl. Arzneik.' s. 275, Wien, 1834.)

The observations of Bernt show that the natural closure of the duct is a comparatively slow process; but his conclusions are open to many more exceptions than those which he admits. Neither in his works, nor in those of other authorities on Medical Jurisprudence, is any case recorded which shows that the duct can become quite impervious from natural causes in a child which has survived its birth only a few hours.

Although the closure may take place as a result of the establishment of respiration, the time of its closure after birth is so uncertain as to render any evidence derivable from the non-closure altogether fallacious. The author examined the bodies of several children that had survived birth for some hours, and was not able to discover any perceptible alteration in the diameter of the duct either at its aortal or cardiac end. In other cases partial contraction has been apparent. As the closure depends on a diversion of blood through the lungs, so it follows that, when respiration is feeble or imperfect, the duct will be found either of its natural patency, or, if closed, the closure must be regarded as an abnormal deviation. In the case of a child that died at the age of ten weeks, the ductus arteriosus was found to be freely open. ('Med. Gaz.' vol. 40, p. 994.) Chevers has shown that there are numerous abnormal conditions which may give rise to non-occlusion of the duct. ('Med. Gaz.' vol. 36, p. 190; and vol. 38, p. 961; see also Orfila, Méd. Lég.' 1848, 212.) From the

facts collected by Chevers, it appears that the duct is liable to become contracted and even obliterated before birth, and before the child has actually breathed. In these cases there has been, in general, some abnormal condition of the heart or its vessels; but this, even if it existed, might be overlooked in a hasty examination: hence the contracted or closed condition of the duct cannot be taken as an absolute proof that a child has been born alive or survived its birth. In 1847, Chevers laid before the London Pathological Society the case of a child born between the seventh and eighth months, in which this vessel was almost closed, being scarcely onetwelfth of an inch in diameter, and capable of admitting only the shank of a large pin. The tissues of the duct had altogether an appearance of having undergone a gradual process of contraction; and its state proved that its closure had commenced previously to birth. In fact, the child survived only fifteen minutes; while, according to Bernt's rule, the medical inference might have been that this child had lived a week. In this case the heart and lungs were in their normal or natural state. ('Med. Gaz.' vol. 39, p. 205.) On the other hand, the open or pervious condition of the duct is consistent with the child having breathed after birth; it sometimes remains pervious for many years. Peacock met with an instance in a man, æt. 30, in whose body the duct was found pervious, and of sufficient capacity to give passage to a writing-quill. (Med. Times and Gaz.' Nov. 1861; also a case by Fagge, 'Guy's Hosp. Rep.' 1873, p. 23.)

The medical evidence derivable from the condition of the ductus arteriosus in a new-born child was submitted to a rigorous examination in the case of Frith (Ayr Circ. Court of Just. Oct. 1846.) The body of a child was found in a bag which had been buried in the sands on the seashore at Ayr, a little above highwater-mark, with such marks of violence about it as left no doubt that it must have been deliberately and intentionally destroyed. Independently of severe injuries to the throat externally, the mouth and throat internally were found to be so closely stuffed with tow and other substances that there was some difficulty in removing them. The body when found was much decomposed; the brain was pulpy, and the cuticle, as well as the bones of the skull, were easily separated. The weight of the body was seven pounds, and the child had the characters of maturity. The prisoner had, beyond doubt, been delivered of a child about three weeks previously to the discovery of this body. It was alleged that this was her child, and she was put on her trial for the murder. The material question in the case was one of identity, depending on two sets of facts-ordinary and medical. The bag in which the body was found was part of the covering of a cushion belonging to the mother and grandmother of the child. This evidence so connected the prisoner with the dead body, that the medical facts raised in the defence became only of secondary importance. The following appearances were met with:-The heart and lungs weighed one ounce; the latter organs were collapsed; the right lung was considerably decomposed, and sank when placed on water; the left was of a red colour, firm in texture and floated on the surface when immersed in a vessel filled with water; but on pressure there was no crepitation. The right side of the heart was filled with coagulated blood, the foramen ovale being partly open, and the ductus arteriosus impervious. The liver was large and of a leaden hue, the ductus venosus almost obliterated, and meconium was found in abundance in the lower bowels. The medical men were of opinion, from the perfect conformation of the child's body and the above-mentioned appearances, that it had been born alive. The circumstantial evidence established that not more than five hours could have elapsed from the birth of the child to the time at which its body was buried in the spot where it was subsequently found; and that,

EVIDENCE FROM THE STATE OF THE ARTERIAL DUCT. 361

admitting it to have been born alive, there was the strongest reason to believe it did not survive its birth more than ten minutes. The results of experiments on the lungs were not alone sufficient to show that the child had been born alive. The organs were light, and not crepitant; the right lung was decomposed, and yet it sank in water, while the left was firm, and floated. The defect in this part of the medical evidence was, however, removed by the evidence of a man lodging in the prisoner's house, who deposed that he distinctly heard the child cry. He slept in the same room with the prisoner on the morning on which she was delivered. Under these circumstances, the defence taken up was, that, considering the state in which the ductus arteriosus was found, this could not have been the child of the prisoner, because, if destroyed after being born alive, it must clearly have been destroyed immediately after birth. In that case the ductus arteriosus could not have been found impervious-ergo, the body found was not the body of the prisoner's child. It was contended that, according to all previous experience, the duct, except as a result of congenital disease, could not be found impervious in a child which had ceased to live within a few minutes, or even a few hours, after birth. One medical witness for the prosecution admitted that it required some days or weeks for the duct to become impervious: but a case was reported by Beck in which it had closed within a day. Another stated that it is generally a considerable time before the duct becomes closed. Medical evidence was given in defence, to the effect that the earliest case of closure was twentyfour hours; and from the state of the duct in this case, the witness considered that the child must have survived for one day at least, or not much less. Another witness stated that the discovery of the closure in a body would lead him to infer that the child had survived three or four days. According to this evidence the body produced could not have been that of the prisoner's child. The jury, however, found that the child had been born alive, but that murder had not been proven. ('Med. Gaz.' vol. 38, p. 897; 'Edin. Month. Jour.' Nov. 1846, p. 385.)

It

appears from the evidence given at the trial that circumstances quite irrespective of medical testimony proved that this child had been born alive, that it was the child of the prisoner, and that it could have survived its birth only a few minutes. The medical evidence left it undoubted that the child had been destroyed by violence. The facts that the mouth and throat were firmly packed with tow, and that there had been copious effusions of blood in the seats of violence, admitted of no other explanation. To what, then, was the early closure of the duct in this case to be referred? There is no instance on record of the arterial duct becoming impervious within a period of five or six hours (in this case only as many minutes could have elapsed) after birth. Its closure is naturally the result of free and perfect breathing in a healthy child: but the state of the lungs in this instance showed that respiration had neither been full nor complete. It is probable, therefore, that the case was similar to that described by Chevers, and that there was an abnormal condition of the duct. Either this must be assumed, or the closure must have depended on other causes than perfect respiration: but experience shows, as a general rule, that it proceeds pari passu with this process.

Admitting that this abnormal state of the duct, i.e. its closure previous to birth, is in general accompanied by malformation either of the heart or of the great vessels connected with it, yet Chevers' case, already related, proves that this is by no means a necessary accompaniment. Hence, the better rule will be to place no confidence on a contracted condition of this duct as evidence either of live-birth or of the time during which the child has lived. It can only have any importance as evidence when the death of

a child speedily follows its birth; and these are precisely the cases in which a fallacy is likely to arise, for the contraction or closure may be really congenital, and yet pronounced normal. If a child has lived for a period of two or three days (the time at which the duct naturally becomes contracted or closed), then evidence of live-birth from its condition may not be necessary: the fact of survivorship may be sufficiently apparent from other circumstances. Hence, this species of evidence is liable to prove fallacious in the only instance in which it is required, and the case of Frith (p. 360) shows the dangerous uncertainty which must attend medical evidence based on the closed condition of the duct.

Ductus, or canalis venosus.-This is a branch of the umbilical vein which goes directly to the inferior vena cava : there is no known instance of the obliteration of this vessel previous to birth. When respiration is fully established, it collapses, and becomes slowly converted, in a variable period of time, into a ligamentous cord or band, which is quite impervious. There is no doubt that in those cases in which it is stated to have become obliterated in children that could have survived birth only a few minutes or hours, the mere collapse of the coats has been mistaken for an obliteration of the canal. It is probably not until the second or third day after birth that its closure begins, although nothing certain is known respecting the period at which it is completed. The condition of this vessel, therefore, can throw no light upon those cases of live-birth in which evidence of the fact is most urgently demanded.

Foramen ovale.-This is a large oval opening placed at the lower and back part of the partition between the right and left auricles of the heart. It is considered to attain its greatest size at about the sixth month. It is represented in the following illustrations open and closed. Fig. 163—1, cavity of the right auricle laid open; B, situation of the right ventricle; a,

The heart of the child, showing the foramen
ovale nearly closed by its valvular mem-
brane after respiration.

(Bock, Gerichtl. Sectionen des Menschlichen Körpers.')

the right auricle; b, the partition between the right and left auricles; c, the foramen ovale or opening between the two auricles, partly closed by the valve d. In fig. 164 it will be observed that the valvular membrane d almost entirely closes the aperture; e, opening into the right ventricle; f, opening of the superior vena cava into the upper part of the right auricle; g, opening of the inferior vena cava into the lower part of the same auricle; 1, the superior vena cava; 2, the inferior vena cava; 3 3, the two right pulmonary veins; 4, trunk of the pulmonary artery, with its two

EVIDENCE FROM THE STATE OF THE FORAMEN OVALE. 363

branches; 5 the right, and 6 the left, pulmonary artery; 7, the arterial duct; 8, the aorta.

At an early period of foetal life, there is no valve to the foramen ovale. About the twelfth week the valve rises upon the left side of the entrance of the vein, which thus comes to open into the right auricle. The separation of the two auricles is at the same time rendered more complete by the gradual advance of the valve over the foramen ovale, but the passage nevertheless continues open until after birth. Another valvular fold is formed on the right of the opening of the inferior vena cava, between it and the superior vena cava. This is called the Eustachian valve; it is represented by the letter d in the engravings.

As a general rule, this valvular opening between the right and left sides of the heart, exists during foetal life, and becomes gradually closed after the establishment of respiration. It is, however, often found open in children that have survived birth several hours; and the period of its closure is as variable as in the case of the ductus arteriosus. Hence, it is not capable of supplying with certainty evidence of live-birth, in those instances in which this evidence is most required. According to Billard, the foramen becomes closed between the second and third days; but there are numerous cases in which it is found not closed at much later periods after birth. Handyside states that it is more or less open in one case out of eight. In 1838 two subjects were examined at Guy's Hospital, one aged fifty, the other eleven years, and in both the foramen was found open. There is, however, another serious source of fallacy, which must be taken into consideration-the closure of the foramen ovale has been known to occur as an abnormal condition previously to birth and the performance of respiration. One case is mentioned by Capuron (Méd. Lég. des Accouchemens,' p. 337), and another is reported (Med. Gaz.' vol. 38, p. 1076). Other instances of this abnormal condition are adverted to by Chevers ('Med. Gaz.' vol. 38, p. 967); and it appears that in these the arterial duct remained open, in order to allow of the circulation of blood not only before but subsequently to respiration. The children rarely survive birth longer than from twenty to thirty hours. Chevers observes :-'Cases of this description are of great importance in a medico-legal point of view, as they fully disprove the opinion maintained by many anatomists, that obliteration of the foramen ovale must be received as certain evidence that respiration has been established. It is assuredly impossible to deny that in the heart of a child which has died within the uterus, and has been expelled in a putrid condition, the foramen ovale may be found completely and permanently closed. In such cases as these it would, however, probably be always possible to determine, by an examination of the heart and its appendages, that the closure of the foramen had occurred at some period antecedent to birth.' Still it would be unsafe in practice to rely upon the closure of this aperture as a proof of live-birth, in the absence of other good evidence and in no instance can its patency be regarded as a proof that a child has come into the world dead. Kidd met with the case of a new-born child, in which a thick layer of lymph had been deposited across the aperture, so as nearly to block it up, and the ductus arteriosus was completely closed: the child could not have survived its birth more than a few hours. (Assoc. Jour.' Feb. 4, 1853, p. 104.) This deposit of lymph is a condition not usually found. Peacock considered that the foramen is closed by the contraction of the muscular fibres of which the valve is constituted. In a medico-legal point of view, therefore, the patency or closure of this aperture possesses no longer any importance. ('Assoc. Jour.' Feb. 25, 1853, p. 177.)

:

As a general rule, these peculiar paris of the foetal circulation are rarely