Often there are evidences of strangulation in addition to those of suffocation, the mother holding the child's head by a grasp around its neck. Another method which has been occasionally used is the tucking of some foreign material into the pharynx, thus shutting off the supply of air. Such a means may leave no trace, but occasionally the tampon has been found left in place. Burial alive may occur, although this is rare. If a child was buried alive the general signs of suffocation would be present, in addition to the presence of dirt in the nose and throat.

The appearance of suffocation is generally borne out by the following evidence: There is cyanosis of the skin, protrusion of the tongue, congestion of the brain, and ecchymoses under the skin and conjunctivæ. The condition of the lungs, however, is more significant, as the above are suggestive of death by asphyxia. The color of the lungs, if the child has not breathed, is not bright-red, but is dark bluish-red; the bronchi contain mucus stained with blood, which must be distinguished from the slight exudation of serum; and if the child died from bronchitis, section of the lungs and pressure upon the bronchi will give the characteristic appearance of the exudate.

Tardieu considers the subpleural and subpericardial ecchymoses and similar spots under the pericranium as characteristic of suffocation. These ecchymoses must not be confused with those of hemorrhagic diseases, such as purpura, which are irregular, large, diffuse areas of fluid blood. The subpleural ecchymoses are described as follows:

"One sees on the surface of the lungs, small, punctate spots, very regularly rounded, of a very dark red, almost black color, of which the size varies in the new-born from that of a head of a pin to that of a hemp-seed. The spots are scattered under the pleura in variable numbers, sometimes reduced to five or six, sometimes thirty or forty; in certain cases so numerous that the lungs have the appearance of granite. Sometimes they are united and agglomerated so as to give the appearance of marbling. But in all cases they are exactly circumscribed and distinct against the general background of the lungs. Their location is not less regular than their number; however, they are found most often at the root of the lung, at its base, and at the edge of the inferior border. These punctate spots are formed by little bloody effusions, little ecchymotic droplets under the pleura, arising from the rupture of the superficial vessels of the lungs. I have found these subpleural

ecchymoses distinct on the lungs of a new-born infant whose body had lain for ten hours in a privy. . . . Just like these found under the pleura, one finds ecchymotic spots almost constantly under the pericardium, principally at the origin of the great vessels."

Strangulation not uncommonly occurs with suffocation and fracture. of the skull. If it has been done by hand, there are the marks of the

finger-nails on the neck. If by a string, cord, stocking, or some other article frequently taken from the dress of the mother, there are the signs of the constricting band on the neck, as in the adult. But the very delicate skin of the infant shows the marks of the excoriations much more clearly, although the strength necessary is only slight. Strangulation by the umbilical cord has been recorded.

The general signs of suffocation are similar to those of strangulation. The evidence of drowning of an infant is similar to that in the adult. Water is found in the lungs and stomach and the blood is generally fluid. Where the infant is found in a privy, distinction must here be made as in drowning, between those cases where a dead child has been thrown into a vault or water, and one who has suffered death from immersion.

Death of the child has also been caused by wounds or mutilation of the body, such as may occur in adults, although, of course, the instruments used are, as a rule, of a different kind. Scissors, knives, pins, needles, etc., have been used as instruments, where they would have hardly produced fatal injury to man.

Poisoning is extremely rare. Accidental poisoning may occur in very young children and is quite common. Death may also occur from lack of proper care, either intentional or from thoughtlessness on the part of the mother or attendant. Exposure to heat or cold may cause the death of a child, although this means is seldom used, as it is too slow. Of course, where a child has been exposed to cold, bronchitis may occur, and it may die as a result of this exposure.

CHAPTER XVI.

SEXUAL DISABILITY IN THE MALE

Sexual disability is of considerable importance in legal medicine. It includes both impotence and sterility. Impotence is the incapacity for sexual intercourse, while sterility is the inability to conceive on the part of the woman or to beget on the part of the man. Both conditions apply to both sexes, although some authors restrict sterility as belonging to the woman alone; this is erroneous. A sterile person may not be impotent, but an impotent person is sterile, at least so long as the impotency persists. The law, however, does not distinguish between the two conditions.

The Massachusetts law concerning divorce is "A divorce from the bond of matrimony may be decreed for impotency of either party." Impotence has been used as a plea in defense in trials for reputed bastardy and adultery, but it is especially in divorce suits that this question arises.

Not only may this question come up in legal medicine, but it also concerns the practicing physician, as a husband or wife who desires heirs may consult him as to their sexual capacity. A mother seeks advice as to the propriety of her daughter marrying, the latter having some real or fancied malformation; a man seeks to know if he can fulfill his obligations if he marries; or a couple wish to know if they are too old to have children. It is a common practice for young men to consult disreputable quacks who advertise to "restore manhood".

Casper, speaking of this subject, says: "There is no department in forensic medicine in which such incredible lies and shameful assertions will be made to the practitioner in order to obtain a favorable opinion as in this. And very naturally, since the result in cases of pregnancy, paternity, divorce, etc., frequently affects for life the future position of the parties concerned. And, also, because the most ignorant nonprofessional person is conscious that in a matter that never permits any witnesses, no third party, not even a physician, can come forward either for or against him. I might fill volumes with the shameful and absurd declarations which have been brought to me. In one case a former opera

tion on the genitals was said to have rendered impotent for a long time, a man accused of the paternity of an illegitimate child. He showed, as the still visible cicatrix of the operation, the natural raphe of the scrotum. In another case a shameless fellow had shaved all the hair from his pubes and dared to present himself as imperfectly formed and impotent."

Legal questions may arise in divorce cases where it is sought to annul the marriage contract on account of the inability of one or the other party to procreate children. This is a well-recognized principle which obtains in all civilized countries, even in China. The impotence must be established and it must be absolute and not amenable to treatment. Examination of both parties may be desirable. Divorce is sued for on this ground more often by women because it is difficult to prove the condition in women. It may be temporary; it may be permanent; it may be curable or incurable; it may be natural or accidental; it may be physical, mental or psychical.

Causes of Impotence in the Male.-The first condition that suggests itself as an incurable cause of impotence in the male is absence of the penis. This may be congenital or due to accident, disease, or surgical interference. The absence must be absolute, for cases are recorded where a small remnant of the organ has proved sufficient to accomplish fertile intercourse.

The entire absence of the testes is another cause of impotence, but the mere fact that they are not in the scrotum is not evidence that they are absolutely lacking. Where they are lacking the person shows the other genital organs imperfectly developed, and generally there is also absence of the sexual desire, and a habitus which is distinctly feminine. There is softness of the skin and the figure approaches the female type; the beard is scanty, the voice feminine, the breasts well developed, the feet and hands small, and there are other evidences of this peculiar condition.

Cryptorchids, on the other hand, usually possess the mental and physical development of the normal male. They are generally sterile, though they may not be impotent, and many authors state that they are not sterile. Monorchids may not be impotent or sterile. Atrophy of the testicles is another cause of sterility. It may result from gonorrhea, varicocele, and syphilis, mechanical injury to the spinal cord or brain, and occasionally from the use of certain drugs, such as potassium iodid. Such atrophy is permanent and not amenable to treatment.

Double castration, will, of course, cause sterility, but the removal of one of the testes does not interfere with the power to procreate. The sterility following castration is not always immediate, for the seminal vesicles may retain for a certain time the spermatozoa that

have been secreted before the operation. If it was performed after puberty, the power of erection is retained; while if performed before. puberty, this power is generally lost. Even in this condition of castration there may occur more or less secretion, but this is composed chiefly of prostatic fluid or of mucus. Successful impregnation has occurred after castration, but in these cases it was accomplished soon after the loss of the testes, and was due to the spermatozoa within the seminal vesicles. Destruction of the vas deferens, whether congenital or acquired, produces sterility in males, and perhaps this is the most common cause of sterility among men.

Exstrophy of the bladder results from arrest of development of the anterior wall of the abdomen and bladder. The ureters open externally, the penis is short and imperforate and the testicles are generally within the abdominal cavity.

Certain malformations are sometimes spoken of as causing impotence, but most of them are remediable, and hence cannot be classed as true causes of impotence; for example, adhesions of the penis to the scrotum, as well as incurvation of the penis, but in either case surgical treatment will generally remedy the cause. Theoretically, a double penis may be considered to interfere, but the reverse has been proved

Taylor reports the case of a Portugese who had two organs placed side by side. The one on the right side was the smaller of the two, but both were capable of erection at the time same. The left one was the one that he used. Abnormalities in size may be remedied, and in any case may be considered as causing only relative impotence. Distortion of the penis is caused by congenital shortening of the corpus spongiosum, but this is easily remediable, as are other conditions causing a deviation in the direction of the organ. A large scrotal hernia, hydrocele, or elephantiasis may cause relative impotency.

Abnormal development of the penis may cause relative impotency, but rarely, if ever, absolute. This refers particularly to those cases of hypospadia and epispadia. Casper says: "Where the formation is otherwise, that of a normal male hypospadia and epispadia of themselves form no basis for assuming sexual incapacity, so long as it cannot be proved in any given case that it is impossible for any seminal fluid to enter the vaginal canal." Of course, under such conditions, intercourse is only imperfectly performed, and the incapacity or impotence varies according to the amount of malformation. A moderate degree of hypospadia offers no presumption of impotence. Epispadia is rare, and, according to Casper, never occurs alone.

There are certain functional disorders of the genito-urinary system that are of more interest to the practitioner than to the medico-legal expert. A person may exhibit "atonic" impotence due to the failure