conditions, in from six to twelve days, as a slight greenish
discoloration of the abdomen which gradually spreads throughout the
body. The time at which putrefaction shows itself and the rapidity with
which it advances is dependent upon so many factors, many of which
it is impossible often for the medical examiner to ascertain, that
too much reliance must not be placed upon it. Casper estimates the
following to be the _average_ changes generally found in the periods of
time given:
TWENTY-FOUR TO SEVENTY-TWO HOURS after death a slight green color is
visible over the centre of the abdomen. The eyeballs are soft and yield
to external pressure.
THREE TO FIVE DAYS after death the green color of the abdomen becomes
intensified and general, spreading if the body be exposed to the air or
buried in the ground in the following order: genitals, breast, face,
neck, upper and lastly lower extremities.
EIGHT TO TEN DAYS after death the discoloration becomes more
intense, the face and neck presenting a shade of reddish-green. The
ramifications of the superficial veins on the neck, breast, and limbs
become very apparent. Finally the patches congregate. Gases begin to be
developed and distend the abdomen and hollow organs and to form under
the skin in the subcutaneous and intermuscular tissue. The cornea falls
in and becomes concave. The sphincter ani relaxes.
FOURTEEN TO TWENTY-ONE DAYS after death the discoloration over the
whole body becomes intensely green, with brownish-red or brownish-black
patches. The body is bloated and appears greatly increased in size
from the development of gases within the abdomen, thorax, and scrotum,
and also in the cellular tissue of the body generally. The swollen
condition of the eyelids, lips, nose, and cheeks is usually of such
extent as to obliterate the features and to destroy the identity of the
body. The epidermis peels off in patches, while in certain parts, more
particularly the feet, it will be raised in blisters filled with red or
greenish liquid, the cuticle underneath frequently appearing blanched.
The color of the iris is lost. The nails easily separate and the hair
becomes loosened.
FOURTH TO SIXTH MONTH after death the thorax and abdomen burst and the
sutures of the skull give way from the development of gases within the
head. The viscera appear pulpy, or perhaps disappear, leaving the bones
exposed. The bones of the extremities separate at the joints. At an
advanced stage the soft parts gradually disappear.
In giving an opinion as to how long a time has elapsed since death when
a body has undergone marked putrefactive changes, we must consider
carefully not only the conditions of the organs, but the mode of death
and the “surroundings.” By these I mean the quantity of clothing worn,
the depth of the grave in which the body has been interred, the season
of the year, the heat and moisture of the atmosphere. The question
sometimes presents itself to the medical examiner, Of two persons
found dead, which died first? The importance of this point was well
illustrated in the “Lizzie Borden case.” By a careful consideration of
all the conditions presented by each body in the ways I have indicated,
the question will not ordinarily be a difficult one to decide.
THE
MEDICO-LEGAL CONSIDERATION
OF
WOUNDS,
INCLUDING
PUNCTURED AND INCISED WOUNDS, AND WOUNDS MADE BY BLUNT INSTRUMENTS
OTHER THAN GUNSHOT WOUNDS.
BY
GEORGE WOOLSEY, A.B., M.D.,
_Professor of Anatomy and Clinical Surgery in the Medical Department of
the University of the City of New York; Surgeon to Bellevue Hospital;
Member Medical Society of the County of New York, New York Academy of
Medicine, New York Surgical Society, etc., etc._
WOUNDS.
GENERAL CONSIDERATIONS. THE DIFFERENT KINDS OF WOUNDS.
THE surgical and medico-legal ideas of wounds are quite different, the
latter including the former as well as other varieties of injuries.
=Definitions.=—Surgically a _wound_ means a solution of continuity and
refers to every such lesion produced by external violence or developing
spontaneously. The medico-legal acceptation of the term is much broader
and includes any injury or lesion caused by mechanical or chemical
means. Vibert[601] quotes Foderé as defining a wound medico-legally as,
“Every lesion of the human body by a violent cause of which the results
are, singly or combined, concussion, contusion, puncture, incision,
tear, burn, twist, fracture, luxation, etc.; whether the cause is
directed against the body or the body against the cause.” The same
author quotes another definition of a wound as, “Every lesion however
slight, resulting in concerning or affecting the body or health of an
individual.” Taylor[602] defines a wound in a medico-legal sense as “a
breach of continuity in the structures of the body whether external or
internal, suddenly occasioned by mechanical violence.” Thus, the term
wound in its medico-legal acceptation includes not only surgical wounds
but contusions, fractures, burns, concussion, etc. In France at least
the voluntary inoculation of syphilis has been considered as coming
under the category of wounds.[603]
Medico-legally, the severity of a wound is much more important than
the kind of wound. Thus we may consider wounds according to their
comparative gravity, as mortal, severe, or slight.
A _mortal_ wound is one which is directly fatal to life in a
comparatively short time, usually from hemorrhage, shock, or the injury
of a vital part. A wound may result fatally without being a mortal
wound, as when a slight wound causes death on account of some wound
infection.
_Severe wounds_, or “wounds causing grievous bodily harm,” as they have
long been called, do not put life in imminent danger, though they may
be inconvenient or detrimental to health. Pollock, C. B., says that a
wound causing grievous bodily harm is “any wound requiring treatment.”
A medical opinion or certificate may be required as to the danger of a
given wound, and on this opinion may depend the question of bail for
the prisoner. By the danger of a wound in such a case is usually meant
imminent danger, as any wound may be remotely dangerous to life.
_Slight wounds_, as already stated, may result fatally under certain
conditions. Under the French practice a slight wound is one which does
not incapacitate one from work for more than twenty days. Looked at
in another way, slight or severe wounds may be classified according
as they are completely curable, leaving no infirmity or disturbance
of function, or not completely curable. The latter are such as are
necessarily followed by permanent or temporary infirmity.
The question as to the severity of any given wound may sometimes be
left to the jury to decide from the description of the wound, or a
medical opinion may be required.
Although the intent of the assailant is often of equal or greater
importance than the severity or kind of wound, yet this can only
occasionally be inferred from the surgical aspects of the wound.
The classes of wounds to be treated in the following pages are incised
and punctured wounds and wounds with blunt instruments, some of the
characteristics of which we will now consider.
=Incised wounds= are such as are produced by a cutting instrument, and
they are distinguished by the following characteristics: They measure
more in length than in the other dimensions. They are usually straight
in _direction_, though not infrequently curved, and they may even be
zig-zag, especially where the skin lies in folds. The _edges_ of an
incised wound are linear, and show no signs of contusion. They are
either inverted or everted and the edges and sides of the wound are
retracted. The eversion of the skin is due to its elasticity, but in
some regions of the body, _e.g._, in the scrotum, etc., the skin is
inverted owing to the contraction of the muscle fibres immediately
beneath. The gaping of the wound is due to the retraction of the
divided muscles and fibrous structures. It varies according as the
muscles are cut directly across or more lengthwise, and in proportion
to the distance of the wound from the points of attachment of the
muscles.
The fibrous tissues, fasciæ, and aponeuroses retract less, and so give
a somewhat irregular surface to a large wound.
Ogston[604] divides incised wounds into three parts, the commencement,
centre, and end, of which the end often has two or more serrations
differing from the commencement, which has but a single point. There
are often one or more slight, superficial, tentative incisions situated
almost always, though not invariably, near the commencement.[605] The
deepest part of the wound is more often near the commencement. If
there are angular flaps on the edges their free angles point to the
commencement of the wound.
Coagula and clots of blood are to be found in the wound, more or less
filling it up if it has not been interfered with. On examination the
ends of the divided vessels are found plugged with clots which may
protrude somewhat from their openings.
If the wound is seen very shortly after its infliction, hemorrhage is
in progress, and the divided arteries show their position by their
individual, intermittent jets of blood. The severity of incised wounds
depends upon the amount of hemorrhage, which is greater the deeper and
larger the wound, and the more vascular the tissues in which it occurs,
especially if large and important vessels are concerned. In the latter
case an incised wound may be very rapidly fatal.
Incised wounds present the least favorable conditions for the
spontaneous arrest of hemorrhage of any form of wounds. The edges of an
incised wound may be quite rough and even dentated or lacerated if the
edge of the weapon be rough and irregular.
The kind and condition of a weapon which has produced a given incised
wound may often be learned by an examination of the characteristics of
the wound.
Weapons cutting by their weight as well as by the sharpness of their
edges, such as axes, etc., may cause a certain amount of contusion
about a wound; they crush the soft parts to a certain extent, and the
bones may be indented or even fractured.
Wounds caused by fragments of bottles, pieces of china, earthenware,
or glass, though strictly speaking incised wounds, are often curved,
angular, and irregular, and their edges jagged and contused.
Wounds caused by scissors may sometimes be of the nature of incised
wounds. When they present a double wound of triangular shape, with the
apex of the triangle blunt, they are more of the nature of punctured
wounds. In general a “tail” or long angle in the skin at one end of an
incised wound indicates the end of the wound last inflicted, and some
light may thus be thrown upon the inflicter of the wound.
Incised wounds present very favorable conditions for healing by primary
union, but often fail in this and heal by secondary union. When an
incised wound fails to unite by primary union, bleeding continues
for several hours or even as long as a day, the blood being mixed
more or less with a serous discharge. The latter continues until the
third day or so. By the fourth or fifth day the surface has begun to
granulate, and there may be a more or less profuse purulent discharge
from the surface. The granulating surfaces do not necessarily discharge
pus, however. For some days, therefore, after the infliction of an
incised wound, or until the surface is covered with granulations, the
characteristics of the wound permit of a diagnosis as to the nature of
the wound.
The _diagnosis_ of an incised wound is generally without difficulty.
Some wounds by blunt instruments, however, in certain regions of the
body, resemble incised wounds very closely. Such instances are found
where a firm, thin layer of skin and subjacent tissue lies directly
over a bony surface or a sharp ridge of bone. These are seen most often
in the scalp or in wounds of the eyebrow where the sharp supra-orbital
ridge cuts through the skin from beneath. The diagnosis of an incised
wound can often be made with great probability from the cicatrix. This
is especially the case if the wound has healed by primary union and the
cicatrix is linear.
The _prognosis_ in incised wounds is good as to life unless a large
vessel has been divided or unless an important viscus has been
penetrated. The prognosis as to function varies with the position and
extent of the wound, and the circumstance of the healing of the wound.
=Punctured Wounds, Stabs, etc.=—These are characterized by narrowness
as compared to depth, though the depth is not necessarily great.
They are more varied in character than incised wounds owing to the
great variety of form of the weapons by which they may be made. From
the form, etc., of a particular wound we may often infer the variety
of weapon by which it was produced. According to the weapon used,
punctured wounds have been divided into several classes, of which M.
Tourdes distinguishes four: 1st. _Punctured wounds by cylindrical or
conical instruments_ like a needle. If the instrument be very fine like
a fine needle, it penetrates by separating the anatomical elements
of the skin, etc., without leaving a bloody tract. Such wounds are
generally inoffensive, even when penetrating, if the needle is aseptic,
and they are difficult to appreciate. On the cadaver it is almost
impossible to find the tract of such a wound. If the instrument be a
little larger it leaves a bloody tract, but it is difficult to follow
this in soft tissues, more easy in more resistant structures, such as
tendon, aponeurosis, cartilage, or serous membrane.
If the instrument be of any size this variety of punctured wounds
presents a form quite different from that of the weapon. Instead of a
round wound it is generally a longitudinal wound with two very acute
angles and two elongated borders of equal length, showing but little
retraction. This is the shape of the wound even when the instrument
producing it is so large that the resulting wound resembles that made
by a knife (see Fig. 2). The direction of the long axis of these wounds
varies in different parts of the body and is uniform in the same part.
Their shape and direction are explained by the tension of the skin or
still more clearly by the direction of the fibres of the skin, just
as with the same round instrument in a piece of wood a longitudinal
opening or split would be made parallel to the grain (see Fig. 1). In
some regions, as near the vertebræ, the fibres may run in different
directions, and the resulting wound is stellate or triangular in shape
as if a many-sided instrument had caused it. As the direction of the
fibres of the various tissue layers, such as aponeuroses, serous and
mucous membranes, etc., may be different, a deep wound involving
several such layers would have a different direction for each layer. In
illustration of this, examine the figure of a wound through the wall of
the stomach (see Fig. 3).
[Illustration: FIG. 1.—Direction of the Long Axis of Wounds of the
Back caused by Conical Instruments.
(After Langer.)]
The wounds above described when large are smaller than the weapon,
as the splitting of the skin has certain limits and also owing to the
elasticity of the skin, which is put on the stretch by the weapon and
relaxed on its withdrawal. When such wounds are small they are larger
as a rule than the instrument causing them.
[Illustration: FIG. 2.—Slit-like Wound caused by a Pointed Conical
Instrument 2.5 cm. in Diameter. Natural size.]
[Illustration: FIG 3.—Wounds of Stomach Wall by a Conical Instrument,
showing the Different Direction of the Long Axis of the Wounds in
Different Layers.]
[Illustration: FIG. 4.—Stab-Wound of the Skin with a Knife a Few
Minutes before Death.]
2d. _Punctured wounds by instruments both sharp pointed and cutting_,
like a knife or dagger. If these wounds are perpendicular to the
surface, they have more or less the form of the weapon used. The angles
may show whether the knife, etc., had one or two cutting edges, but
even though the back of the knife is broad the wound may resemble
one caused by a double-edged weapon. Thus stab-wounds from a common
pocket-knife show only exceptionally a wedge-shape, but regularly a
slit, the edges of which are slightly curved to one another and end in
two acute angles. The reason of this lies in the fact that the wound is
only caused by the cutting edge of the knife, so that we cannot tell
as a rule which angle was occupied by the back of such a knife (Figs.
4 and 5). The depth of these wounds may equal the length of the weapon
or be almost any degree less, but the depth may even be greater than
the length of the weapon by reason of a depression of the parts at
the time of the blow. The wound is often shorter and broader than the
weapon causing it, though more often it is larger than the weapon from
the obliquity of the wound and the movement of the weapon on being
withdrawn. The wound is smaller than the instrument where the parts are
on the stretch at the time the wound is inflicted.
[Illustration: FIG. 5.—Nine Suicidal Stab-Wounds in the Region of the
Heart made by a Knife used for Cutting Rubber.]
This variety of punctured wounds may resemble the former class in the
direction of its long axis, if the cutting edge of the instrument is
blunt. The regularity and smoothness of the edges distinguish them from
certain contused wounds.
3d. _Wounds made by instruments with ridges or edges_, files, foils,
etc. If the edges are cutting the wound presents more or less the shape
of the weapon (Fig. 6). But this is not always so, probably from the
instrument puncturing obliquely or from the tissues being unequally
stretched (Fig.7). If the edges are not cutting the wound resembles
those of the first class, though the edge often presents little tears,
and the wound may thus be more or less elliptical with two unequal
angles. The wound of entrance and exit may be different.
[Illustration: FIG. 6.—Stab-Wounds caused by a Three-Sided Sharp-Edged
Pointed Instrument.]
4th. _Irregular perforating instruments_, the wounds from which
resemble contused wounds.
=Contusions and Contused Wounds.=—A contusion is a wound of living
tissues by a blow of a hard body, not sharp-edged or pointed, or by a
fall, crushing, or compression, and without solution of continuity of
the skin. A contusion usually involves a moderately large surface in
comparison to the two other classes of wounds. Contusions are of all
degrees of severity. If the blow or injury is slight, there is only
slight redness and swelling of the skin with pain, disappearing in a
few hours, and leaving no traces. If the blow be harder it produces
more or less crushing of the tissues, accompanied by ecchymosis with
or without a wound or excoriations of the skin, etc. The contusion may
have the shape of the contusing body, such as a whip, the fingers, etc.
[Illustration: FIG. 7.—Stab-Wounds caused by an Eight-Sided
Sharp-Edged Instrument. Some show a transition stage to wounds made by
a conical instrument.]
=Ecchymosis.=—This is characteristic, as a rule, of contused wounds.
It consists in the infiltration of blood into the tissues, especially
the cellular tissues. The source of the blood is from the rupture
of blood-vessels, and the size of the ecchymosis varies partly with
the number and size of the blood-vessels, or with the vascularity of
the part. The size of the ecchymosis also varies with the looseness
of the tissues into which it is infiltrated. This looseness of the
tissues may be natural as in the scrotum and eyelids, or it may be due
to the attrition of the tissues caused by the blow. An ecchymosis is
larger when the contused parts cover a bony or resisting surface, and
there may be no ecchymosis whatever, even from a severe blow, where
the underlying parts are soft and yielding, as is the case with the
abdominal parietes. Here we may have rupture of the viscera without any
signs of ecchymosis superficially. An ecchymosis may be infiltrative
or it may mostly occupy a cavity usually formed by a traumatic
separation of the tissues; this is especially the case in the scalp
and extremities when the injury is severe. These tumors, which are
called _hematomata_, may be rapidly absorbed or they may remain a long
time and occasionally suppurate. Sometimes the anatomical conditions,
especially of the connective-tissue spaces, allow the extension or
migration of the ecchymosis under the action of gravity, even to a
considerable distance. When it meets an obstacle it accumulates above
it, as in the inguinal region for abdominal ecchymosis and at the knee
for those of the thigh. The course along which the ecchymosis travels
is indicated externally by a yellowish stain, soon disappearing, so
that soon no sign persists at the site of injury, but only below where
the blood is arrested.
An ecchymosis becomes visible at varying times after the injury
according to the depth of the ecchymosis and the thinness of the
skin, for the ecchymosis is mostly beneath, not in the skin. If the
ecchymosis is superficial it shows in one or two hours or even in less
time where the skin is very thin, as in the eyelids and scrotum. In
such cases it increases for thirty or forty hours and disappears in a
week, but may last longer, _i.e._, as long as fifteen to twenty-five
days.
An ecchymosis may not show at the point struck, at least not until
several days have elapsed, or it may only show on the under surface
of the subcutaneous fat until it has imbibed its way, as it were, to
the surface. This may explain the discrepancy in the description of an
injury examined by two medical experts at different times.
If an ecchymosis is extensive and deep, especially if it occupies a
cavity, there may be nothing to see in the skin for four or five days,
and then often only a yellowish discoloration instead of a dark blue
color. In such cases, too, the appearance in the skin may be more or
less remote from the injury, having followed the course of the least
anatomical resistance. Between these two extremes, an ecchymosis may
become visible at almost any time. Rarely an ecchymosis occurs only
deeply between muscles (pectorals, etc.) and not superficially at all.
The extravasation of blood which forms an ecchymosis has sometimes
been given different names, according to its extent or position, for
instance, parenchymatous or interstitial hemorrhages or apoplexies,
suffusions, ecchymoses, petechiæ or vibices. All such may, however, be
called ecchymoses or hematomata. When blood is effused into the serous
cavities of the body, special names are sometimes applied according to
the position, such as hemothorax, hematocele, etc.
The color of an ecchymosis is at first a blue-black, brown, or livid
red. This color changes first on the edges, later in the darker centre,
and becomes in time violet, greenish, yellow, and then fades entirely.
This change in color is owing to a gradual decomposition of the
hæmoglobin of the blood. We can tell the age of an ecchymosis from its
coloration only within rather wide limits, for the rapidity of change
of color varies widely according to a large number of circumstances,
especially according to whether the ecchymosis is superficial or deep.
We can only say that the first change, _i.e._, that to violet, in a
superficial ecchymosis, occurs in two or three days.
As an exception to the above color change, we may mention
subconjunctival ecchymosis, which always remains a bright red, as the
conjunctiva is so thin and superficial that the coloring matter of the
blood is constantly oxidized.
The form of an ecchymosis often reproduces well enough that of the
instrument, except if the latter be large it cannot all be equally
applied to the surface, and its form is not distinctly shown by that
of the ecchymosis. After its first appearance an ecchymosis spreads
radially, the edges becoming less clear. This change occurs more
rapidly the looser the surrounding tissues, and at the end of a few
days the first form of an ecchymosis may be changed, so that an
examination to determine the nature of the weapon should be made as
early as possible.
Ecchymoses are more easily produced in the young, the aged, and
in females, also in the case of such general diseases as scurvy,
purpura, hemophilia, etc. In fact, in the last three classes they may
occur spontaneously. This fact should never be lost sight of, as the
attempt may be made to explain a traumatic ecchymosis in this way. The
diagnosis between the traumatic variety and such cases of spontaneous
ecchymoses is, in general, easy, for in the latter case their number,
form, size, and occurrence on parts little exposed to injury and on the
mucous membranes, as well as the general symptoms of the disease, leave
little or no room for doubt.
From an oblique or glancing blow a considerable area of skin may be
stripped up from its deep attachments forming a cavity which may be
filled by a clear serous fluid alone, or with some admixture of blood.
These cases have been studied especially by Morel Lavallée and Leser,
and the fluid has been thought to be lymphatic in origin, hence the
name “_lymphorrhagia_.” Carriage accidents, especially where the wheels
do not pass directly but obliquely across or merely graze the body, are
especially liable to show this form of extravasation, which is thought
to be more common than is generally supposed, being often obscured by a
small quantity of blood.
[Illustration: FIG. 8.—Linear Wound with Nearly Clean-Cut Edges, with
Strands of Tissue bridging across at the Bottom and caused by a Fall on
the Head on a Smooth Surface.]
=Contused Wounds.=—If with the contusion we have a solution of
continuity of the skin, then we have a contused wound. This may
sometimes resemble an incised wound if the weapon has marked angles or
edges, as a hammer, or, as we have already seen, in wounds of the scalp
or eyebrow (Fig. 8). Careful examination, however, by a small lens if
necessary, is sufficient to distinguish them if they are fresh. If
they are four or five days old and have begun to granulate, it may be
impossible to distinguish them. Contused wounds present on examination
small tears on the edges which are widely separated and more or less
extensively ecchymosed. Contused wounds are often irregular, and
have thickened or swollen and ragged borders. They may, like simple
contusions, show by their shape the form of the instrument which caused
them. In contused wounds, unless they be perfectly aseptic, we usually
find sloughing of the contused, necrotic tissues. This leaves a cavity
to be filled up by granulation like wounds with loss of substance.
They therefore often present large cicatrices which may be mistaken for
those of ulcers. In contused wounds the bone may sometimes show the
impression of the instrument causing the wound.
A variety of contused wounds is that where the wound of the skin
consists merely of an _erosion_ or _excoriation_ with an ecchymosis
beneath. The wound may reproduce the shape of the weapon, _i.e._,
finger-nails, etc. After death the skin becomes brownish-yellow,
hard, and dry, and then they are called by the French “_plaques
parcheminées_.” They are distinguished, as a rule, from those produced
after death, by the ecchymosis beneath.
=Lacerated wounds= resemble contused wounds very closely, but are not
ecchymosed to any considerable extent. The solution of continuity is
sometimes very extensive and irregular, and may present several flaps.
The bone or bones are often fractured at the same time. They seldom
bleed much. The course of repair resembles that of contused wounds as
a rule. The prognosis is variable, for there may be slow and extensive
cicatrization and impairment of function, etc. These wounds usually
result from machinery accidents and accidental tears, etc. They are
therefore seldom the occasion of criminal proceedings but more often of
a civil suit, and thus require medical examination.
The injury which causes a contusion or contused wound may not
infrequently produce effects far more serious and more or less
remote from the contusion. Some of these effects it may be well to
particularize. Blows on the abdomen are sometimes quickly followed by
death without visible lesion to account for it. That authentic examples
of this exist has been denied by Lutaud, except for cases of rapid
death following contusions of the abdomen which had caused extensive
rupture of the viscera and abundant hemorrhage. But Vibert gives two
cases from his own experience, which are as follows:
A young man, twenty years old, received a kick in the stomach at a
public ball. Numerous witnesses of the scene testified that he only
received this one blow. The man collapsed immediately and died in a few
minutes. On autopsy nothing was found but two small ecchymotic spots in
the peritoneum covering the intestine, the largest not the size of a
bean.
In the second case, the injury was also a kick in the stomach and the
man died almost immediately. Absolutely no lesion was found on autopsy.
Both were in full digestion.
König[606] says: “A number of severe contusions of the belly run
a rapidly fatal course without the autopsy showing any definite
anatomical lesion of the viscera.” He also adds that the less severe
cases at first often show very profound shock, which is out of
proportion to the force of the injury. The cause of death has been
explained, like that of sudden death from a blow on the larynx, by the
theory of inhibition. These cases are often illustrated experimentally
on frogs, where the same result is obtained under similar conditions.
Such cases are the more remarkable from the fact that the fatal blow
may cause no ecchymosis or other mark of injury to appear on the
abdominal walls.
Blows on the head may produce a variety of results besides that of
the contusion itself. In fact, death itself may result though the
marks of contusion are very slight or even imperceptible. Intracranial
hemorrhage, laceration with ecchymosis of the brain, on the same or
opposite side to the injury, and concussion of the brain may result. Of
these only concussion will be considered now.
=Concussion= has been defined as a shock communicated to an organ
by a blow or fall on another part of the body, which may or may not
be remote, and without producing a material or appreciable lesion.
According to Lutaud,[607] English pathologists understand by it a
temporary or permanent nervous exhaustion resulting from a sudden or
excessive expense of nervous energy. Its effect is observed in the
function of an organ and especially in the brain. Concussion of the
brain causes stupidity, loss of consciousness, amnesia, coma. The
intracranial lesion most often associated with concussion is ecchymosis
and laceration on the surface of the brain, but there may be no lesion
visible even if the case is a fatal one. Fatal concussion has been
observed where the marks of external violence were very slight or even
failed entirely, as illustrated by the two following cases cited by
Vibert:[608]
Vibert made an autopsy on a man who had been struck by a pitchfork,
one of the teeth of which struck behind the ear, the other two in the
face, only producing slight skin wounds. The man immediately lost
consciousness and died in two days in coma. No lesion whatever was
found within the skull, and only three slight ones externally.
He observed another case where the man fell three or four metres
into an excavation, landing on his feet, and died in a short time.
On autopsy only slight erosions and no intracranial or extracranial
lesions were found.
This case belongs to a rare class where the blow is transmitted through
the spinal column without sign of injury externally or internally to
the head.
The following case cited by Vibert is even more remarkable in the
production of the severe though not fatal concussion: An officer
was riding at full speed on horseback, when his horse suddenly
stopped short. By great exertion the officer clung to the horse, but
immediately lost consciousness. His fall from the horse was broken by
those about him, and the concussion he received was not due to the
fall, but to the shock of stopping suddenly when his momentum was great.
As a rule, however, the diagnosis of concussion, especially if it is
severe enough to be fatal, is easily made by the marks of external
violence with or without intracranial lesions. The effects of
concussion may be transient and leave no trace, but, on the other
hand, they may be prolonged and severe, _i.e._, paralysis, aphasia,
loss of memory, imbecility, etc. The medical examiner should be on
his guard against simulation in respect to these prolonged effects of
concussions. One of the most frequent consequences of concussion is
temporary amnesia, which ordinarily succeeds immediately after the
injury, but sometimes develops more slowly. The following curious case
is quoted from Lutaud as cited by Brouardel:
A woman in getting out of a train at Versailles, where she had gone
to attend the funeral of a relative, was struck by the door of the
compartment. She fell, but did not lose consciousness, and picked
herself up, but forgot what she had come for.
Another result of an injury which has caused a contusion or contused
wound may be a fracture or dislocation. Fractures and dislocations of
special parts will be referred to later, in considering injuries of the
several regions of the body, but it seems appropriate here to refer to
some of those general considerations relating to these injuries which
may especially demand the attention of the medical expert.
=Fractures= may be produced by blows or falls, or from muscular action.
The medical witness may be questioned as to the cause of the fracture
or, if it was produced by a blow, whether a weapon was used or not, as
the defence is likely to assert that it was caused by an accidental
fall. The nature of the associated wounds and contusions, if any exist,
may, as we have seen, indicate the weapon used. If anything exists to
indicate that a fall which caused the fracture was not accidental, this
should be noted, as the assailant is responsible for the effects of the
fall.
A number of conditions influence the ease with which a fracture is
produced and account for a fracture being due to a slight injury, and
so are mitigatory circumstances in the case.
Fractures are more easily produced in the old and young, especially
the former, than in the adult from the same force. This is due to
brittleness of the bones in the old and their small size in the
young. Certain diseases like syphilis, arthritis, scurvy, carcinoma,
and rickets make the bones more frangible, and there is a peculiar
brittle condition of the bones known as _fragilitas ossium_, more or
less hereditary, in which the bones become fractured from very slight
violence. Mercer is quoted by Taylor as stating, but on how good
authority it does not appear, that in general paralysis of the insane
the bones are particularly liable to fracture. Certain it is that not
uncommonly insane patients are found dead with single or multiple
fractures, but the attendants are generally convicted.
In some parts, like the orbital plate of the frontal bone, the bone is
very thin and brittle, but brittleness from any cause only mitigates,
it does not excuse.
Taylor[609] reports a case in point where it was proved that the bones
of the skull were thin and brittle, and the fractured skull proved
fatal from inflammation of the brain. The punishment was mitigated
owing to the circumstance of the brittleness of the bones.
SPONTANEOUS FRACTURES may occur from only a moderate degree of muscular
action, and even where there is no disease of the bones, but the
above-mentioned condition of fragilitas ossium, rendering the bones
more brittle, aids in the production of such fractures. The olecranon,
patella, and os calcis are particularly liable to such fractures, but
the long bones of the ribs and extremities are sometimes so fractured,
as instanced in the following cases cited by Taylor:[610]
The humerus of a healthy man has been broken by muscular exertion
simply by throwing a cricket ball.[611] In 1858 a gentleman forty years
old, during the act of bowling at cricket, heard a distinct crack like
the breaking of a piece of wood. He fell immediately to the ground, and
it was found that his femur was fractured.
Again, in 1846, a healthy man, æt. 33, was brought to Gray’s Hospital
with the following history: He was in the act of crossing one leg over
the other to look at the sole of his foot, when something was heard to
give way; his right leg hung down and he was found to have received
a transverse fracture of the femur at the junction of the middle and
lower thirds.
The writer had a case in Bellevue Hospital during the past winter
(1892-93) of a man who stated that he had been well and active until
some weeks previously, when, from muscular force alone, he sustained a
fracture of the neck of the femur. Something abnormal in the bone may
be present in such cases.
In cases of spontaneous fractures there are no marks of external
violence which, if present, would remove the idea of spontaneity.
Fractures of the extremities are not dangerous _per se_, unless they
are compound or occur in old, debilitated, or diseased persons, and
they are more severe the nearer they are to a joint. The healing of
fractures is more rapid in the young than in the old and in the upper
than in the lower extremity. It is not proven that adiposity of itself
impedes union.
The question may be asked, how long before examination a given bone was
fractured. As a rule, we can only say as to whether the injured person
has lived a long or short period since the injury, as the process of
repair varies according to age and constitution. No changes occur until
eighteen to twenty-four hours, when lymph is exuded. According to
Villermé the callus is cartilaginous anywhere between the sixteenth
and twenty-fifth days, it becomes ossified between three weeks and
three months, and it takes six to eight months to become like normal
bone.
The question may also be asked: Has a bone ever been fractured?
The existence and situation of a fracture can often be recognized
long after the accident, by the callus or slight unevenness due to
projection of the edges or ends of the fragments. Where the bone lies
deeply covered by soft parts, it is difficult and often impossible to
tell, long after union has taken place, whether or where a fracture has
occurred.
The answering of this question may sometimes be of importance in
identifying the dead, especially in the case of skeletons. In the
latter instance by sawing the bone longitudinally we can tell by the
thickness, irregularity, or structure of the bone tissue whether a
fracture existed, and if it were recent or old at the time of death.
=Dislocations= call for a medico-legal investigation less often than
fractures. They are less common in the old and where the bones are
brittle, when fracture occurs more readily. They are seldom fatal _per
se_, unless between the vertebræ or when compound. They may occur from
disease in the affected joint or even spontaneously. The diagnosis of
a dislocation is easy until it has been reduced, and then it may leave
no trace except pain in and limitation of the motion of a joint besides
swelling and ecchymosis. These effects are transient, and after they
have disappeared it may be impossible to say whether a dislocation has
existed on a living body, unless, as sometimes occurs, especially in
the shoulder joint, there may be a temporary or permanent paralysis
of a nerve and muscular atrophy. After death, the existence of an old
dislocation may often be recognized on dissection by scar tissue in and
about the capsule.
EXAMINATION AND DESCRIPTION.
The examination of wounds or injuries in a case which is or may become
the subject of a medico-legal investigation should be made with
particular care and exactness.
As the examination of the wounded person is to give most, and in some
cases all, the information to the medical expert on which he is
to base his testimony, it should be made with reference to all the
possibilities of the case.
The particular variety of wound as described in the foregoing section
should be noted, and any peculiarities as to its situation, shape,
extent, length, breadth, depth, direction, and the parts involved.
Besides these points, the condition of the edges of the wound, whether
swollen and ecchymotic, smooth and straight or dentated and irregular,
and whether inverted or everted and gaping, are matters of importance.
The presence or absence of coagula and clots, the staining of the
tissues with blood, the presence of ecchymosis and its comparative age,
as shown by its color, should also be noted.
Many of the above points help us in solving another problem, namely,
the form of the instrument used. This question will be discussed
in a subsequent section, but the basis for our opinion is founded,
of course, on an examination of the particulars of the wound. The
solution of still another question which often arises and which will
be discussed in the next section, namely, whether a wound was produced
before or after death, is based upon particular features of the wound
such as the fluid or clotted condition of the blood on the surface,
or ecchymosed in the tissues, also the amount of the hemorrhage as
compared to the vascularity of the part as well as the greater or less
staining of the tissues with blood, and the conditions of the edges,
whether inverted or everted and whether or not retracted. The question
as to whether a wound was directly, secondary or necessarily the cause
of death, is determined, in part at least, by examination of the wound.
In this connection we take note as to whether a wound has opened or
divided a large vein or artery or is situated in such a vascular part
as to be fatal from hemorrhage. We also note whether death could have
been due to shock from the situation of the wound, or whether an
inflammation which was directly responsible for death was necessarily
due to the wound, as in case of a penetrating wound of the viscera,
etc. Further, we note whether one of the many forms of wound diseases
from infection of the wound has complicated the case and caused death
in the case of a wound not otherwise necessarily fatal. It may be added
that often the necropsy aids us in the solution of the question as to
whether the wound was the necessary and direct cause of death, by
showing a healthy or diseased condition of the viscera.
The question as to which of a number of injuries was first inflicted,
also as to the relative position of the victim and assailant, can be
answered, if at all, only by an accurate and close examination of the
wounds.
Finally, the most important question of all, from a medico-legal
standpoint, namely, the distinction between homicidal, suicidal, and
accidental wounds, is decided or inferred from the characteristics of
the wound after careful examination.
All the foregoing questions contribute to the solution of this the
most important one. The various questions referred to above will be
considered at greater length in the subsequent sections. They have been
merely referred to in brief above, to show the various lines of thought
a medical examiner must have in mind in making an examination.
As to the act of examination itself, the physician should conduct
it in such a way as not to harm the wounded person. Often simple
inspection is the most that can be done, or the examination may have
to be deferred altogether until the physician in charge informs the
court that an examination may be safely made. It is often necessary
for the expert to get information as to the original lesion from the
physician in charge. If the wound has been a fatal one and if we are
called in after death, we may examine the wound on the dead body with
much more freedom. Here we may examine the depth, direction, etc., of a
punctured wound by cutting down on a probe or director. After careful
inspection of the wound we may examine it by palpation, and go on to
the dissection of the wound and the surrounding parts, tracing and
noting the various vessels, muscles, etc., involved in the wound, and
looking for the presence of any foreign body in the wound.
Furthermore, if the cause of death be at all obscure, we should examine
not only the wound itself and the parts about the wound, but also, by
an autopsy, all the cavities and organs of the body. For death may have
been due to natural causes in an organ not examined, if the examination
has not included all, and the physician has to disprove it.
In examining at an autopsy the depth of a wound in reference to the
instrument which caused it, it should be borne in mind that the wound
may be deeper than the weapon owing to a depression of the surface by
the handle of the weapon. This may appear especially marked in the case
of the movable viscera, as at the time of the accident the viscus may
have been as near as possible to the surface, and at the examination as
far as possible from the surface, as in the case of a given coil of the
intestines. Also the thorax when opened at autopsy enlarges or expands
a little, so that the measured depth of a wound may be greater than the
weapon which caused it. Vibert[612] mentions a case of a penetrating
wound of the thorax involving the heart, where the measured depth of
the wound was 0ᵐ.035 greater than the length of the instrument. This
may also be accounted for by a depression or flattening of the thorax
by the blow, as in the case of soft parts. It is often difficult in an
examination to measure accurately the depth of a wound, for one may
find it hard to determine the precise end of a wound. Also, for exact
measurement it is necessary to have the parts in the same position as
at the time of the accident, and these parts are more or less displaced
by the necessary dissection.
Besides the examination of the wound there are other points the
examination of which may aid us in solving the problems presented by a
case. Among these, the examination of the clothing or dress is perhaps
the most important. This may indicate the weapon used in an incised or
punctured wound. Contused and lacerated wounds or fractures, etc., may
be produced without injuring the clothing. Blood, dirt, or grease on
the clothing may throw light on the case. In self-inflicted wounds the
wound in the clothing and that on the body may not and often do not
correspond, as an intending suicide often (a murderer rarely) opens
the clothing to select the spot for the wound. The wound in the dress
is then added by a second blow not corresponding to the first. In this
way we may sometimes distinguish between a homicidal and suicidal
wound, and thus remove a false suspicion of murder or show that a wound
was self-inflicted to conceal other crimes or to falsely impute it to
another. The suspicion of homicide in accidental wounds may be cleared
up by an examination of the dress, as in the following instance related
by Taylor:[613]
A woman was found dead in bed with two indentations about the middle
of the right parietal bone, a large superficial clot here and three
ounces of clotted blood between the dura mater and skull, which latter
was fractured over an area of four inches. No other cause of death was
found. The evidence brought out the facts that she had been knocked
down the evening before, about 7:30 o’clock, by a man accidentally
running into her. She fell on the back of the head, was stunned, raised
up, and stimulated; she then walked home, ate her supper, and was
last seen at 9 o’clock by a fellow-lodger who let her in and noticed
nothing unusual. The next morning she had evidently been dead some
time. Suspicion fell upon the lodger, who had often quarrelled with
her, and the two claws of a hammer found in his room corresponded more
or less closely with the two indentations found in the skull. At the
adjourned inquest, however, the _bonnet_ worn by the deceased at the
time of the accident was found to have two indentations on the back of
it corresponding to those on the woman’s skull and containing dust and
dirt, and rendering probable what from the history seemed unlikely,
that the fall in the road caused the fatal injury. The examination of
the dress thus avoided an unjust accusation of murder.
Contused and lacerated wounds and fractures or dislocations may be
produced without injury to the dress, especially if the latter be
elastic or yielding. The comparison of the wound in the clothes with
that on the body may indicate the position of the body at the time of
the blow. The examination of the clothes of the injured person may
indicate a struggle which would support the idea of homicide. A blunt
instrument may indirectly cause an injury by striking something in or
on a person’s clothes. Instances have been reported where a wound has
been caused by an article in the pocket, or worn outside the clothing,
without any trace of an injury to the clothes or pocket lining.[614]
The examination of the dress may further show which of several cuts or
stabs was first inflicted. This is shown by the staining of the edges
of the cuts in the clothing, the edges of the first cut or stab showing
no blood-stain or only on the inner surface, as the knife is clean
of blood on entering and all that is removed by the clothing on its
withdrawal is found on the inner edges. If the edges of the cuts in the
outer layers of clothing are bloody, it is evident that the knife was
already bloody when used, and the corresponding wound was not the first
inflicted.
The imprint of the bloody hand of the assailant may sometimes be found
on the clothing of the one injured, and is especially important as
evidence, when the hands of the assaulted are not bloody. In the case
of a severe wound, especially if it is likely to become the object of a
criminal investigation, the physician should always require to see the
dress of the wounded. The examination of the clothing which the accused
wore at the time the assault took place may give important evidence by
showing evidences of a struggle or blood-stains. Absence of the latter
would not prove the innocence of the accused, as the clothes actually
worn may be destroyed and others substituted, or the marks and stains
may be removed. In the latter case, the eye of a medical man may detect
traces of blood which otherwise would go unnoticed, and a microscopical
and chemical examination would reveal the real character of the stain.
Besides the examination of the clothing of the accused, the examination
of his person may furnish evidence of his being engaged in a more or
less desperate struggle by the scratches, marks of nails, contusions,
bites, etc., on the face, neck, front of chest, forearms, and hands.
If the accused should attempt to explain these wounds and spots, the
latter may or may not verify the explanation, and thus additional
evidence may be obtained as to the guilt or innocence of the accused.
It is well for the medical expert, as well as for others, to collect
the statements of the wounded person relative to the circumstances of
the injury. Also, if the accused will vouchsafe any such statements we
may compare these with one another and with the facts indicated by the
wound, etc.
Other points to examine, especially in cases of suspected suicide,
may be briefly mentioned. The presence of the weapon in the hand of
the victim and firmly grasped in general indicates suicide, if it
corresponds to the weapon causing the wounds, for otherwise it may
have been used for defence. If not in the hand, note the spot where
the weapon was found. In the case of a suicide, the hand as well as
the weapon held by it is likely to be bloody, also in case of murder
the generally empty hand is apt to be bloody, as the hand is naturally
carried to the wound.
We cannot further describe the many points which the medical examiner
should bear in mind in making an examination in a medico-legal case,
without repeating too fully what will be given at greater length in
subsequent sections, reference to which should be made for further
particulars. Tardieu proposed as a basis for examining and studying
wounds, (1) to visit the wounded person and see what state he is in,
and to determine (2) the nature, (3) the cause, (4) the consequences
of the wound. Also if the wounded person is dead (5) to examine the
body for the cause of death in order to see if the latter is due to the
wound. Also (6) to determine the circumstances of the affray.
=The description= of a wound should be given in plain language,
avoiding the use of scientific terms or expressions, so as to be
readily understood by judge and jurors. Otherwise the usefulness of the
medical expert is very much decreased. The description should also be
precise and sufficient to justify the conclusions arrived at as to the
cause of a wound, its gravity and results, and the weapon used. With
a view to exact statement in description, it is well to take notes as
to the result of the examination and not depend merely on memory. The
object of the witness should be to be understood and not to be thought
thoroughly scientific.
WAS THE INJURY INFLICTED BEFORE OR AFTER DEATH?
This is a question which may often be asked in cases of fatal injuries,
and it is one which must be answered as definitely as we are able, for
the defence may rest on the assertion that the wound or injury was post
mortem and not ante mortem. What are the means we have to enable us to
answer the above question? The most important factor is the condition
of the blood and the changes that it undergoes after death. For some
hours after death the body retains its animal heat. As long as this is
retained rigor mortis does not set in and the blood is more or less
fluid. This period varies, but on the average it does not last longer
than eight or ten hours. Before this time, however, the blood has begun
to undergo certain changes. These changes result in the inability of
the blood from a post-mortem wound to coagulate completely. At first
the greater part may coagulate, but after a time coagulation is less
and less complete, and the coagula are not as firm as those from the
blood of a living person. The period at which these changes occur also
varies, but they may generally be clearly noticed in from three to four
hours after death, or even sooner. In the first two to four hours after
death, therefore, as far as the condition of the blood is concerned, it
may be difficult or impossible to say whether a wound was made before
or soon after death. In other words, this difficulty exists as long as
the tissues of the body live after the body as a whole is dead.
There are certain general pathological or occasional conditions of the
body in which the blood during life does not coagulate at all or only
imperfectly, as in scurvy and in the case of the menstrual blood. Also
blood in a serous cavity, especially if it be abundant or there exists
inflammation, is found not to coagulate or only imperfectly. Post
mortem the blood remains liquid long after death in cases of death by
drowning, asphyxia, etc., and in such cases hemorrhage may be free in a
wound made some time after death. Furthermore, after putrefaction has
set in the blood again becomes more or less liquid, and may flow away
from a wound like a hemorrhage, but it no longer coagulates.
The principal signs of a wound inflicted during life are (1)
hemorrhage, (2) coagulation of the blood, (3) eversion of the lips of
the wound, and (4) retraction of its sides.
1. HEMORRHAGE varies in amount with the size of the wound, the
vascularity of the part, and the number and size of the large vessels
involved. In incised or punctured wounds the amount, as a rule, is
quite considerable. If there is a free exit most of the blood runs
off; the rest stays in the wound, where it soon coagulates with the
exceptions mentioned above. But besides partly filling the wound in
the form of a clot, the edges of the wound are deeply stained with
the coloring matter of the blood, and this stain cannot be removed by
washing. This staining involves especially the muscular and cellular
tissues.
Further, a hemorrhage during life is an active and not a passive one;
the blood is forced into the interspaces of the tissues in the vicinity
of the wound, and is found infiltrated in the cellular tissue, the
muscles, the sheaths of the vessels, etc. It is here incorporated,
as it were, with the tissues so that it cannot be washed away. In an
ante-mortem wound the arterial nature of the hemorrhage may show by
the marks of the jets of blood about the wound or on the clothes or
surrounding objects. When a large vessel has been divided and the
exit for the blood is free, this may run off without infiltrating the
tissues or even staining the edges to any considerable extent, and
there may remain but little in the wound. In the case of lacerated and
contused wounds the amount of hemorrhage is less, but rarely fails
entirely, and if the wound is in a vascular part it is liable to cause
death from hemorrhage, though a whole limb may possibly be torn off
without much hemorrhage. In the latter case, however, there are usually
found clots of blood adhering to the edges of the lacerated wound
and the ends of the vessels. In contusions where there is no wound
of the skin the blood is prevented from flowing externally, and its
accumulation and distribution form an ecchymosis. Here again we see the
active power of the hemorrhage which infiltrates between the tissues,
stains them deeply, and appears either as a mere stain or in fine
clots incorporated, as it were, with the tissues or partly occupying a
cavity formed by an extensive displacement of the surrounding parts.
The amount of blood varies under the same conditions as in incised
wounds, and also according to the greater or less disintegration of
the tissues by the blow, allowing a larger or smaller central cavity
to be formed. In “bleeders” the amount of the hemorrhage does not
vary under the normal conditions, but a fatal hemorrhage may occur
from a very insignificant wound. After hemorrhage from a wound made
during life the veins are empty about the wound, especially those
situated centripetally, while normally after death the blood is mostly
aggregated in the veins. They are the source of post-mortem hemorrhage,
but do not empty themselves to any great extent.
The _hemorrhage from a wound made after death_ may be extensive if
the blood remains fluid as in the cases mentioned above, _i.e._,
after death from drowning or asphyxia or after the commencement of
putrefaction. Otherwise the amount of hemorrhage decreases with the
length of time after death, until the blood loses its fluidity and
hemorrhage no longer occurs. In general, it is slight unless a large
vein is opened, for the veins are the source of the hemorrhage. There
is usually scarcely any hemorrhage after the first two to four hours.
This applies also to subcutaneous hemorrhages or ecchymoses. These
post-mortem hemorrhages are passive and not active, consequently there
is less infiltration of blood into the surrounding tissues, which
merely imbibe it, and the stain is less deep and may be washed off the
edges of the wound, in contrast to the stain of ante-mortem wounds.
After putrefaction has set in the hemorrhage may be more abundant,
as the blood is driven to the surface by the formation of gas in the
abdomen and thorax. At the same time, the coloring matter of the blood
transudes through the walls of the veins and is imbibed by and stains
the tissues, so that it may be impossible to distinguish it from a true
ecchymosis. Fortunately these conditions are of small moment, as an
examination is seldom deferred so long.
CADAVERIC ECCHYMOSES show almost invariably while the body is still
warm and the blood more or less liquid, _i.e._, during the first eight
or ten hours after death. They are not due to injury or violence before
or after death, but they may closely resemble ecchymoses produced on
the living body and be mistaken for them. This is the more important as
they are quite constant on the cadaver.
In this connection, it may be said that an ecchymosis due to a blow
before death may not show till after death, as it requires some time
for a deep ecchymosis or even an ecchymosis covered by a thick layer
of skin to show superficially. Thus a man kicked in the abdomen died
thirty-five hours after the injury from peritonitis, due to a rupture
of the bladder. No ecchymosis appeared at the site of the injuries
until after death. It is not uncommon in cases of hanging to observe
an ecchymosis along the course of the cord appearing only after death.
Huize met with a case of this description. Devergie remarked that on
the bodies of those drowned ecchymoses are often hidden for a time on
account of the sodden state of the skin, and they appear only after
the water has evaporated, which may require some days. Furthermore,
it is not necessary to survive long after an injury in order that an
ecchymosis may show post mortem. If the blood is fluid at the time of
the blow and any capillaries or larger blood-vessels are torn, then we
may have an ecchymosis though death be almost instant. Casper thought
that it required some time before death for an ecchymosis to develop,
and that if the person injured by a contusion died soon after the
injury, an ecchymosis would not appear after death. There are many
well-authenticated cases to prove that Casper’s opinion is wrong. Among
the most famous of these is that of the Duchesse de Praslin.[615] She
was attacked and killed by her husband while she was asleep in bed.
The thirty or so wounds showed a mortal conflict, and she could not
have survived more than one-half hour, and yet after death there were
numerous ecchymoses from the contusions.
Another case is also mentioned by Taylor.[616] A young man died
suddenly after a blow from a companion, having been struck in the side
a fortnight before by a heavy box, which knocked him senseless and
nearly killed him. The post mortem revealed an ecchymosis on the side
which on the authority of Casper’s opinion was attributed to the old
injury. The color of the ecchymosis would be sufficient to settle all
such doubts, as the changes of color would have fully developed or the
color even disappeared in part in fourteen days’ time.
An ecchymosis made post mortem does not undergo the color changes
seen in ecchymoses during life, unless the tissues are œdematous in
which the ecchymosis occurs. These changes in color have already been
described, the deep blue changing to violet in eighteen to twenty-four
hours at the earliest. In support of the foregoing and disproving
Casper’s views, Christison found that within two hours after death
severe blows on a dead body are followed by a livid discoloration,
similar to those produced by a blow shortly before death. This livid
discoloration is due to the effusion of a very thin layer of blood
external or superficial to the true skin, sometimes in a stratum of
the true skin or more rarely into the cellular tissue, staining deeply
the partition walls of the fat-cells. Of course, a more or less recent
contusion or ecchymosis on a dead body was not necessarily produced at
the same time as the cause of death. It should be borne in mind in
this connection that ecchymosis is not a necessary result of a blow or
contusion.
According to Devergie, ecchymosis does not appear when a blow inflicted
post mortem is received by skin directly covering a bony surface
beneath, and rarely appears where there is a large amount of fat and no
solid point of resistance beneath the site of the blow.
We have already referred to the fact which Portal long ago remarked,
namely, that the spleen has been ruptured without ecchymosis or
abrasion of the skin. The same absence of ecchymosis has been noticed
in cases where the liver, stomach, intestines, bladder, etc., have been
ruptured as the result of contusing blows.
The following case cited by Taylor[617] illustrates this point. Henke
reported the case of a man who died of peritonitis a few hours after
fighting with another man. There was no mark on the skin or ecchymosis,
though there existed peritonitis from rupture of the small intestine.
The blow was proven by direct evidence, and though some medical
witnesses on account of the absence of external signs thought that no
blow could have been struck, others of more experience admitted that it
could have been the cause of the rupture.
Watson[618] reports a similar case of a girl nine years old who
received a blow from a shoe on the abdomen. This was followed by great
pain, collapse and death in twenty-one hours. No marks of injury were
visible externally, but peritonitis existed from rupture of the ileum.
A similar case is reported by Williamson,[619] where peritonitis
resulted from complete rupture of the ileum without any trace of injury
externally, though the blow was struck by the hoof of a horse.
Another case was brought into Guy’s Hospital[620] who had been run over
by an omnibus. No injury was discoverable, though the wheel had passed
over the chest and abdomen. He died of peritonitis, however, which set
in on the second day, and on post-mortem examination the liver and
small intestines were found ruptured.
Christison thought as the result of his experiments and experience
that the most reliable signs of an ecchymosis made during life, and
distinguishing it from one caused by a blow after death, were as
follows: The skin of the ecchymosed area is generally much darkened and
discolored from blood infiltrated through its entire thickness; the
skin is also much firmer and more elastic from swelling of the part if
the contusion is received some hours before death. But we may have an
effusion beneath and not in the substance of the skin, and the above
signs might possibly be due to an injury inflicted only a few minutes
after death. The above signs may therefore be absent, and when present
are not absolutely indicative of an injury received during life. In
general, the effects of severe contusions inflicted soon after death
may closely resemble those of slight contusions received during life.
There is little danger of contusion if the blow be inflicted on a dead
body after the loss of body heat and the beginning of rigor mortis.
2. COAGULATION OF BLOOD.—As stated at the beginning of this section,
blood from a wound inflicted during life coagulates with the exception
of that from those suffering from certain pathological or occasional
conditions or in certain locations, already mentioned. This coagulation
is not immediate, but is complete in about five minutes. The entire
amount of blood lost is thus coagulated and the coagula are firm. These
coagula (if the wound is not interfered with) occur in the opening of a
wound and on its edges, especially at the mouths of the blood-vessels,
which are thus plugged. The blood which infiltrates the interspaces of
the tissues is coagulated in the form of these interspaces. The same is
true of the blood of an ecchymosis whether there be a hematoma or only
an infiltration between the tissues, or both. These clots represent
more or less the form of the space occupied by the blood. In the case
of the scalp a subcutaneous clot may be mistaken for a depressed
fracture of the skull from the fact that the edges of the clot become
very hard while the centre is still quite soft. A wound in which a
large artery has been divided may present very little clotting in the
wound if the opening is free and the blood has mostly escaped in a jet.
In a wound produced soon after death there may be some clotting,
but less in amount, firstly, because there is less hemorrhage, and,
secondly, because not all the blood clots. These conditions increase
with the length of time after death, so that after a time a wound made
on a cadaver would show very little if any clotting owing to very
slight hemorrhage, and little or no clotting of the blood extravasated.
When the body has lost its animal heat and rigor mortis has begun to
set in, then there is no more coagulation of the blood and no more
hemorrhage, under normal conditions, for the blood has mostly become
clotted in the vessels of the body. Consequently, with the exception
of wounds inflicted very soon after death, we can distinguish an
ante-mortem from a post-mortem wound by the condition in which the
blood is clotted. If there is any hemorrhage, the wound being inflicted
before the loss of animal heat and the blood remains entirely fluid on
the surface or in an ecchymosis, we know that the wound was produced
after death and some hours after death unless any of those conditions
exist in which the blood does not normally coagulate. If the hemorrhage
is slight or quite moderate in amount and venous in character, if the
blood is only clotted in part and the clots are rather soft and do
not form a plug at the mouth of each artery, and especially if the
staining of the walls of the wound can be washed off, then the wound
was probably produced post mortem, but not so long after death as in
the first case supposed. If the characters of the hemorrhage and the
clotting are still more like those normal to a wound inflicted during
life, then, as a rule, it is impossible to say from these two features
of the wound, hemorrhage and clotting, whether the wound was inflicted
during life or a very short time after death.
3. EVERSION OF THE LIPS OF THE WOUND.—The edges or lips of a wound
inflicted during life may be inverted, instead of everted, if a thin
layer of muscular fibres is attached directly to the deep surface of
the skin, as is the case in the scrotum. The eversion of the edges of
the skin is due to their elasticity, and ceases to occur as soon as the
skin loses its vitality. Consequently eversion ceases to occur soon
after death, within a very few hours. A wound in which the edges are
neither inverted or everted was therefore inflicted after death. If
this sign is present and marked, the wound was inflicted during life or
within two or three hours or less after death. If this sign is present
but very slightly marked, the wound may have been made even somewhat
longer after death.
4. RETRACTION OF THE SIDES OF THE WOUND is also dependent on their
vitality and ceases to occur when this is lost a few hours after death.
In the retraction of the edges of the wound we have all the parts
involved, but unequally. The muscles, arteries, skin, and layers of
connective tissue all retract, varying in the degree of retraction
according to the order in which they are named. In different parts
of the body this comparative order of retraction is liable to more
or less variation. Every surgeon is familiar with this retraction
of the tissues, which necessitates certain rules in the technique
of operations, especially of amputations. Muscles retract the more
the longer they are and the farther the incision is made from their
attachment. Without specifying a definite time, we may say that, as
a rule, this retraction lasts no longer than about two hours after
death, consequently when it is absent we may infer that the wound was
inflicted two hours or more after death. The amount of retraction grows
less and less after death for about two hours, after which it is very
slight if it occurs at all, owing to the loss of elasticity of the
tissues. This sign is especially useful in the case of a mutilated
body where, by examining the degree of retraction of the muscles, we
may infer whether the mutilation was done before or after death. The
sides of a cut made on the cadaver are comparatively smooth and even,
owing to the absence of the unequal retraction of the various elements,
which makes the surfaces of a gaping ante-mortem wound uneven and
irregular. Relying on these circumstances in the “affaire Ramus,” cited
by Vibert,[621] one was able to recognize the order in which the body
had been mutilated.
OTHER MINOR SIGNS of a wound inflicted during life may be briefly
mentioned. If the edges of the wound are swollen, or show signs of
inflammation or gangrene, or if pus or adhesive material is present on
the edges of the wound, we may infer that the wound was inflicted some
little time before death. Of course, if cicatrization has commenced,
some days must have elapsed before death after the wound was received.
If the blow causing a contusion was inflicted some time before death,
there will be more or less of a general swelling of the region, partly
due to the blood effused, but also partly due to œdema.
It is not always easy to say whether a _fracture_ was produced while
the body was living or dead. If the body was still warm when a
post-mortem fracture was produced there is little difference from an
ante-mortem fracture, except that there may be a little less blood
effused. In a fracture produced after rigor mortis has set in there
is little or no blood effused. In the case of fractures the presence
of callus, indicating the process of repair, shows that the accident
occurred during life, and, as we have already seen, we may form some
idea of the length of time elapsed between the injury and the time of
death. On the cadaver it is said to be harder to cause fractures and
lesions of the skin than on the living body. Casper says that fractures
of the hyoid bone and the larynx are impossible after death, and he
also was not able to rupture the liver or spleen.
In distinction to the characteristic signs of a wound inflicted during
life, we may mention briefly some of the signs of post-mortem wounds
when the wound has been inflicted from two to ten or twelve hours or
more after death:
(1) The hemorrhage is slight in amount and may fail altogether.
(2) The character of the hemorrhage is venous, corresponding to the
source of the hemorrhage from the veins, the arteries being nearly
empty after death.
(3) The edges of the wound are not deeply stained, and this staining
may be removed by washing. The spaces between the tissues are not
infiltrated with blood.
(4) The blood remains either entirely fluid or, if there are clots,
these are _softer_ than those in an ante-mortem wound, and only a
portion of the blood is thus clotted. There are no clots plugging the
open mouths of the arteries on the surface of the wound; the veins may
or may not be closed by an imperfect clot.
(5) The skin of the edges is not everted or inverted.
(6) The sides of the wound do not gape and their surfaces are smooth
and even, as the tissues are not unevenly retracted.
RÉSUMÉ.—It is very easy from the foregoing to distinguish between a
wound inflicted before death and one ten or twelve hours after death.
If the hemorrhage has been abundant and arterial, if it has infiltrated
between and deeply stained the tissues and the stain cannot readily
be washed off; if the blood coagulates completely and the coagula
are firm and are found lying in the wound, plugging the vessels, and
incorporated with the tissues between which they lie; if the edges
of the skin are everted and the sides of the wound are retracted and
uneven—under these circumstances, we may be sure that the wound
was inflicted during life or a very short time after death. If, on
the contrary, the hemorrhage is slight in amount or almost fails
altogether; if it is venous in character; if the edges of the wound
are only stained by imbibition of the blood, which is not infiltrated
between the tissues, and the stain may be washed off; if the blood is
not at all or only slightly clotted and the clots are soft; if the skin
is not everted and the sides of the wound are smooth and lie nearly in
contact; if there are no clots plugging the divided arteries on the
surface—then we need have little hesitancy in saying that the wound
was produced after death, but probably not later than ten or twelve
hours after death. If the wound was inflicted still longer after death
and before putrefaction, then we would have a lack of the signs due
to hemorrhage, clots, staining, etc. If we find the conditions more
or less midway between the first two, we may be left in some doubt as
to the date of the injury. Thus if the hemorrhage is moderate, the
blood mostly but not altogether clotted and the clots moderately firm,
the skin slightly everted, and the sides slightly separated and not
altogether smooth on their surface; if the surfaces are fairly deeply
stained and the stain cannot be easily washed off—then we can only
say that the wound was inflicted during life or within two hours or
so after death, and this fact is often enough for the purposes of the
medico-legal inquiry.
The same is the case with contusions where there is no bleeding
externally. If we have a bluish, violet, green, or yellow tumor with or
without more or less superficial œdema; if this tumor fluctuates or is
hard, but in either case is elastic; if on incision the skin and the
tissue spaces are infiltrated with blood which is coagulated, or if
there is a cavity filled with clotted blood, the coagulum being firm
and the entire amount of blood coagulated—then the wound was inflicted
during life. If, however, the surface shows a bluish or violet color,
little or no swelling of the skin, which is of natural thickness, and
the ecchymosed area is not tense and elastic to the touch; if further
the blood is found on incision to be fluid or if coagulated only partly
so, and the blood is not infiltrated into the tissue spaces, but merely
imbibed by the tissues—then the blow was inflicted after death, and
probably more than two or three hours after.
In contusions especially we may have difficulty, as the sign of
fluidity of the blood may fail and putrefaction may modify the
conditions of the wound unless parts deep beneath the surface be
examined.
We see, then, that in some cases it is very easy to say that a wound
was inflicted post mortem. If a wound was not inflicted until ten or
twelve hours after death or even sooner, we cannot easily mistake it.
But in many cases it may be hard or impossible to say whether a wound
was inflicted during life or within an hour or two after death. Here
we must be cautious in expressing an opinion which should be guarded.
But we should remember that it is important to be able to state that a
wound was inflicted before or immediately after death, as no one but a
murderer would think of inflicting a fatal injury on a body immediately
after death. In such cases a well-guarded medical opinion may often
meet all the requirements of the case.
Granted that a given wound was produced before death. There are, then,
one or two questions which may arise, and which depend for their
answer on the length of time the wounded person could have lived and
the physiological or muscular acts which he could have performed after
receiving the injury and before death. The first of these questions may
be expressed as follows:
COULD THE VICTIM HAVE PERFORMED CERTAIN ACTS AFTER HAVING RECEIVED HIS
FATAL INJURY? The term “certain acts” here refers to almost any thing
or things which would require time and strength—in other words, the
continuance of life with bodily and mental powers for a certain time
after receiving a mortal injury.
This question may be raised in relation to an attempted alibi of the
accused, who may have been proved to be in the presence of the victim
a moment before death. If after this moment the victim has moved
from the spot or performed certain acts before death, the attempted
alibi may depend upon the answer to the question as to whether the
given acts of the victim were compatible with the fatal character of
the wound. An alibi can aid in the acquittal of the accused only when
the nature of the injury was such that death would be supposed to be
immediate or nearly so. Great care should be taken on the part of
the medical witness in answering this question, for after very grave
wounds, proving speedily fatal, the victim sometimes can do certain
acts requiring more or less prolonged effort, as shown by numerous
examples. Wounds of the brain are especially noticeable in allowing
a survival of several hours, days, or even weeks, during which time
the injured person may pursue his occupations. Where the survival
has lasted days or weeks, the alibi has no importance, but not if
the survival is of shorter duration. The following case is cited by
Vibert[1] and may be mentioned in this connection, though the wound
was caused by a bullet which traversed from behind forward the entire
left lobe of the brain. After the injury the victim was seen by
several witnesses to climb a ladder, though with difficulty, for he
had right-sided hemiplegia. He was found insensible more than half a
mile away, and did not die until six or eight hours after the injury.
Severe injury of important organs is sometimes not incompatible with
an unexpectedly long survival. Devergie cites two illustrations of
this which are quoted by Vibert.[622] A man received several extensive
fractures of the skull, with abundant subdural hemorrhage, and rupture
of the diaphragm with hernia of the stomach. The stomach was ruptured,
and nearly a litre of its contents was contained in the left pleural
cavity. Notwithstanding all this, he was able to walk about for an hour
or so and answer several questions. He died only after several hours.
Another man, crushed by a carriage, received a large rupture of the
diaphragm, complete rupture of the jejunum, and rupture and crushing of
one kidney. Yet he walked nearly five miles, and did not die until the
next day.
More rarely wounds of the great vessels are not immediately fatal.
M. Tourdes is quoted by Vibert[623] as citing the case of a man who
descended a flight of stairs and took several steps after division
of the carotid artery; also of one who lived ten minutes after a
bullet-wound of the inferior vena-cava.
Even wounds of the heart are not as speedily fatal as is commonly
supposed, and often permit of a comparatively long survival.
Fischer[624] found only 104 cases of immediate death among 452 cases
of wounds of the heart, and healing occurred in 50 cases among 401.
Vibert[625] mentions two striking cases of long survival after wounds
of the heart. A woman received a stab-wound which perforated the
right ventricle, causing a wound one centimetre long. She did not die
until twelve days later, when on autopsy there was found an enormous
extravasation of blood in the left pleural cavity and pericardium. The
second case, though one of bullet-wound, is equally applicable and
instructive in this connection. A man received a bullet-wound which
perforated the left ventricle, the bullet being found later in the
pericardium. After being wounded he threw a lamp at his assassin which
set fire to the room. He then went into the court-yard, drew some
water, carried it back in a bucket, extinguished the fire, and then lay
down on his bed and died.
In studying the wounds of different regions of the body, we may find
many other mortal wounds which, though speedily fatal, leave the
possibility of more or less activity before death. We see, therefore,
that even in those wounds which are commonly supposed to be immediately
fatal, even by many medical men where attention has not been called to
the exceptions, such exceptional cases are not uncommon in which death
is not immediate. Time and even strength may thus be allowed for more
or less complicated activity. An alibi cannot, therefore, be allowed
without question on the part of the medical expert, who must exercise
great caution in expressing an opinion. The second question which may
sometimes arise in connection with the last, but having little to do
with the subject of this section, is the following:
HOW LONG BEFORE DEATH HAD THE DECEASED ACCOMPLISHED CERTAIN
PHYSIOLOGICAL ACTS? For instance, how long after a meal did he die?
This is hard to answer with precision, as digestion varies with the
individual, and digestion begun during life may go on to a certain
extent after death. We may be able to say if digestion has just
commenced, is well advanced, or has terminated. What was eaten at the
last meal may be learned by the naked eye, the microscope, the color of
stomach contents and their odor. The state of the bladder and rectum is
sometimes called in question. All the above facts have less bearing on
the case than those in relation to the former question.
THE CAUSE OF DEATH FROM WOUNDS.
The cause of death should be certain and definite. In reality, there is
only one real cause, though one or many circumstances may be accessory
causes. In most cases of death from the class of wounds which we have
been considering, there is no difficulty in determining the cause of
death so as to be able to state it definitely. But if the deceased had
recovered from the first effects of the wound and then died, or if
death seems as much due to disease as to injury, then the _real_ cause
of death may be obscure. If the medical witness is in doubt as to which
of two causes was the primary cause of death the doubt should be stated
at once, as it may weaken the testimony if brought out later.
Wounds may be directly or indirectly fatal. They are directly fatal if
the victim dies at once or very soon after the wound, with no other
cause internally in his body or externally from his environment. Wounds
are indirectly or secondarily fatal if the injured person dies from a
wound disease or complication, the direct consequence of the wound,
or from a surgical operation necessary in the treatment of the case.
Wounds may also be necessarily fatal either directly or secondarily,
or not necessarily fatal. In the latter case death may be due as
much, if not more, to other causes than the wound, and sometimes not
at all to the wound itself. Thus death may be due to natural causes,
latent disease, an unhealthy state of the body, imprudence or neglect
of treatment, or improper treatment, etc. These various degrees of
responsibility of a wound as the cause of death we will now consider
more at length.
I. WAS THE WOUND THE CAUSE OF DEATH DIRECTLY?
If so, it must have caused death in one of the following ways:
1. =Hemorrhage.=—This may act by producing syncope. But the amount of
the hemorrhage may not be sufficient for this result, and still cause
death by disturbing the function of the organ into which it is effused,
as in the brain or in the pleural or pericardial cavities. The blood
here acts mechanically. Blood in the trachea may also kill mechanically
by causing asphyxia.
The _amount_ of hemorrhage required to produce syncope varies under a
variety of circumstances. Less is required in the very young, the aged,
and the diseased, also less in women than in men. Young infants may
die from hemorrhage from very slight wounds, even from the application
of a leech or the lancing of the gums. A sudden loss of blood is much
more serious than an equal amount lost slowly. This is the reason that
the wound of an artery is more serious and more rapidly fatal than
a similar loss of blood from other sources. It is hard to specify
the absolute quantity which must be lost in order to cause death by
syncope. The total blood in the body is about one-thirteenth of the
weight of the body, making the total amount of blood weigh about twelve
pounds. Of this, about one-fourth is in the heart, lungs, and large
blood-vessels. According to Watson, the loss of an amount varying from
five to eight pounds is enough to be fatal to an adult. But less is
enough to prove fatal in many cases, as the rapidity of the loss of
blood and the age, sex, and bodily condition of the wounded person
affect the amount necessary. Though death from a small artery is
slower than that from a large one, yet it may occur in time, as shown
in the instance quoted by Taylor,[626] where a man bled to death in
thirty-eight hours from the wound of an intercostal artery. Thus, too,
a wound of the branches of the external carotid artery is often enough
to cause death, and a wound in a vascular part may cause death from
hemorrhage, though no vessel of any size be divided.
INTERNAL HEMORRHAGE may be fatal from mechanical interference with the
function of an organ, as well as from syncope. Thus we may have death
from syncope due to hemorrhage into the peritoneal cavity or, after
contusions, into the intercellular spaces and the cavity due to the
blow, into which several pounds of blood may be extravasated. Internal
hemorrhage is most fatal when due to the rupture of a viscus such as
the heart, lungs, liver, kidney. Taylor[627] cites a case of a man
run over and brought to Guy’s Hospital in November, 1864. He had pain
in the back, but there were no symptoms or marks of severe injury. He
left the hospital and walked home, where he was found dead in bed a few
hours later. His abdomen contained a large amount of blood from the
rupture of a kidney. After severe flagellation blood may be effused in
large quantity beneath the skin and between the muscles, which is just
as fatal as if it had flowed externally from a wound. In fact, if the
injuries are numerous the loss of much less blood is enough to prove
fatal, the element of shock here assisting that of hemorrhage.
_How are we to ascertain whether a person has died from hemorrhage?_
This may be more difficult in the case of an open wound, for the body
may have been moved from the spot where it lay after the wound was
received, and the blood on the body, clothes, and surrounding objects
may have been removed. Then the case may be presumptive only, but we
may arrive at a definite conclusion by attention to the following
points: If the wound was in a very vascular part and of some size, or
if a large vessel or many moderately large vessels were divided and
the vessels, especially the veins in the neighborhood, are empty, then
we may be quite sure of death from hemorrhage. If there is no disease
found which could be rapidly fatal the case is still stronger. The body
should be pallid after fatal hemorrhage, but the same may be the case
from death from other causes. In case the body and surrounding objects
have not been disturbed, then the amount of clotted blood in the wound,
on the body and clothes, and about the body, taken in connection with
the foregoing points, can leave no doubt. We should remember, however,
that not all the blood about the body was necessarily effused during
life, but a little hemorrhage may have occurred after death while the
body was still warm and the blood fluid, _i.e._, during the first four,
eight, or ten hours. But the amount thus lost is small. In cases of
death from internal hemorrhage we do not have so much difficulty in
pronouncing an opinion, as by post-mortem examination we can determine
the amount of the hemorrhage. We can judge, too, from its position,
whether it has acted mechanically to interfere with a vital function,
and has thus caused death, or whether the latter was due to syncope
from the quantity lost.
=2. Severe mechanical injury of a vital organ=, such as crushing of
the heart, lungs, brain, etc. This crushing may be accompanied by
hemorrhage, but death may be more immediate than the hemorrhage would
account for. The mechanical injury done to the vital centres in the
medulla by the act of pithing is the direct cause of the sudden death
which follows it. Exceptionally slight violence to a vital organ is
fatal, but this may be better explained by attributing it to shock.
=3. Shock.=—An injury is often apparently not enough to account for
the fatal result so speedily. The marks of external injury may fail
entirely or be very trifling. Thus more than once persons have died in
railway collisions with no external marks of violence. So, too, a blow
on the upper abdomen, on the “pit of the stomach,” has been rapidly
fatal without any visible injury to the viscera. Death is attributed to
the effect on the cardiac plexus, and there may be no marks externally
or only very superficial ones. In Reg. _v._ Slane and Others (Durham
Wint. Ass., 1872), quoted by Taylor,[628] the deceased was proved to
have sustained severe injuries to the abdomen by kicks, etc., but there
were no marks of bruises. All organs were found healthy on post-mortem
examination, but the injured man died in twenty minutes. Death was
attributed to shock and the prisoners were convicted of murder.
Death from concussion of the brain is another example of death from
shock. This may occur with only a bruise on the scalp and with no
intracranial hemorrhage or laceration of the brain. The medical witness
should be cautious in the above classes of cases in giving evidence, as
the defence may rely upon the absence of any visible signs of mortal
injury to prove that no injury was done, a principle fundamentally
wrong.
Also a _number of injuries_, no one of which alone could be the direct
cause of death, may cause death on the spot or very soon afterward.
Death in such cases, where there is no large effusion under the skin,
is referred to exhaustion, which, however, is merely another term
for shock. Such cases are exemplified by prize-fighters who, during
or after the fight, become collapsed and die of exhaustion. Having
sustained numerous blows on the body during the many rounds, the body
presents the marks of various bruises, but there may be nothing else
to explain the sudden death. No one injury or bruise is mortal, and
yet, when the deceased was previously sound and in good health, death
must be referred directly to the multiple injuries received in the
fight. We have already stated above that if the injuries are numerous,
the loss of a smaller amount of blood may be fatal. We see, therefore,
that there is not always a specific and visible “mortal” injury to
account for death. This is a well-known medical fact, but it does not
accord with the erroneous popular prejudice that no one can die from
violence without some one visible wound which is mortal. In other
words, the non-professional mind leaves out of account the idea of
shock, only regarding material injury and not functional disturbance.
If the circumstances accompanying death are unknown, it is well to be
cautious. But if the deceased was in ordinary health and vigor and
there was no morbid cause to account for the sudden death, we need not
hesitate to refer death to the multiple injuries.
II. WAS THE WOUND THE CAUSE OF DEATH NECESSARILY?
This brings up a number of interesting questions to be considered. In
medical jurisprudence there is probably no condition so common as that
the injury is admitted, but death is attributed to some other cause.
Thus _if there are several wounds_ it may be hard to decide on the
relative degree of mortality of any particular one, so as to be able to
say that death was directly or necessarily due to this or that one. The
defence may plead that death was not necessarily due to the particular
wound attributed to the prisoner. This brings up the question—
=Which of two or more Wounds was the Cause of Death?= No general
rule can be laid down for all cases, but each case must be judged
by itself. Another way of putting the question is: “_Which of two or
more wounds was mortal?_” The questions are not quite synonymous, for
two or more of the wounds might be “mortal” but not equally the cause
of death. In fact, as we have already seen, no one of the wounds if
they are multiple may be of itself mortal, but taken together they
are so. Consequently we will suppose that there are but two wounds,
and not multiple ones, and the question remains which of these wounds
was the cause of death. A wound may be said to be of itself mortal
when it is the cause of death directly or indirectly in spite of the
best medical assistance. In some continental states mortal wounds are
divided into two classes, those absolutely and those conditionally
mortal, the former including those in which the best medical assistance
is at hand, sent for or timely rendered without everting the result.
The mortal result in the second class is conditional on want of
treatment, improper treatment, or accidental circumstances. As Taylor
says, it is better to look at the effect of the wound and the intent
of the assailant, as is done in English law, rather than at accidental
relations of the wound.
To return to the question, we can readily imagine that a man may
receive two wounds at different times or from different persons, and
die after the second wound. Taylor[629] mentions the following case
in which the question arose as to which of two injuries caused death:
In Reg. _v._ Foreman (C.C.C. February, 1873) the prisoner had struck
the deceased some severe blows on the head. A fortnight later, having
partially recovered, another man gave him some severe blows on the
head. A fortnight later still he had left hemiplegia, and died a few
days later of a large abscess in the brain. The question arose which
set of blows had been the cause of the abscess. The prisoner, the
first assailant, was acquitted, as the deceased had had no serious
symptoms until the second assault, and there was no satisfactory
medical evidence as to the relation of the two assaults to the abscess
formation. The same author also supposes the following case: A man
having received a gunshot wound of the shoulder is doing well, when
in another quarrel he receives a penetrating stab-wound of the thorax
and abdomen. He dies after lingering for a time, under the effects
of these wounds. If the wound of the shoulder could be proven to be
the cause of death, the second assailant could not be convicted of
manslaughter, and so too with the first assailant if it could be shown
that the victim died of the stab-wound. It might be possible for a
surgeon to decide the question definitely at once if death occurred
soon after the stab, which was found to have penetrated the heart, a
large blood-vessel, or one of the viscera; or, on the other hand, if
the stab-wound was found to be superficial and not penetrating, and the
wound in the shoulder had suppurated and caused septicæmia.
In either or any case, everything would depend upon the evidence
furnished by the medical witness. His knowledge and judgment are
required to distinguish the guilty from the innocent.
Again, sometimes death may appear to be equally the result of either
or both wounds, in which case, as far as the medical evidence goes,
both assailants would be liable to the charge of manslaughter. Or the
second wound may be accidental or suicidal, and again the question
would arise as to the cause of death. A case illustrating this is
told by Taylor[630] substantially as follows: A grocer’s assistant
pursued a thief, who had stolen from a cart, into a coal-shed, where
he was stabbed twice in the abdomen. The larger wound suppurated,
the smaller wound healed up, and the man died of peritonitis. On
post-mortem examination the suppurating wound was found not to involve
a vital part, while the small healed wound had wounded the liver
and gall bladder and had set up the fatal peritonitis. The large
suppurating wound had apparently been inflicted purposely; the fatal
wound, directed upward and backward, might have been accidental by the
deceased rushing upon the knife held more or less in self-defence. The
case never came to trial, as the assailant was never found, but it can
be readily imagined what complications might have arisen.
Furthermore, the wounded person may have taken poison or been
subsequently ill-treated, and he may have died from these causes rather
than the injury. But the question arises as to whether the wound
was necessarily the cause of death. Here, in order to exculpate the
assailant, the supervening disease or maltreatment must be such as to
account for sudden or rapid death under the symptoms which actually
preceded death.
=Was Death Due to Natural Causes?= Again, the injury may be admitted,
but it may be claimed that death is due to natural causes. It is not
unusual for wounded persons to die from natural causes, though the
case may appear otherwise to laymen. This is often seen with suicidal
wounds, especially those inflicted during the delirium of a disease,
or the disease may supervene later and cause death without relation
to the wound. Where the wound was inflicted by another, accurate
discrimination is especially important in order to save the accused
from imprisonment under false accusation and consequent loss of
character. A careful examination is the only way to determine such
cases, which depend therefore on the medical testimony.
Again, the question may arise as between DEATH FROM WOUNDS OR LATENT
DISEASE, the wound perhaps being admitted, but death being attributed
to latent disease. Here a close attention to symptoms and a careful
post-mortem examination can alone decide. A man may die from the
rupture of an aneurism, from an apoplexy or some other morbid condition
after receiving a severe wound. Or a man with a hernia may receive a
blow upon it causing a rupture of the contained intestine followed by
peritonitis and death, or the recipient of a blow may have a calculus
in the kidney which may perforate a blood-vessel or the kidney tissue
and set up a fatal hemorrhage as the result of a blow.
Thus, medically speaking, the result of the injury is unusual and
unexpected, and due to an abnormal or unhealthy state of body of the
wounded person.
If it can be clearly shown by the medical testimony that death was due
to the above or any other latent diseases, the responsibility of the
assailant may be lessened or removed. The law looks to this point and
is lenient in its punishment in the absence of malice on the part of
the assailant. The crime is still manslaughter and may even be murder
if the assailant was actuated by malice and the abnormal or unhealthy
state of the body of the victim was taken advantage of. Generally there
is no intention of murder, but the nature of the wound and the means of
infliction will help to show this, which is for the jury rather than
the medical witness to decide. There is less ground for mitigation of
the punishment if the assailant was aware of the peculiar condition of
the wounded person, especially in the case of those notoriously ill or
of pregnant women.
Closely allied with this subject are those rare cases where ABNORMAL
ANATOMICAL CONDITIONS, such as a thin skull or brittle bones, cause a
slight injury to be followed by unexpected and untoward results, not to
be looked for in the average individual. In such cases the evidence of
the abnormal condition furnished by the medical witness may diminish
the responsibility and mitigate the punishment.
Furthermore, the responsibility of the assailant may not be altogether
removed, for the question naturally arises, Was death accelerated by
the wound? This depends upon the circumstances in each case upon which
the medical witness must base his opinion. Maliciously accelerating
the death of another is regarded as criminal on the principle that
that which accelerates causes. The following cases are quoted from
Taylor[631] to illustrate the above distinctions. In Reg. _v._ Timms
(Oxford Lent Ass., 1870) the deceased had been struck on the head by
the accused with a hatchet, from which injury he had partly recovered
under treatment in twelve days. But six weeks later he was seized with
inflammation of the brain, with convulsions, and died. At the autopsy
disease of the kidneys was found, and death was referred to this and
the inflammation of the brain due to the blows. The prisoner was
convicted after the judge had charged the jury that it was manslaughter
if they believed that the blows conduced in part to the death of the
deceased.
In the following cases there was no connection between the violence
and the cause of death. A man struck his father on the head with a
hammer and was sentenced to two months’ imprisonment, as the injury
did not appear serious. The father thought the punishment too little,
became much excited, and was hemiplegic six days after the wound was
inflicted and died three days later. No injury of the brain was found
under a fracture of the inner table at the site of the blow, but a
large clot was found in the lateral ventricle which, in the opinion of
the medical witnesses, was not dependent on the blow, and the prisoner
was acquitted (see Reg. _v._ Saxon, Lancashire Sum. Ass., 1884). Also
in Reg. _v._ Hodgson (Leeds Sum. Ass., 1876) the prisoner had struck
his wife with a belt, a short time after which she fell back and died
suddenly. The cause of death was found to be heart disease, and the
blow not being causative in producing the fatal result, the prisoner
was acquitted. Or again in Reg. _v._ Thompson (Liverpool Sum. Ass.,
1876): The prisoner had stabbed his wife in the cheek. The wound was
severe but not mortal. Two days later she was delivered of a child
in the infirmary to which she was taken. She died nine days later of
puerperal fever. The prisoner was acquitted on the charge of murder, as
there was no necessary connection between the wound and the puerperal
fever. Acquittals have taken place in cases of death occasioned by
terror or dread of impending danger produced by acts of violence, as
in the case of Reg. _v._ Heany (Gloucester Lent Ass., 1875). Here
the prisoner in an altercation with his wife, who was suffering from
cancer, held up a knife in a threatening manner, but did not touch
her. This gave her a shock; she died two days later from fright. As
there was no distinct proof that death was accelerated by this act,
the prisoner was acquitted of the charge of murder. Taylor[632] found
among a large number of cases occurring in England during twenty years
that the latent causes of death, as registered in wounded persons, were
chiefly inflammation of the thoracic or abdominal viscera, apoplexy,
diseases of the heart and large blood-vessels, phthisis, ruptures of
the stomach and bowels from disease, internal strangulation, and the
rupture of deep-seated abscesses. Sometimes the person was in good
health up to the time of injury, while in other cases there was merely
a slight indisposition. It was only by carefulness on the part of the
medical experts that the true cause of death was ascertained.
Again, it may be claimed that DEATH was not necessarily the result
of the wound and was AVOIDABLE BY GOOD MEDICAL TREATMENT. There are
many cases of wounds not mortal with proper and skilled treatment
which might become so by improper treatment. They may thus become
directly mortal by interfering with a source of hemorrhage which had
been arrested, or secondarily mortal by infection of the wound by
meddlesome treatment. It would depend on the medical witnesses to
determine whether and how far the treatment had been responsible for
the fatal result. If the wound is not of itself mortal and it has
only become so from improper treatment, this should be a mitigating
circumstance in favor of the accused. Medically speaking, we can
seldom make the sharp distinction which Lord Hale did legally between
a wound becoming mortal from improper treatment and one in which
improper treatment causes death irrespective of the wound. In case of
a slight wound this distinction might be possible, but not so in case
of severe wounds. Also there would probably be no conviction, as far
as the medical evidence is concerned, if the wound was only mortal
in consequence of improper treatment and not mortal as its usual and
probable result. This may naturally introduce the question of the
COMPARATIVE SKILL IN TREATMENT. If death is entirely or partly due to
a wound the responsibility of an assailant is not altered by unskilful
treatment. The entire question of the relation of the wound to the
fatal result and the effect on this result of the treatment employed
is left to be determined by the medical experts, and in its solution
great care and judgment must be used. Although a given fatal wound
might not have caused death under the best possible treatment and
surroundings, yet, according to the above rule, the assailant is held
responsible as long as the fatal result is due partly, at least, to the
wound. Therefore we see the responsibility of the surgeon not only for
the life of his patient, but also for that of the prisoner. He should,
therefore, not deviate from the ordinary and most accepted practice
in such cases, as any such deviation is taken hold of by the counsel
for the defence. In fact, every point of the treatment is subjected to
criticism.
In a lacerated wound of the foot, if death occurs from tetanus, it may
be claimed that death would not have occurred if the foot had been
amputated, or, if the foot were amputated and death followed, it may be
claimed that amputation was unnecessary and was the cause of death. The
surgeon should, therefore, be able to give the best reasons for every
step of treatment.
Again, it may be claimed that DEATH was not a necessary result of the
wound and WAS AVOIDABLE BUT FOR IMPRUDENCE OR NEGLECT on the part of
the wounded person. A man after being wounded may refuse to receive
medical assistance, or, after receiving it, may disobey instructions
or refuse to submit to an operation proposed. Thus with a compound
depressed fracture of the skull the patient may either refuse to see
a surgeon, or he may refuse to submit to an operation proposed, or he
may with or without operation disobey the instructions as to diet and
quiet, and eat or drink heavily and refuse to go to bed. Such a case we
can readily imagine might die of meningitis, etc.
If the symptoms of a wound are unfavorable from the start, or if the
wound of itself is likely to prove mortal, the responsibility of the
assailant is unmitigated by imprudence or neglect of medical assistance
by the wounded person. This is not allowed as mitigatory, as a sane
man is a free agent and is not obliged to call in or submit to medical
treatment. Moreover, a medical witness in many cases could not swear
that an operation or other plan of treatment would certainly save life.
Thus an amputation of the leg for wound of the foot causing tetanus
is by no means a certain means of cure. But we can readily imagine a
case where the refusal to submit to the treatment proposed might be
an important element in causing death. Thus in a compound depressed
fracture of the skull with compression, the medical witnesses would
agree that the operation would in all probability save life. This fact
would probably be only mitigatory in diminishing the penalty, and,
as stated above, would not secure acquittal. But it is none the less
important for the medical witness to bear these facts in mind and bring
out the facts and conclusions clearly in his testimony.
DEATH FOLLOWING SLIGHT PERSONAL INJURIES.—Here again the claim might
apparently be justified that death was not necessarily due to the
trifling injury. And in reality there is commonly some unhealthy state
of the body to explain such an unexpected result. When the disease
accounting for this unhealthy state of the body is in some other part
than the injury, an examination with ordinary care will explain the
case. But if the disease and injury are located in the same part,
especially in the head, the case is more perplexing, but may be cleared
up by careful and thorough examination. Also the usual results of
such an injury should be considered, and whether the disease would
be a usual result of the injury, or whether the sum total of the
pathological conditions found would be accounted for by the violence.
It should be remembered that the presence of chronic disease is no
excuse. Thus Taylor[633] cites the case of Reg. _v._ Hapley (Lewes Aut.
Ass., 1860), where a boy with chronic disease of the brain suffered
from no unusual symptom until he received a severe flogging, which was
followed by death in less than three hours. The same author mentions
also the following case to show that fatal results may follow very
slight and trivial blows. Annan[634] tells of a healthy four-year-old
girl who received a slight blow from the shaft of a wheelbarrow on the
skin about three inches below the knee. There was even no external
mark of violence, and the injury was thought to be so slight as not
to require treatment. There was pain, however, which increased on
the following day, marked constitutional symptoms appeared, and the
child died on the fourth day. Even to the punishment inflicted by
schoolmasters death has been imputed.
When DEATH occurs FROM WOUNDS AFTER LONG PERIODS the injury may be
admitted, but it may be claimed that death was not necessarily due to
the wound. Medically speaking, death is just as much the result of the
injury as if it occurred on the spot. Of course, death must be clearly
traceable to the usual and probable results of the injury, and not be
dependent on any other cause. An examination of the wounded part and
of the whole body will enable the medical witness to determine the
cause of death and whether it is clearly traceable to the injury. A
doubt on this point may lead to acquittal. Certain forms of wounds
or wounds in certain localities are especially liable to end fatally
after a long delay, but as the direct result of the wound. These are
wounds of the head and of the spine. As to the first class, the injured
person may apparently recover and be doing well, when he may suddenly
die from a cerebral abscess, for instance. This is the result of the
injury, but remains a longer or shorter time latent. In wounds of the
spine the patient is generally paralyzed below the point of fracture,
but is apparently in good health. In a longer or shorter time he may
die of a pneumonia, cystitis, or bedsores, which are the known and
regular consequences of the injury or injured condition. Astley Cooper
cites the case of a man who was injured on the head and died two years
later from the effects of the injury, as was clearly made out by the
continuance of brain symptoms during the entire period. An interval of
eleven years occurred in another head injury between the injury and
the fatal result. The first result of the injury was concussion of the
brain, and the case is mentioned by Hoffbauer.[635] This long interval
is unusual. There is a rule in English law by which the assailant
cannot be indicted for murder if the victim of the assault lives a
year and a day. Practically this makes little difference, as nearly
all cases would die within that time; but the principle is wrong as
looked at from the medical standpoint. The protracted cases concern,
as above stated, mostly injuries of the head, spine, and chest, among
which there are some cases, like the examples cited, where, according
to English law, justice would fail to be done.
III. WAS A WOUND THE CAUSE OF DEATH SECONDARILY?
A wound is secondarily the cause of death when the victim, having
recovered from the first ill effects, dies from some wound disease or
accident or from a surgical operation rendered necessary in the proper
treatment of the wound. There may be much difficulty in establishing
the proof of death from a wound by means of secondary causes, for,
1st, the secondary cause must be in the natural course of things; and,
2d, there must be no other accidental circumstances to occasion the
secondary cause.
The secondary cause may be partly due to the constitution of the
deceased from habits of dissipation, which fact would serve as an
expiatory circumstance in the case. Among the secondary causes of death
may be mentioned septicæmia, pyæmia, erysipelas, tetanus, gangrene,
that is, wound diseases, also the wound accident—as we may call
delirium tremens, and surgical operations rendered necessary to the
treatment of the case. We may add, besides the regular wound diseases,
inflammation in and about the wound, septic in character, perhaps not
justifying the title of septicæmia, but which, with its accompanying
fever, may be the “last straw” in a case which might otherwise
recover. Some of these secondary causes will now be considered more at
length.
SEPTICÆMIA is a general febrile disease due to the absorption into
the system from a wound of the products of bacteria or due to the
introduction into the blood and tissues of the bacteria themselves.
Depending on the two sources of origin, we have two forms of
septicæmia: 1. Septic intoxication or sapremia, due to the absorption
of a chemical poison, ptomaïnes, and often readily influenced and
cured by the removal of the source of these ptomaïnes in decomposing
blood-clots, secretions, etc. 2. Septic infection comes on less rapidly
but is more serious than the former is, if properly and quickly
treated, because the source of the trouble cannot be removed, but is
in the blood and the tissues. The latter form is the more common one
in wounds, though the former may occur in abdominal wounds, especially
when a blood-clot is present. The first form begins acutely, the
second form more gradually. The infection in septicæmia takes place
through a wound and may be due to the weapon which caused the wound,
the unclean condition of the parts wounded, or to the subsequent
treatment or want of treatment. It may even take place through the
intestinal mucous membrane as in cases of tyrotoxicon poisoning. It
is most likely to occur during the first four or five days before the
surfaces of the wound granulate, and it consists in the introduction
of bacteria, especially staphylococci and streptococci. The disease
is characterized by severe constitutional symptoms, acute continuous
fever, inflammation of certain viscera and of the wound, and nervous
disorders. A pronounced chill ushering in the fever is generally
absent. Prostration is especially marked, the patient finally passing
into a typhoid condition indifferent to surroundings. Anorexia and
headache are usually present; diarrhœa is common, vomiting is not. The
skin is pale and dusky, but not commonly icteric; at first it is hot
and dry, later moist and finally cold and clammy. The spleen is often
enlarged. The pulse becomes weak and rapid and delirium is followed by
coma. The prognosis is grave. Antiseptic treatment generally prevents
and often cures the disease, as is the case with many other of the
wound diseases; hence the failure to employ it may be alleged by the
defence in mitigation of the responsibility of the assailant for the
fatal result.
PYÆMIA is closely allied to septicæmia. It is due to the setting
free of bacterial emboli or septic emboli from a broken-down, septic
thrombus in the neighborhood of the wound, and the circulation of these
emboli in the blood until they are arrested and form the characteristic
metastatic abscesses, especially in the lungs, joints, abdominal
viscera, and parotid gland. Almost always the source of infection is an
infected wound. Granulation does not prevent the occurrence of pyæmia,
which, as a rule, commences at a later stage than septicæmia. It is
most important, however, for our purpose to remember that there is
such a thing as spontaneous pyæmia. An injury not causing a wound may
here be the exciting cause, but the resulting pyæmia is an unexpected
consequence. A bruise of a bone, for instance, by allowing bacteria,
which in certain conditions may be circulating in the blood, to find
an exit from the vessels into the bruised part, may develop an acute
osteo-myelitis, which may be a starting-point of a pyæmia. It is but
proper to state, however, that spontaneous pyæmia is a rare occurrence.
In fact, it is so rare that if pyæmia occurs and we find ever so
trifling an infected wound, we can safely attribute the pyæmia to the
wound and not to a spontaneous origin.
Pyæmia begins, as a rule, in the second week of the healing process or
even later. It usually begins with a chill, which may be frequently
repeated. The fever is very irregular and exacerbations occur with
each metastatic abscess. The skin is icteric, the icterus being
hematogenous. The pulse is rapid and becomes weaker. Infective
endocarditis may develop, which increases the danger of metastatic
abscesses, which may then occur in the brain. Otherwise the mind is
clear and unaffected until the final delirium and coma. The disease may
become chronic, but usually lasts a week or ten days. The prognosis is
very grave.
ERYSIPELAS is a still more frequent complication of medico-legal
wounds, and though not so fatal as the two preceding, it is probably
more often the secondary cause of death on account of its far greater
frequence. It too is an acute infective inflammation due to the
presence of a micro-organism, _streptococcus erysipelatis_. This occurs
mostly in the lymphatics of the skin, and effects an entrance through
some wound or abrasion of the skin or mucous membrane, which may be
almost microscopic in size. Probably there is no such thing as true
_spontaneous erysipelas_, though the wound may be often overlooked and
only visible on the closest examination. If a wound has been inflicted,
the size and severity of it cannot be alleged as a reason why it
was not the starting-point of an erysipelas. The erysipelas must be
clearly traced to the injury. That is, it must occur before recovery
from the wound or not later than a week after it has healed, for the
incubation is probably not longer than this. It is difficult to connect
an erysipelas with a wound if it occurs some time after it has healed
or if it occurs at a different place and not about the wound. Wounds of
certain regions, as, for instance, scalp wounds, are especially liable
to develop erysipelas, but this is probably owing to the imperfect
antiseptic treatment or delay in applying it. Certain individuals are
more prone to it than others; thus it has been stated that blondes and
those suffering from Bright’s disease are more susceptible, though how
true this is it is hard to say. It is also probably more prevalent at
certain times of the year, particularly in the spring. A wound after it
has scabbed over or has begun to granulate, that is, after the first
four or five days, is very much less apt to serve as the avenue for
infection. Erysipelas usually begins with a chill, or a convulsion in
children. Nausea and vomiting are the rule. The fever is remittent and
ranges from 102° to 104° F., and the temperature may be subnormal when
the inflammation is subsiding. Prostration is marked and the pulse more
or less weak. There may be delirium while the fever is high. Locally
there is rarely anything characteristic until twenty-four hours or
so after the chill. Then we have a reddish blush with some tension,
burning and itching of the skin. At first the redness is most marked
about the wound, later at the edge of the advancing, serpentine margin.
It spreads widely and rapidly, and after three or four days the part
first attacked begins to improve. Desquamation follows. The duration
may be a week or ten days or as long as a month. The inflammation may
be much more severe, involving the subcutaneous connective tissue in
_phlegmonous erysipelas_.
FACIAL ERYSIPELAS is a common variety and was once regarded as
idiopathic, but a wound on the skin or mucous membrane is probably
always present. The prognosis of erysipelas is usually favorable.
Since the use of antiseptics it is far less common than formerly,
though still the most common of the infective wound diseases.
If a man wounded in an assault is taken to a hospital where erysipelas
prevails, the question of responsibility arises, for, medically
speaking, he is subjected to great and avoidable risks.
TETANUS is an infective bacterial disease affecting chiefly the central
nervous system and almost always, if not always, originating from a
wound. Tetanus, like erysipelas, is probably always traumatic and never
strictly idiopathic. The wound may be so slight as to escape notice.
When it follows such injuries as simple fracture internal infection
probably occurs, though such cases are extremely rare. It is said
that the weather influences the development of tetanus, and that it
is more common in the tropics. There are also certain sections where
tetanus is much more common than elsewhere and where it may be said to
be almost endemic. Punctured wounds are most likely to be followed by
tetanus, for they offer the best opportunity for the development of the
bacteria, which are anaërobic. Wounds in dirty parts of the body, like
the hands and feet, are more apt to be followed by tetanus than those
elsewhere. Tetanus usually appears about the end of the first week
after a wound has been received, but it may not appear for a longer
period, even three or four weeks, so that the wound may have been some
time healed. To connect tetanus with a particular wound, note (1) if
there were any symptoms of it before the wound or injury, (2) whether
any other cause intervened after the wound or injury which would be
likely to produce it, and (3) whether the deceased ever rallied from
the effects of the injury. Tetanus comes on suddenly without warning.
The injured person first notices that he cannot fully open the mouth,
he has lock-jaw, and the back of the neck is stiff. The muscles of the
abdomen and back are next involved so that the back is arched in the
position known as _opisthotonos_, and the abdomen presents a board-like
hardness. The muscles of the fauces, pharynx, and diaphragm may next
become involved, causing difficulty in swallowing and breathing.
The thighs may or may not be involved, but the arms and legs almost
never. Owing to the spasm of the abdominal muscles, micturition and
defecation are difficult and respiration is hindered. The muscles are
in the condition of tonic spasm which permits the patient no rest, the
face bears the “risus sardonicus,” and the suffering is extreme. If
the patient lives more than two or three days the tonic spasm partly
gives way to increased reflex irritability, in which a noise, jar,
or draught of air may give rise to clonic and tonic spasms in the
muscles affected. The patient may die at such times from tonic spasm
of the respiratory muscles, or he may die of prostration from want
of food and sleep, worn out by the suffering and muscular spasm. The
mind is usually clear to the last. Fever is not characteristic of the
disease. Tetanus may be rapidly fatal; in two or three days, or it may
be or become more chronic. The _prognosis_ of acute tetanus is almost
invariably fatal; that of chronic tetanus is grave, but a certain
proportion of cases recover.
_Diagnosis._—This is easy. It differs from a true neuritis in the
peripheral nerves in that no matter where the wound is situated the
first symptom is in the muscles of the jaw and the back of the neck,
and not at the site of the injury and distally from this point.
_Trismus_ is applied to a milder form of the disease in which only
the face and neck muscles are involved and “lock-jaw” is a prominent
symptom. Some cases of _tetany_ may be mistaken for so-called
spontaneous tetanus. Tetany may follow child-bed, fevers, mental
shocks, exposure to cold and wet, extirpation of goitre, intestinal
irritation, etc. It consists of painful tonic spasms of the muscles of
the arms and feet. The attacks last one-half to two hours or more, and
may be preceded by a dragging pain. They may be brought on by pressure
on the nerve leading to the muscles affected. Striking the facial nerve
often causes contraction of the face muscles. There is no trismus but
there may be opisthotonos. The patient seems well between the attacks
and most cases recover without treatment.
DELIRIUM TREMENS may occur as a secondary consequence of injuries, or
necessary surgical operations in the case of those who are habitually
intemperate. Those who habitually use opium, tobacco, cannabis indica,
or even tea or coffee to excess are said to be subject to it. It
may, therefore, be justly alleged that death is avoidable in very
many cases, but for an abnormal and unhealthy state of the body.
The disease is characterized by delirium, a peculiar tremor of the
muscles, insomnia, and anorexia. Pneumonia may complicate the case.
The patients die in fatal cases from exhaustion due to insomnia,
lack of nourishment, and their constant activity of body and mind.
The prognosis is usually favorable, taking all cases together, but
in delirium tremens secondary to surgical injuries or operations the
prognosis is serious.
DEATH FROM SURGICAL OPERATIONS performed for the treatment of wounds.
The operation is a part of the treatment, and if it is done with
ordinary care and skill the accused is responsible for the result.
The necessity and mode of operation must be left to the operator’s
judgment. As the defence may turn on the necessity for and the skilful
performance of the operation, it is well to wait for the advice and
assistance of others if practicable, for death is not unusual from
severe operations. The patient may die on the operating-table after
losing little blood, from fear, pain, or shock. Or he may die from
secondary hemorrhage or any of the secondary causes of death from
wounds enumerated above. The evidence of the necessity of the operation
must, therefore, be presented by the operator. If an operation is
necessary and not performed, the defence might allege that death
was due to the neglect of the surgeon. Another question for the
medical witnesses to determine is whether the operation was rendered
necessary because of improper previous treatment, for if it was the
responsibility of the assailant may be influenced. The meaning of the
term “necessity” is here a matter of importance. Unless an operation
is necessary to the preservation of life, if death occurs there is
some doubt whether the assailant is responsible. But, medically
speaking, we would not hesitate to urge an operation on a wounded man
in order to preserve function, or even to save deformity as well as to
save life. In the case of operations done under a mistaken opinion,
neither necessary to save life nor, as the result proves, to save
function or guard against deformity, if death follows the assailant
may be relieved from responsibility. Thus an aneurism following an
injury might be mistaken for an abscess and opened with skill but
with a fatal result. It is also for the medical experts to determine
whether an operation was unnecessary or unskilfully performed, for
if it were and death resulted from it, the responsibility of the
prisoner is affected unless the original wound would be likely to be
fatal without operation. According to Lord Hale, if death results from
an unskilful operation and not from the wound, the prisoner is not
responsible. But yet death may occur as the result of the most skilful
operation necessary to the treatment of a wound, and not be dependent
at all on the wound itself. If the operation is skilfully performed,
and yet the patient dies from secondary causes, such as those above
enumerated or any others, the prisoner is still responsible, and the
medical testimony is concerned with the performance of the operation
and the secondary causes of death. The relative skill of the operator
or surgeon is probably not a question for the jury in criminal cases,
on the ground that the man who inflicts the injury must take all the
consequences, good or bad. In a civil suit, for instance an action
for malpractice, the case is otherwise, and all the medical facts and
opinions are submitted to the jury. The law regards three circumstances
in death after surgical operations: (1) The necessity of the operation,
(2) the competence of the operator, and (3) whether the wound would be
fatal without operation.
_Death_ may occur _from anæsthetics_ used in an operation without any
recognizable contributing disease of the patient, or carelessness or
lack of skill in the administration of the anæsthetic. Of course, the
question of absence of contributing disease on the part of the patient
and of its proper administration must be satisfactorily answered in
cases of death from the anæsthetic in an operation rendered necessary
in the treatment of a wound. Death from an anæsthetic may occur before,
during, or after an operation itself. Medically speaking, the necessity
of the use of an anæsthetic in operations cannot be questioned, and
in emergencies where an operation becomes necessary, and not a matter
of choice, its use, with special care, is justifiable even with
existing organic disease, which usually contraindicates it. As death
may be alleged to be due to the use of a particular anæsthetic, it is
always best in operating on account of an injury which may require
a medico-legal investigation, to use that anæsthetic which is most
generally used and indorsed in the particular section of country in
question. Of course, it is not lawful to operate against the will
of a person who preserves consciousness and will. It may be added
in this connection that if a medical man be guilty of misconduct,
arising either from gross ignorance or criminal inattention, whereby
the patient dies, he is guilty of manslaughter, according to Lord
Ellenborough. Omissions or errors in judgment, to which all are liable,
are not criminal.
IV. WAS THE WOUND MADE BY THE INSTRUMENT DESCRIBED?
It is not often necessary to prove that a weapon was used, though it
may affect the punishment. For the use of a weapon implies malice and
intention and a greater desire to do injury. The prisoner may swear
that no weapon was used when the nature of the wound clearly proves
that one was used. The explanation of the prisoner of the origin of the
wound may thus be discredited. We cannot often swear that a particular
weapon was used, but only that the wound was made by one similar to it
in shape and size. Thus Schwörer tells of the case of a man stabbed in
the face by another. The medical witness testified that the wound was
caused by a knife shown at the trial which had a whole blade, but a
year later the point of the knife which had really caused the wound was
discharged from an abscess in the cheek at the site of the wound. The
surgeon thus made a too definite statement in regard to the knife shown.