In investigating the subject of Wounds, it will be convenient to adopt,
on the present occasion, the usual classification of local injuries,
viz. 1. _Incised wounds_, or cuts; 2. _Punctures_, or such as are
inflicted by pointed instruments; 3. _Bruises_, injuries occasioned by
blunt instruments; 4. _Lacerations_, where the integuments are torn, and
5. _Gun-shot wounds_; upon each of which we shall offer a few
observations, and, in the first place, it may be remarked generally,
that no graduated scale of wounds, expressive of the degree in which
they are curable or dangerous, can ever be constructed; in appreciating
the probable degree of danger that attends a wound other data will be
required for the solution of the problem than those deduced from
situation and extent, such as the constitution and temperament, age,
habits of life, especially as they regard temperance and sobriety,
previous state of health, unnatural structure and disposition of parts,
and existing diseases of the wounded individual; together with the
temperature of the season, and other extrinsic circumstances. As a
general rule for our guidance a division of wounds into four classes has
been suggested, viz. 1. _Absolutely mortal._ 2. _Dangerous._ 3.
_Accidentally mortal._ 4. _Not mortal._ Every practitioner, however,
must be aware that death will occasionally supervene on the slightest
injury, and at other times that the patient recovers in spite of the
most serious and extensive mischief; in proof of the former assertion,
the author may state that he has seen a case in which the extraction of
a tooth was followed by death in less than forty-eight hours; and every
experienced surgeon must in the course of his practice have observed the
slightest wound[101] productive of alarming and even fatal consequences;
in illustration of the occasional occurrence of a contrary result we may
recal to the recollection of the reader the extraordinary case[102] of
Mr. _Thomas Tipple_, who recovered after an accident, by which the shaft
of a chaise had been forced through the thorax! There have also been
instances of the recovery of persons whose brain has been wounded to a
considerable depth, of others shot through the head; Dr. _Male_ states
that a pauper in Paris, some years ago, used to receive charity in a
piece of his skull. In the second volume of the _Medico-chirurgical
Transactions_, we have a well attested case of a bayonet wound in the
heart not causing immediate death. _Littre_ has given us a report of a
man who inflicted upon himself no less than eighteen stabs in the
abdomen with a knife; and although some of them did not penetrate beyond
the parieties, yet others wounded the contents; the symptoms which
followed are stated to have been very severe, but by judicious treatment
the patient recovered; seventeen months afterwards, however, he threw
himself into the street from a three pair of stairs window, and was
instantly killed. On examining the body all the wounds were found
healed, and, with the exception of one, all the cicatrices were firm and
level; they were traced into the intestines, where corresponding
adhesions were observed.[103]
The surgical practitioner will, after such cases, be cautious in his
prognosis, and profit by the experience of Hoffman, who says, “_In
judicio de vulnerum lethalitate ferendo multorum Medicorum fama et
fortuna periclitantur_.”[104] Fortunately for the administration of
justice, that act of the Legislature, called “_the Ellenborough act_,”
relieves us from many of those embarrassments under which the
professional witness[105] must otherwise have laboured, and the surgeon
will appreciate the high importance and utility of the law, by which
wounding with an intent to kill is deemed equally criminal, whether
death be the result or not. Still, however, the testimony of the medical
practitioner will always be important; indeed the evil intent is often
to be inferred, or disproved, by the nature of the injury inflicted; as
is so well illustrated in the case of a man, who fractured the skull of
a boy with a stick, upon finding him in the act of plundering his
orchard; when it was clearly made out in evidence, that a mere
chastisement was only intended, for the size of the stick was not such
as to have occasioned any fatal effect, had not the skull of the
unfortunate boy been unusually thin.
If the surgeon is called upon to inspect a wound, with a view to
ascertain whether it produced death, he should in the first instance,
endeavour to examine its nature and direction, so as to disturb as
little as possible the position in which the body was found; the knife
of the anatomist must afterwards explore its more particular condition
and relations, by a dissection, for the performance of which we shall
give ample directions in a future chapter.
The importance of examining the wound, so as not to alter the position
of the parts must be obvious when we consider how necessary it may
afterwards become to compare as strictly as possible the internal
appearances with the external lesions. The direction of a wound is
frequently a circumstance of much greater importance than may at first
appear, we ought not therefore to probe it without extreme caution, lest
we should give to it a direction which it did not originally possess.
This precaution becomes the more necessary as the putrefactive process
advances.
_Of incised wounds, or cuts._ The prognosis of wounds made with a
cutting instrument varies, _cæteris paribus_, according to the extent
and depth of the division, the nature of the injured parts, and the
circumstances which attend the operation; where the instrument has been
so sharp as not to occasion any contusion or laceration, the fibres and
texture of the wounded part will have suffered no other injury but their
mere division; and there is consequently less tendency to inflammation,
suppuration, gangrene, and other bad consequences; if the wound be large
and deep it will be more dangerous, as well as more difficult to heal,
than one which only affects the skin. Wounds, accompanied with injury of
considerable vessels or nerves, are more or less hazardous, according to
the magnitude or number of those vessels or nerves; generally speaking,
the most dangerous examples of incised wounds are those which are made
about the throat; here there are so many large blood-vessels, nerves and
other parts of great importance, that deep incised wounds often prove
fatal, either immediately, or in a few days; in some cases of suicide
the carotid artery is opened, and the person perishes from hemorrhage on
the spot, before any assistance can be afforded; in other instances he
divides some of the principal branches of the external carotid, and
after losing a great deal of blood, he faints, and the hemorrhage being
thus checked, the life of the patient is preserved, until surgical
assistance can be procured. Cut wounds of the extremities, when such
arteries as the femoral and brachial are injured, may also suddenly
destroy the patient, by hemorrhage.
_Punctures_, or such as are made by the thrust of pointed weapons, as by
swords, daggers, lances, and bayonets, or by the accidental and forcible
introduction of considerable thorns, large nails, skewers, &c. into the
flesh,[106] comprise a class of wounds of great importance and danger,
as they generally penetrate to a great depth, so as to injure large
blood-vessels, nerves, viscera, and other organs of importance; and
being inflicted with considerable violence the parts always suffer more
injury than what would be produced by their simple division. It must
also be considered, that a great number of the weapons by which such
wounds are occasioned, increase materially in diameter from the point
towards their other extremity; and hence, when they penetrate far, they
must force the fibres asunder like a wedge, and cause a serious degree
of stretching and contusion. It is this circumstance which gives so
dangerous a character to bayonet wounds in the soft parts. The opening
which the point of such a weapon produces is quite insufficient for the
passage of the thicker part of it, which can therefore only enter by
forcibly dilating, stretching, and otherwise injuring the fibres of the
wounded flesh. But mortal injury may be inflicted by an extremely
slender instrument, so as to occasion an apparently trivial puncture;
and in some cases, the external injury is healed before the death, which
it occasions, takes place. Such cases can only receive satisfactory
elucidation from the lights of an anatomical dissection, under which
head we have furnished several instructive examples.
_Bruises_, or _Contusions_, strictly comprehend those injuries which are
occasioned by the violent application of blunt or obtuse instruments to
the soft parts. They are not unfrequently complicated with severe
internal injury resulting from the violence which the parts have
sustained, such as inflammation, suppuration, or even the rupture of
some of the viscera, of which we shall hereafter present several
illustrative cases.
A blow on the region of the stomach sometimes occasions instant death;
an effect which would appear to arise from an injury inflicted upon the
eighth pair, and great sympathetic nerves, by which the heart is
instantly paralysed. In these cases the heart has been found empty, and
the stomach has appeared red and inflamed; this latter appearance is the
obvious effect of the sudden cessation of the heart, producing the
settling of the blood in the extreme arterial branches.
Wounds of this description are, of course, more or less important,
according to their locality; unless complicated with laceration, they
are never attended with any considerable hemorrhage, although the minute
vessels are necessarily ruptured, and the effusion of their contents
produces the discoloration so characteristic of this kind of injury.
As in the case of wounds, so also in respect of blows, injuries
apparently inadequate have produced death; it then becomes difficult to
fix the degree of guilt which should be attached to the aggressor; for
though according to the strict letter of the law, every man is
responsible for the ultimate effect of an illegal act committed by him;
yet in moral justice there is much difference between the atrocity of
him who strikes a grievous wound with a deadly weapon, from which by
chance his victim may recover; and the fault of him who transported by
sudden passion gives an ordinary blow, which by accident, by reason of
some inward and unknown disease of his adversary, or by injudicious
treatment, becomes fatal. Numerous cases might be cited in support of
this position: that of _Brain_ for the murder of _Watts_, _Cro. Eliz._
778: _H. P. C._ 455. is one of the most remarkable, not only from the
circumstances attending the trial, where the jury were fined and
imprisoned for a corrupt verdict, but also for the physiological
circumstance, that the deceased died instantly from a blow on the calf
of his leg. The parties had previously quarrelled and fought; and
_Brain_, the prisoner, was hurt; the next day _Watts_ passing his shop
made mouths at him, on which new provocation _Brain_ hit him the blow
which instantly proved fatal. The Court held that the new provocation
was insufficient, and that the death must be referred to precedent
malice—might they not also have considered that a blow on the calf of
the leg was more insufficient to produce death under ordinary
circumstances, than a wry face to induce or inflame a quarrel? The
prisoner was found guilty, but not without considerable and as it
appears to us proper resistance on the part of the jury; the case being
on Appeal, the Crown could not pardon, though the appellant might
compromise his suit:—we are not informed whether the prisoner was
executed.
A case, nearly parallel to the above, is that of _Lydia Alder_, who was
tried in 1744 for the murder of her husband, whom she kicked on the
groin; in consequence of which, having at the time an inguinal rupture,
mortification came on, and he died. Verdict, _Manslaughter_. The
circumstances attending the case of _Bartholomew Quain_ were, in some
respects, different; he was tried and convicted for the murder of his
wife, at the Assizes for the Isle of Ely, in 1790. It appeared in
evidence, that a rupture of the spleen was produced by the violent
kicks, of which the indictment stated that she had died. The jury, under
the direction of the Chief Judge of Ely, found a special verdict, in
order to take the opinion of the Court of King’s Bench upon the
following question, whether the facts found by the jury amounted to
murder, or only to manslaughter, when the Court was clearly of opinion
that it was murder, because there did not appear to have been any
provocation on the part of the deceased; and no man had a right, even to
inflict chastisement, without a just provocation.
_Lacerations_, where the integuments are torn.—These differ from incised
wounds not only in the circumstance of their being less disposed to heal
by the first intention, but in the singular fact of their not bleeding
to any extent; there are perhaps no facts, in the history of surgery,
more extraordinary than those which have been recorded on the subject of
whole limbs being torn away, without hemorrhage. The most remarkable of
these is related by _Cheselden_, in his work on Anatomy, being the case
of a miller, “whose arm, with the scapula, was torn off from his body,
by a rope winding round it, the other end being fastened to the coggs of
a mill; there was no hemorrhage, nor did any severe symptoms supervene,
so that the wound was cured by superficial dressings only, the natural
skin being left almost sufficient to cover it.” Analogous cases are
recorded by _La Motte_, in his _Traité des Accouchemens_; by Mr.
_Carmichael_, in the fifth volume of the _Edinburgh Medical
Commentaries_; and by others, in the second volume of the _Mem. de
l’Acad. de Chirurgie_. In appreciating the degree of danger attendant
upon wounds of this description, the practitioner must not overlook the
possible occurence of Tetanus.
_Gun-shot wounds._ Long after the invention of gunpowder, Surgeons
continued to entertain very vague opinions respecting the nature of
wounds produced by it; some considered that the injured parts were
either dreadfully burnt by the heat of the projected body, or were
irritated by the presence of poison, communicated to them by the powder.
_Thomas Gale_, who served as a Surgeon in the army of _Henry_ 8th, at
Montreuil in 1554, was the first to refute the absurd opinions of “the
poisoning, burning, and conquassation of gun-shot wounds.” A gun-shot
wound is now defined “a violent contusion, with, or without a solution
of continuity, suddenly and rapidly effected by a solid body projected
from fire-arms.” If a musket or pistol ball has struck a fleshy part,
without injuring any material blood-vessel, we see a hole about the size
of, or smaller than the bullet itself; with a more or less discoloured
lip forced inwards, and if it has passed through the parts, we find an
everted edge, and a more ragged, and larger orifice at the point of its
exit; the pain in this case is so inconsiderable that the wounded person
is frequently not aware of his having received any injury. The course of
balls is frequently most extraordinary, and it behoves the judicial
surgeon to keep in mind a fact which may often throw considerable light
upon the subject of his investigation. A ball will often strike the
thorax or abdomen, and, to an inexperienced eye, appear to have passed
directly across, or to be lodged in one of the cavities. If great
difficulty of breathing or hemorrhage from the mouth, with sudden
paleness and laborious pulse, in the one case, or deadly faintness,
coldness of the extremities, and the discharge of stercoraceous matter
from the wound, in the second, are not present, we shall perhaps find
that the ball has coursed along under the integuments, and is marked in
its progress either by a redness, which Mr. _Hunter_ compared to a
blush, or by a wheal, or dusky line, terminated by a tumour, on the
opening which it will be easily extracted. In some of these long and
circuitous routes of balls, where we have not this mark, a certain
emphysematous crackling discovers their course, and leads to their
detection. The ball is in many instances found very close to its point
of entrance, having nearly completed the circuit of the body. In a case
related by Dr. _Hennen_, as one that occurred to a friend of his in the
Mediterranean, the ball, which struck about the _Pomum Adami_, was found
lying in the very orifice at which it had entered, having gone
completely round the neck, and being prevented from passing out by the
elasticity and toughness of the skin which had confined it to this
circular course. This circuitous route is a very frequent occurrence,
particularly when balls strike the ribs, or abdominal muscles, for they
are turned from the direct line by a very slight resistance indeed,
although they will at times run along a continued surface, as the length
of a bone, along a muscle, or a fascia, to a very extraordinary
distance. If there is nothing to check its course, and if its momentum
be very great, it is surprising what a variety of parts may be injured
by a musket ball. Dr. _Hennen_ states that in one instance, which
occurred in a soldier, who having his arm extended in the act of
endeavouring to climb up a scaling ladder, had the centre of his humerus
pierced by a ball, which immediately passed along the limb, and over the
posterior part of the thorax, coursed among the abdominal muscles,
dipped deep through the glutæi, and presented on the fore part of the
opposite thigh, about midway down. In another case, a ball which struck
the breast of a man standing erect in the ranks lodged in the scrotum.
The propensity of balls to take a curved direction is often seen in
their course on a concave surface; in short, they take very unusual and
deep-seated routes, not at all to be accounted for by any preconceived
theories drawn from the doctrine of projectiles, nor to be explained by
diagrams founded upon mathematical rules. These considerations ought to
render the Surgeon very cautious how he delivers his opinion, as to the
direction in which the shot was fired, and yet instances frequently
occur where no difficulty can arise upon this point, such was the case
of _Richard Annesley_, tried for the murder of _Thomas Eglestone_ (9
_Harg. Sta. Tri._ 327). The deceased was a poacher. _Annesley_ who was
in company with the game-keeper, stated in his defence, that his gun had
accidentally gone off in his attempt to secure the deceased. The
instructions given by the Court on this occasion was that if the jury
were of opinion that the gun had so gone off accidentally, they should
bring in a verdict of _Chance-medley_, which was returned accordingly,
in consequence of the evidence of the Surgeon who had examined the
wound, and stated that its direction being upwards, very satisfactorily
proved that the fowling-piece had not been levelled from the shoulder,
which would have implied design; but must have been discharged at the
trail, which must have been accidental.[107] An idea long existed that a
ball might produce injury without striking any part of the body; this
was supposed by some to arise from the violent commotion produced in the
air by the rapid motion of the ball; and by others, to depend upon an
electrical shock on the parts, in consequence of the ball being rendered
electrical by friction in the calibre of the gun, and giving off the
electrical matter as it passes by. This, however, is contrary to all our
received notions respecting electricity; metals can never acquire such a
property by friction.
In avowing our total disbelief in the existence of such
_wind-contusions_, as they have been called, we are well aware that we
shall oppose many very respectable authorities. “_Amicus Plato, sed
magis amica Veritas._”
An important question, connected with the present subject, still remains
for elucidation; where a body has been found dead with wounds and
contusions, by what signs we are to determine whether they were
inflicted during life, or after death. As the solution of this
interesting problem requires various data, its consideration will be
reserved for that part of our work, where all the Objects of Inquiry, in
cases of sudden and mysterious death, are considered in their various
relations to each other, with a view to appreciate their individual and
joint importance.