our opinion chiefly on two sources: 1st, and most important, by an
examination of the wound, and, 2d, by an examination of the instrument
said to have been used. Certain particulars of the wound may furnish
indications as to the weight, form, and sharpness of the instrument
used. There are certain wounds which must have been made by an
instrument, namely, incised and punctured wounds. The above question
is determined more or less by what has been said in a former section
on wounds, but we will now consider what special features of these and
other classes of wounds indicate the nature, shape, size, etc., of the
weapon used.
=Incised wounds= must be made by a cutting instrument. We would here
exclude those contused wounds of the scalp and eyebrows which closely
resemble incised wounds, but we have already seen that we can diagnose
between these wounds and incised wounds by careful inspection. But the
locality should put us on our guard, so that in case of wounds of these
two regions we should be especially careful in making the examination.
In the case of incised wounds we cannot often tell the shape or size of
the weapon, but we are able to tell certain characteristics about it.
_The sharpness_ of the instrument may be inferred from the clean and
regular edges. The depth of the wound may also indicate the sharpness
of the weapon. A long “tail” in the wound indicates that the weapon was
sharp as well as that this was the part of the wound last made. If the
edges of the wound are rough, we may infer that the edges of the weapon
were rough and irregular. Wounds caused by bits of china or glass or
fragments of bottles, besides having rough and lacerated edges, are
characterized by an irregular or angular course in the skin.
Some cutting weapons, like an axe, act as much by means of their weight
as by their cutting edges. Wounds caused by such weapons we can often
distinguish by the following signs: The edges are not as smooth as
is the case with a cutting instrument, and they may be more or less
lacerated and show signs of contusion. The wound is often deep in
comparison with its length, and the ends of the wound abrupt instead of
slanting up from the bottom to the surface. The section of resisting
organs and the impression of the edge of the weapon on the bone are
further signs of the use of such a weapon.
The form and direction of a wound may possibly give some indication of
the form of the instrument—for instance, whether it be straight or
curved like a pruning-knife, as in the case cited by Vibert[636] of a
wound of the neck which suddenly became deeper toward its extremity and
changed its direction; the whole being explained on the supposition
that it was made by a pruning-knife.
But it is in =punctured wounds= especially that we are enabled most
often and most accurately to determine the kind of a weapon used.
Here from the form of the wound we may judge of the form and size of
the weapon. In speaking of punctured wounds in a former section we
divided them into four groups, reference to which may here be made. In
the first group, or those caused by cylindrical or conical weapons,
when the weapon is very fine it may leave no track at all; if a little
larger, we may infer from a linear bloody track that the weapon was
needle-like in shape. The length of the instrument or the depth to
which it penetrated may be found, as a rule, only by dissection. If the
weapon were larger and conical, we have seen that the wounds would be
linear with two angles, the length of the wound being parallel to the
direction of the fibres in the skin.
Here we may judge of the form of the weapon from the following
circumstances: From a comparison of the depth with the size of the
opening, we know that it was a punctured wound. The edges and angles
are not smooth and even enough for a stab-wound with a knife, for the
edges are torn and not cut, and a stab-wound would be the only form of
wound with which we would be likely to confuse it. Furthermore, the
direction of the long axis of the wound parallel to that of the skin
fibres in the region in which it occurs and the very slight retraction
of the edges distinguish it from a stab-wound. By these signs we can
almost always distinguish such wounds from stab-wounds, and thus tell
the form of the weapon used. As to the size of weapon used, these
wounds if of any size are generally smaller than the weapon, for the
skin is put on the stretch by the weapon and yields to a certain
extent. The actual wound, therefore, is smaller in circumference than
the weapon. The size of the wound is smaller than that part of the
weapon occupying the wound when the weapon was arrested; it may be very
much smaller than the weapon at its largest point. Small wounds of this
kind are generally larger than the instrument producing them.
The second group of punctured wounds, or _stab-wounds_, are by far the
most common and, therefore, the most important variety of punctured
wounds. If the _stab-wound_ is _perpendicular_ to the surface the
_form_ of the wound may represent pretty closely that of the weapon at
the point where the latter was arrested, whether it has a single or
double cutting edge. But even here there are exceptions. Frequently a
weapon with a broad back and only one cutting edge may produce a wound
resembling that of an instrument with two cutting edges, the second
angle tearing as in the former class. Here on close examination we can
sometimes distinguish the difference between the two angles, and judge
correctly of the shape of the weapon. In fact, wounds made by common
pocket-knives are regularly slit-like and not wedge-shaped, as the
wound is caused only by the cutting edge of the knife. Again, if the
single cutting edge is blunt, in rare cases the wound is produced in
the same manner as those of the first group, or conical and cylindrical
instruments. We would be led to suppose that the wound was produced by
such an instrument, as both angles are torn, unless the direction of
the wound might not follow that of the fibres of the skin, in which
case we would be left in doubt. Stab-wounds are sometimes angular from
the knife being withdrawn in a slightly different direction from that
in which it was introduced or from an unequal retraction of the skin
(see Fig. 9). If the _stab-wound_ is _obliquely directed_, we can
still judge of the general _shape_ of the weapon, with exception of
the cases above mentioned. The dimensions and size of the weapon are
here much harder to determine. The _dimensions_ of a stab-wound in the
skin may be the same as those of the weapon, or of that part of the
weapon which is arrested in the wound, but often they are not so. To
measure the size of a wound exactly so as to get at the exact size of
the instrument, we should place the region of the wound in the same
position, etc., that it was when the wound was inflicted, and this we
cannot often do. As the skin was tense or relaxed at the time the wound
was inflicted, so the wound in the skin appears smaller or larger, just
as with a sheet of rubber under similar conditions. If the instrument
is very blunt, the wound in the skin may be smaller than the weapon
whether the skin near the wound is tense or not. Thus Hofmann saw the
wound from a blunt bayonet one centimetre shorter than the weapon.
The wound of the skin may be shorter and broader than the weapon
used on account of retraction of the edges of the wound, and this is
especially marked when the wound lies transversely to the direction of
the skin fibres. On the other hand, the length of the external wound
is more often greater than that of the weapon, because the wound is
elongated by making pressure toward the cutting edge on withdrawal of
the weapon, and an oblique wound measures longer than the weapon. If
the blow is from above downward and the cutting edge of the weapon is
uppermost, the length of the wound is not so likely to be increased
much beyond the measurement of the weapon as when the cutting edge is
directed downward. There is but one condition in which a stab-wound
is at all likely to correspond in dimensions with that of the weapon,
and that is when the wound is perpendicular to the surface. Even here
the wound may be lengthened on withdrawal of the weapon, and we have
to allow for retraction of the edges and try to put the parts in the
same condition of tension or laxity as at the time of wounding. Even
in the most favorable case, therefore, we cannot with certainty tell
the exact size of the weapon. If a stab-wound be directed obliquely to
the surface, then the length of the wound is greater than that of the
weapon, unless this increase be exactly counterbalanced by the lateral
retraction of the wound. The size of the weapon in such oblique wounds
is further obscured by the changes of size due to withdrawal of the
weapon, retraction of the edges, and the condition of the tension of
the skin at the time the wound was inflicted.
[Illustration: FIG. 9.—Angular Stab-Wounds of the Anterior Chest Wall
caused by a Strong Pocket-Knife.]
Dupuytren remarks that stab-wounds are smaller than the weapon owing
to the elasticity of the skin, but a lateral motion of the weapon may
cause considerable enlargement of the wound. If a stab-wound has
traversed a part of the body, the wound of exit is smaller than that of
entrance.
The _depth_ of a punctured wound may be any part of the length of the
weapon, or it may even be deeper than the length of the weapon owing to
a depression of the surface by the force of the blow, or the pressure
of the handle of the weapon or the hand holding it. We have already
seen that this may occur in a marked degree in penetrating wounds of
the abdomen involving one of the movable viscera, also in wounds of
the thorax, partly from depression of the surface and partly from an
expansion of the thorax when opened at the autopsy, thus increasing the
measured depth of the wound. Punctured wounds of the third class made
by instruments with ridges or edges, like foils, files, etc., present
more or less the shape of the weapon if the edges are cutting, but
not always so if the direction of the wound be oblique or the parts
unevenly stretched. If the edges are not cutting they cause wounds more
or less like the first class of punctured wounds, but we can often
distinguish them from the latter by little tears in the edges. The
entrance and exit wounds may not be alike.
Wounds made by bits of _glass and earthenware_ have irregular and
uneven edges. Taylor[637] relates a case, Reg. _v._ Ankers (Warwick
Lent Ass., 1845), where the wound was attributed to a fall on some
broken crockery, but the wound was cleanly incised and the prisoner
was convicted. As it may be alleged in defence that a given wound was
caused by a fall on broken crockery or other substances capable of
producing a punctured wound, it is important to notice whether the
edges are lacerated and irregular or smooth and clean. The author
quoted above cites another case which occurred to Watson, where the
prisoner alleged that a deep, clean-cut wound of the genitals of a
woman which had caused her death was due to a fall on some broken
glass. The character of the wound disproved this defence. Another
feature of such wounds, especially if they be deep in comparison to
their length, is that they are very apt to contain small particles of
the glass or earthenware which caused them. In fact, in all wounds it
is well to search for any small fragments which will throw light upon
the weapon used.
Wounds caused by _scissors_ are often of characteristic shape. If the
scissors were open we find two symmetrical, punctured diverging wounds,
presenting more or less clearly the form of the blades of the scissors.
If the blades have been approximated there is a triangular interval
between the punctures, the apex of which is truncated if any skin
remains between the punctures.
_Lacerated wounds_ may not indicate the weapon used as clearly as
punctured wounds, but the agent which produced them is often indicated
by the appearance of the wound. They are generally accidental. But
where they occur, as they not infrequently do, on the bodies of
new-born children, they may give rise to the charge of infanticide.
In some cases the weapon which caused the wound fits the wound
produced, and thus important evidence may be furnished the prosecution.
Taylor[638] cites the case of Montgomery (Omagh Sum. Ass., 1873), where
a bill-hook which fitted the injuries on the skull of the deceased was
found buried in a spot to which the prisoner was seen to go. These
facts connected the prisoner with the weapon and the weapon with the
murder. In other cases the wounds may be so lacerated or contused that
the indications of the weapon are obscured.
=Contusions and Contused Wounds.=—The shape of a contusing body is
sometimes reproduced by the contusion and the ecchymosis. Thus we are
enabled to distinguish the marks of a whip, the fingers, the fist, etc.
This is best seen when the ecchymosis is fresh, for soon the edges
extend and the outline is less clearly marked. Plaques parcheminées,
which we have already described as the marks of contused erosions,
may show the form of finger-nails, etc. Contused wounds like simple
contusions may show the shape of the weapon.
If the contusing body has a large area, the whole of this area cannot
often strike the body at once, so that the outline of the contusion
does not represent that of the weapon. But in general, severe
contusions present greater difficulties than the preceding classes of
wounds. We must generally be content if we can determine whether the
wound was caused by a weapon, including the fist, or by a fall, and
we are often unable to say even this. A fall is often alleged by the
defence as the cause of the injury, but of course if the prisoner
was responsible for the fall he is responsible for the results of the
fall. If there are contusions or contused wounds on _several parts_
of the head, or if the wounds are on the _vertex_ of the head, it is
presumptive of the use of weapons. We cannot often swear that each
and every wound on the head was due to the use of a weapon. On the
other hand, the presence of grass, sand, gravel, etc., in a wound is
presumptive of a fall and of the origin of the wound in this manner.
In case of a fall from a height the wound or wounds might be in almost
any part of the body, on the vertex or elsewhere. Such a fall may be
the result of accident, suicide, or murder. It is not unusual for
female complainants to ascribe their wounds to a fall to exculpate
the prisoner, especially if this happens to be her husband. We should
remember that in the scalp or over the eyebrows a contused wound caused
by a blunt instrument may resemble an incised wound. As already stated,
however, if the wound is fresh careful examination will lead to a
correct opinion, and the use of a sharp instrument may be disproved.
If the wound is not recent there is great difficulty in judging of
the cause. It is well to caution against accepting the interested
statements of others in regard to the use of a weapon, unless the
character of the wound bears them out very strongly. There may be a bad
motive for imputing the use of a certain weapon to the assailant. It is
far better to rely solely upon the evidence furnished by the wound in
such cases.
It would be useful if we could lay down some general rules to
discriminate between wounds caused by the blow of a weapon and those
caused by falls, but this we are unable to do so as to cover all cases.
Each case must be judged by itself.
If the question is asked _which of two weapons_ caused certain
contusions or contused wounds, we are still less likely to be able to
answer it. In such a case we must make an accurate examination of the
form of the wound and compare it closely with that of the weapon. In
such cases also the second source of information on which we base our
opinion as to the relation of a weapon to the wound may be of use,
namely, the examination of the weapon. The presence of blood, hair,
cotton or woollen fibres on one of two weapons indicates that this was
the weapon used. The presence of blood is particularly to be looked
for, and in those parts of the weapon from which it could be washed off
least easily. We should further note the condition of the point and
edge of the weapon, and if the edge is broken or nicked at all, whether
this condition is old or recent. The sharpness of the edge should
further be noted, and if the edge is sharp note whether it has recently
been sharpened. All these points have a certain bearing on the case.
Also the location, shape, depth, etc., of the wound should be carefully
noted to see if an accidental fall would be likely to account for it.
For these features of the wound may be such that no fall could cause it.
We see, therefore, that in incised and punctured wounds the use of a
weapon may not be hard to make out, but that in general the question
whether a particular instrument caused the wound is often difficult or
impossible to answer. Often the best we can do is to say that the wound
could have been produced by the weapon.
V. WAS A WOUND SELF-INFLICTED OR WAS IT INFLICTED BY ANOTHER?
In other words, was it _suicidal_ or _homicidal_? Speaking of suicide
in general, its most common cause is alcoholism. It is not infrequent
in youth. Lutaud[639] states that in fifteen years, presumably in
France, there were 1,065 cases of suicide between the ages of ten
and fifteen years. This seems to be only explicable on the ground of
heredity or of cerebral affections. Among 27,737 cases of suicide,
observed in France, the same author gives the following commonest
causes in the order of greatest frequence: Drowning, strangulation,
pistol-wounds, incised and punctured wounds, poison. The age, sex,
and social conditions influence the choice of means. Thus among males
drowning is preferred by the young, pistol-wounds by the adult, and
hanging by the aged, while among females asphyxia is the favorite
method, as there is no pain and no disfigurement.
While many pathologists consider suicide an act of mental alienation,
and though such may be the case in a large number or even in a
majority of cases, yet in a considerable number it is a voluntary
and rationally planned act. The question, Is it suicide or homicide?
may be put in all cases of death by cutting instruments, and in many
from other kinds of wounds. It is often, if not generally, impossible
to answer it with absolute certainty. It is hardly suitable for the
medical witness to try to reconstruct the scene of the crime from the
medical facts, for he should abstain from everything not medical and
should distinguish that which is positively proven from that which is
merely probable.
Suicides often leave a letter or some such indication to show that the
wound was self-inflicted. If such is not the case, the question as to
the cause of the wound may or may not be medical. If the question is
a medical one, there are certain points to notice as to the wound,
such as its _nature_, _situation_, _direction_, and the _number_ and
_extent_ of the wounds, from which we are to form an opinion. There
are also other circumstances which furnish evidence and thus assist us
in answering the question. This evidence is furnished by the weapon,
the signs of struggle, the examination of the clothes and body of the
deceased and the accused, the position and attitude of the body, and
any organic lesions, etc., predisposing to suicide.
The =nature= of the wound bears upon the question of the homicidal or
suicidal origin in the following way: Most suicidal wounds are incised
or punctured wounds. _Incised wounds of the throat_ are generally
presumptive of suicide, but a homicidal wound may be inflicted here
to conceal the source of infliction of the wound. Such a wound if
homicidal would imply malice, on account of the attempt at deception
and concealment, and would convict the assailant of murder. Unless
the deceased was asleep or drunk or was otherwise incapable of
resistance, such a homicidal wound can often be distinguished from
a similar suicidal wound by the form and direction of the wound, by
its irregularity, and by other wounds on the hands or person of the
deceased. Taylor[640] mentions a case in which the peculiar form of
the wound, like that made by butchers in killing sheep, led to the
suspicion that homicide had been committed by a butcher, who was
subsequently arrested, tried, and convicted of murder. The _regularity_
of the wound has been taken to indicate suicide rather than homicide.
That it does so is not questioned, but it is more or less fallacious
if resistance is impossible, in which case a murderer may easily make
a regular, clean, incised wound here. _Contused wounds_ are seldom
suicidal, for they are not sufficiently speedily or certainly fatal.
They are also more painful and disfiguring. Contused wounds usually
indicate murder or accident, though there are not wanting cases of
suicide by such weapons as a hatchet or a hammer. There is more
difficulty in the case of a contused wound from a fall instead of from
a weapon; for here we have to decide whether the fall was accidental,
suicidal, or homicidal. The nature of the wound is of little assistance
in the case of insane or delirious patients, who may commit suicide in
the most unusual and curious manner.
Taylor[641] relates the case of a delirious patient in Guy’s Hospital,
in 1850, who tore away the whole of the abdominal muscles from the
lower part of the anterior abdominal wall. If the case had not occurred
in the hospital or where there were witnesses of the deed, the nature
of the wound would have indicated homicide except for the delirium.
The following case, quoted by the same author, illustrates a wound of
very unusual nature and situation, which might have been taken for
a homicidal wound with intent to conceal as far as the situation of
the wound was concerned. The wound was accidental and occurred in the
following way. A girl fifteen years old jumped on to her uncle’s knee
while he was holding a stick between his legs which she did not notice.
The Stick passed up her anus, but she withdrew it and went on playing,
though she complained of pain. On the following night acute symptoms
of peritonitis set in, and she died of it in forty-eight hours. On
post-mortem examination a rent was found in the anterior part of the
rectum penetrating the peritoneal cavity.
=The Situation or Position of the Wound.=—A suicidal wound must be in
such a position that the deceased could have inflicted it himself. Such
wounds are, therefore, generally anteriorly or laterally situated. The
“site of election” for suicidal wounds is the neck for incised wounds
and the chest, especially in the region of the heart, for punctured
wounds. The situation of suicidal wounds, of lunatics, etc., shows all
kinds of fantasies. The mere situation does not suffice to distinguish
suicidal wounds, as a murderer may simulate a suicidal wound for
purposes of concealment. Some regard a wound in the back as proof
against suicidal origin, but it is not so much the situation of a wound
as the situation taken in connection with the direction which furnishes
the proof against suicide in such wounds.
As a rule, a suicidal wound, besides being in an accessible part of the
body, is also in a part commonly known to be rapidly mortal, as the
neck and heart. But suicidal wounds are not always in the situation
which is anatomically best for being rapidly fatal. Concealed wounds or
wounds in inaccessible parts presumptive of murder may be suicidal and
so placed to impute them to another and give rise to the suspicion of
murder. The blood-vessels of the arms and legs may be selected as the
site of a suicidal wound. This situation is often regarded as uncommon,
though the writer has met with it in one or more cases of attempted
suicide. It is illustrated in the famous case of Abdul Aziz, the Sultan
of Turkey. He was found dead under suspicious circumstances with two
oblique, ragged wounds at the bend of each elbow, directed from above
downward and from within outward. The joint on the left side was
penetrated, while only the skin and veins were involved on the right
side. Death was due to bleeding from the ulnar artery and the veins.
The clothing was soaked with blood and scissors stained with blood
were found on the sofa. These wounds were consistent with suicide,
though not what would be expected. Nineteen physicians who examined the
body agreed in reporting it as suicidal, though one reason given for
this opinion, namely, “that the direction and nature of the wounds,
as well as the instrument which might have effected them, lead to the
conclusion of suicide,” was hardly a valid one, for the wounds were not
typical of suicide in nature, direction, or position. Such wounds are
rarely homicidal, though at least one such case is mentioned.
Suicidal incised wounds, as has been said, are usually in the neck,
where they may sometimes be arrested by the larynx, especially if it be
ossified, though the incision often divides the larynx. The situation
of the wounds is often between the larynx and the hyoid bone, and then
meeting no bony resistance, they may divide the great vessels and
even nick the vertebræ. But it is rare to be so deep, at least on both
sides at once. As a rule, it is deepest on the side on which it is
begun and ends more superficially. As far as the situation of a wound
is concerned, there is no wound which a suicide can inflict but what
may also be inflicted by a murderer. The reverse, however, is not true.
We cannot always certainly distinguish between suicidal and homicidal
wounds from their situation.
=The direction of the wound= is one of the most important points to
notice. It is considered by some to furnish presumptive evidence
for the medical jurist, and taken in connection with the nature and
situation of the wound may often lead us to a positive opinion as
to the question of the suicidal or homicidal nature of a wound. The
evidence from the direction of wounds is only furnished by incised and
punctured wounds, rarely by contused wounds. Suicidal incised wounds of
the throat are almost always directed from above downward and from left
to right if the suicide be right-handed, and in the same direction from
right to left if the person be left-handed. Transverse wounds in this
situation without obliquity are also compatible with suicide, though
perhaps more common in homicide, while obliquely transverse wounds from
above downward and from right to left in a right-handed individual are
indicative of their infliction by another. Homicidal incised wounds
of the neck inflicted from behind or the right side, if the victim
and assailant are right-handed, or from the left side if they are
left-handed, may have the same direction as similar suicidal wounds.
Such a wound may be inflicted by a murderer to deceive as to the cause
of the wound by raising the suspicion of suicide. If an incised wound
of the throat be inflicted by another from in front, then its direction
is usually the reverse of a similar self-inflicted wound.
Homicidal incisions, especially in the throat, may extend at one or the
other end beyond the skin wound. In similar suicidal wounds at both
angles of the wound the skin is the first and the last part injured,
and in such wounds the spine is seldom reached. It should be borne
in mind in this connection that a given suicide may be ambidextrous
and this fact may be unknown to the friends of the deceased. This is
especially the case in the use of the razor from practice in shaving,
and the razor is the usual weapon used in such incised wounds of the
throat. Neglect of this point may lead to an unwarranted suspicion of
murder. The two following cases cited by Taylor[642] well illustrate
this fact:
In the case of Sellis,[643] the man was generally supposed to be
right-handed, though he was found dead in bed with his throat cut
and the razor on the left side of the bed. In point of fact, he was
ambidextrous in the use of the razor. The second case, which occurred
in London in 1865, was still more remarkable.
A publican was found dead in bed with his throat cut in a left-handed
manner. He was supposed to be right-handed and there was bloody water
in a basin in the room. His wife, who gave the alarm, had marks of
bruises on her, and though she said she had found her husband dead in
bed after having left it for a short time, suspicion fell upon her,
especially as they were in the habit of quarrelling. The suspicions
were removed, however, by the explanation that he had been brought up
as a wood-carver, which required him to use both hands equally, and
that he had frequently threatened to kill himself, and further that the
bloody water in the basin was due to a daughter washing her hands after
having touched her father. It is even conceivable that an ambidextrous
person, to avoid suspicion of suicide or to impute murder to another,
might inflict a suicidal wound from right to left. Notwithstanding all
this, the above cases are very rare exceptions, and the rules stated
above as to incised wounds in the throat hold in almost every case.
In the case of stab-wounds of the chest, especially in the cardiac
region, the same rule as to the direction holds good, and in these
wounds we can often define the direction more accurately than in the
case of incised wounds. If the suicide is right-handed the wound is
regularly on the front or side of the body and directed obliquely from
above downward and from right to left, while it is from left to right
in case of a left-handed suicide. A murderer from behind, or from that
side the hand of which the victim would use, may inflict a wound in the
same situation and direction as a suicidal one. Here again this may
be done with the motive of concealment of the nature of the crime.
Homicidal stab-wounds inflicted from in front, as they generally are,
are usually directed from left to right, and they may be directed from
above downward or in the opposite direction. Oblique wounds from above
downward may be either suicidal or homicidal; those directed from below
upward are almost always homicidal.
When a wound is caused by an instrument both cutting and puncturing,
suicide cannot be admitted unless the direction of the wound is
compatible with that which the weapon which inflicted the wound, held
in the hand of the deceased, might cause. Taylor recommends to place
the weapon in the hand of the deceased to see if the direction of the
wound could possibly correspond with that which could be taken by the
weapon in the hand of the deceased with any position possible for
the arm and hand. Therefore certain wounds by position and direction
exclude suicide, but if a wound is possibly suicidal it is also
possibly homicidal.
Though suicidal wounds vary, the above points are sometimes of real
assistance in distinguishing between suicide and homicide, especially
if the body has not been moved.
=Evidence Furnished by the Number and Extent of Wounds.=—Multiplicity
of wounds, as a rule, indicates homicide, and indeed the reverse is
true in a majority of cases that a single wound points to suicide.
There are many exceptions, however, to both statements. Multiple wounds
are possible in suicide, and that, too, with different weapons; even
drowning or hanging may be resorted to after self-inflicted wounds have
failed. If several wounds are found, each one of which or more than
one of which may be considered grave, it is usual to conclude that
the wounds were not self-inflicted, but the medical expert should not
judge too hastily from this fact alone, for most wounds do not kill
instantly. With the presence of several wounds in a case of suicide
only one of these, as a rule, is “mortal” in character. This being so,
some have asserted that if two mortal wounds are present, especially if
one of them is stupefying, such as a wound about the head, such wounds
are incompatible with suicide. A definite statement of this kind cannot
go unchallenged unless the two wounds are in different parts of the
body, and both of such a nature as to be immediately or very rapidly
fatal. For all cases of suicide or homicide do not die immediately
from wounds commonly called mortal; in fact, this may be said to be
the exception rather than the rule. We may safely say, however, that
if there are several distinct wounds on the throat, each involving the
large vessels, the inference is plainly murder.
[Illustration: FIG. 10.—Suicidal Cut Throat from Left to Right,
showing the Tentative Cuts at the Commencement and the Serrations at
the Termination of the Wound.]
Several wounds by the same or different weapons cannot, therefore,
be proof of homicide. The case of a lunatic suicide is reported who
inflicted thirty wounds upon his head. In a case of homicide with
multiple wounds the situation or direction of some one or more of them
may give evidence as to the origin of the wounds. Ogston, Sr.,[644]
states that especially in the case of incised wounds of the throat
a suicide may make a number of small or superficial tentative cuts
besides the principal one, but these incisions are all usually parallel
(see Fig. 10). In the case or multiple homicidal incised wounds of
the throat, on the other hand, the wounds are not parallel, owing
probably to the resistance of the victim in this case and his remaining
passive in the former. The extent of the wound refers to the number
and importance of the parts injured. In regard to incised wounds of
the neck, this point has been thought by some to furnish presumptive
evidence of suicide or homicide—of homicide if the wounds are deep,
of suicide if they are not. While it is true that suicidal wounds of
the neck are, as a rule, not very deep, and that they seldom reach the
vertebræ and generally do not divide the vessels on more than one side,
yet sometimes such wounds are as deep and extensive as homicidal ones.
This may imply a determined purpose not to be foiled in the attempt
at suicide. Thus Marc reports a case of suicide by an incised wound
of the neck, where the wound was so deep as to reach the vertebræ or
their anterior ligaments and to divide the trachea and œsophagus, both
carotids and jugular veins. The extent of this wound was greater than
in most suicides, but still we can hardly lay down a hard-and-fast
rule of much practical value according to which extensive wounds are
evidence of murder. Such wounds are, however, presumptive of murder
taken in connection with other signs pointing that way.
[Illustration: FIG. 11.—Homicidal Cut Throat from Right to Left,
showing a Tentative Cut at the Commencement and the Serrations at the
Termination of the Wound.]
The question may arise in regard to a wound, _whether the victim
wounded himself by precipitating himself on the weapon_. This may be
alleged by the defence, but it is difficult to believe if the wound is
deep, for the body would naturally repulse the weapon. If the wound is
deep the weapon must at least have been strongly held, which may or may
not be consistent with the theory of self-defence. If the direction of
the wound is oblique from above downward, or if there is one external
wound and two separate tracts internally, from a second use of the
weapon on the part of the person holding it, then the above allegation
is doubtful, if not impossible.
By comparing the relative positions of the deceased and accused, as
indicated by the witnesses and accused, with the position and direction
of the wound, we may often judge whether the allegation is possible or
probable.
Besides the above points derived from the wound itself, there are
several other factors which belong to the category of circumstantial
evidence, but which come within the province of the medical expert.
These latter points of evidence are sometimes almost as important as
the former, while taken in connection with them they help to make the
evidence far more conclusive.
=Evidence furnished by the weapon= as to the origin of wounds.
We have already seen in a former section that we can often tell, by
various signs of the wound, with what kind of a weapon it was made. We
may thus be able to say that a wound was made by a weapon similar to
one exhibited. Also by examination of the weapon itself and from the
circumstantial evidence of where and how it was found, we may sometimes
say that the wound was inflicted almost certainly with a particular
weapon. All this evidence may sometimes be made use of in judging
between the suicidal and homicidal origin of a wound.
The POSITION _of the weapon_ or the place where it is found is a
matter of considerable importance. If it has not been touched, its
position should be carefully examined, or inquired about if it has been
moved. The presence of a weapon which might have caused the wounds
in the hand of the victim is in general proof of suicide. The weapon
must not merely lie in the hand, it must be gripped by the hand. One
might suppose that the weapon placed and held in the hand until rigor
mortis sets in would still be firmly held. Casper says that this is
not so, but that the weapon falls from the grasp as soon as the hand
is unbound. Also Hofmann’s[645] experiments proved the same point. By
the use of ligatures and several artificial means he tried to confine
a weapon in the hand of a recently dead body so that it would be as
firmly held as by a contraction of the muscles during life. These
experiments were entirely unsuccessful, for though the fingers remained
closed, the object was simply held and not grasped, and fell from the
hand on the release of pressure.
In suicide the weapon is sometimes held so firmly that force is
required to dislodge it. It seems as if the muscular spasm or grip
persists after death, as cadaveric spasm, until rigor mortis occurs
and sets it, as it were. The murderer, therefore, cannot imitate this
grip, and an unsuccessful attempt to do so would indicate murder. It
should be borne in mind that the weapon in the hand of the deceased
may have been for the purposes of defence; therefore it is necessary
to note whether the wounds on the body correspond to those which could
be made by the weapon. Indeed, this fact is most important to note in
all cases of suspected suicide where the weapon is found. If the weapon
is not in the hand of the deceased, note carefully where it lies. If
death is due to a suicidal or accidental wound which is immediately
or very rapidly fatal, the weapon is generally found near the body.
If so, it is well to note on which side it lies, and if it lies near,
whether it has apparently fallen or been thrown or placed there. If
the relation of the body and the weapon has been disturbed by moving
either, the position of the weapon as found by the medical witness is
of little value. In cases of suicide the weapon _may_ possibly be found
at some distance or even concealed, though this is exceptional. Thus
Taylor[646] states that the razor in one instance was found shut at the
side of the deceased, who had committed suicide by cutting his throat.
In another instance the razor was found in the pocket of the deceased,
bloody and closed. As a rule, the weapon is found lying at the side of
a suicide if it is not grasped in the hand. If the weapon is far from
the body and the wound was quickly fatal, especially if the weapon
is hid or cannot be found, it is strongly presumptive of murder. If
the weapon is found near the body it is well to note whether the edge
is sharp or blunt, straight or bent, or notched, as these points may
assist us in forming a judgment as to suicide or murder.
A weapon belonging to the victim may be substituted by the murderer for
the one really used, and the former may be placed by the side of the
body. Therefore the weapon found should correspond to the wounds as to
length, depth, sharpness, etc., to be compatible with suicide.
Generally a suicide foiled in the attempt to take his life uses the
same weapon over again if he persists in the attempt. But he may not do
so; on the contrary, if the first attempt was made with a knife, the
second may be made with a pistol, etc. Several wounds by the same or
different weapons cannot therefore be an absolute proof of homicide.
=The presence of blood, hair, and other substances on the weapon=
used, or probably used, is a matter of some importance. Blood is
not necessarily found on the weapon used to inflict a mortal wound,
especially in the case of blunt instruments. In stab-wounds, too,
the vessels may be compressed by the blow or the weapon may be wiped
as it were on withdrawal by the elasticity of the skin and by the
clothing, except for a thin yellowish film. Thus it is that the first
stab-wound shows no blood on the outside of the clothes but only on
the inside, but the outside of the second is usually bloody but may
be but little so. To make sure whether or not there is blood on a
knife or other weapon it is necessary to examine all the depressions
on the instrument, as the blade itself may have been washed, and only
those traces of blood remain which are less accessible to cleaning by
washing. Blood coagulated on a blade indicates, as a rule, blood from
a living animal, but it may not do so. Furthermore, it may be hard to
distinguish between a thin layer or spots of dried blood not coagulated
or coagulated and dried blood in a similar form.
If blood is not found on a weapon, hair and other substances which
can be identified may be. This is especially the case with blunt
weapons, on which, as we have seen, blood usually fails. A fragment of
the weapon may break off in the wound, as in stab-wounds, and may be
identified as belonging to one in the murderer’s possession.
=The signs of a struggle= furnish important evidence, as they are
not likely to be found in the case of suicide. If the wounds were
inflicted by a cutting instrument, the existence of a struggle may be
indicated by incisions on the palm of the hand or fingers or on the
dorsum (see Fig 12). Such wounds would not be self-inflicted and would
indicate a struggle with the murderer. Or if contusions or ecchymoses
indicating the form of the foot, fist, fingers, or finger-nails are
found on the face, neck, chest, forearm, or hand of the deceased, this
again indicates a struggle with the assailant, and goes far to prove
murder. The same is true of the imprint of a bloody or dirty hand on
the clothes of the victim when the victim’s hands were not bloody. Also
such an imprint in a position where the deceased could not have reached
with the particular hand indicated, as is the case if the impression
of a right hand be found on the victim’s right arm; this indicates a
struggle with a murderer, etc. In one case of murder, on the back of
the left hand of the deceased there was found the bloody mark of a left
hand evidently not that of the victim himself. The presence of marks of
violence about the mouth of the deceased, done to close it to prevent
the victim from giving an alarm, especially if surprised during sleep,
is presumptive of murder. Sometimes hair or fragments of clothing
belonging to the accused are found in the grasp of the deceased,
indicating a desperate struggle, and they are very suspicious of
murder. Thus Taylor[647] cites the case of a murder trial in Ireland,
in 1877, where hairs found firmly grasped in the hands of the deceased
were found to correspond to the hair of the accused. The clothes of the
deceased, as well as those of the accused, often indicate a struggle
unless the accused can satisfactorily account for the condition of his
own clothes in some other way.
[Illustration: FIG. 12.—Incised Wounds of Right Hand in the Struggle
of Defence. Homicide.]
=The examination of the clothes and body= of the deceased and the
accused may furnish important evidence.
If suicide is accomplished by a weapon like a knife, it is rare for the
hand not to be bloody. If it is not bloody we may well suspect a case
of supposed suicide. The presence of blood on the hand does not prove
suicide, though its absence may disprove it, as the hand is generally
bloody in case of murder by being carried to the wound.
The _examination of the clothing of the deceased_ is of great
importance. As we have noticed before, a suicide generally opens them,
a murderer rarely. A suicide is often partly or even wholly undressed
when he inflicts the wound, while murder is usually committed on those
entirely dressed. The wound of the clothes should correspond to that of
the body in case of murder. In suicide the wounds of the body and of
the clothes may not correspond, especially if there exists a motive to
falsely impute the crime. The clothes of the deceased as well as those
of the accused may indicate a struggle, as we have already noticed. Of
course, in regard to the clothes examined, it is necessary to clearly
prove that they were worn at the time by the deceased or accused,
otherwise serious mistakes may be and sometimes are made. In examining
the blood-spots on the clothing, note whether the blood occurs in large
patches or sprinkled as by a spurting vessel or by continued violence.
The _body of the accused_ may present scratches, marks of nails,
contusions, bites, or other wounds indicative of a struggle. It would
be well to ask the accused how he received the wounds or scars, to see
if his explanations tally with the injuries. It is hard to tell when
wounds which have cicatrized were inflicted; we can only distinguish
between old and recent ones, and thus control the statements of the
accused. An examination of the finger-nails of the prisoner soon
after the crime may reveal blood underneath when the rest of the
hands and person are free from it. Note also the site and shape of
the blood-spots, if they exist, and whether or not they came from an
arterial jet. These spots may be on the body or clothes of the accused.
The account of the accused as to these spots may or may not correspond
to the facts as indicated by them. The above leads us to the more or
less important question:
COULD THE ASSAILANT HAVE ESCAPED WITHOUT STAINS?
It is possible for the murderer to escape without being spotted with
blood, but the probability of this occurrence depends on the nature
of the wound and the relative positions of the deceased and the
assailant at the time the wounds were inflicted. This latter fact is
very largely, if not altogether, a matter of speculation as far as
the medical evidence goes. It is a popular, though false, idea that
a murderer’s clothes must be bloody, and the police may be misled in
expecting to find them so in every instance. Taylor[1] cites several
cases in which either no blood was found on the murderer’s clothes,
or only small spots wholly out of proportion to the amount of blood
which must have spurted or flowed from the wound. Absence of blood on
the prisoner’s clothes is often made use of by the defence to prove
the prisoner’s innocence, whereas, besides the possibilities of having
had no spots in the first place, the clothes may have been changed
or washed before the examination was made. This has occurred in more
than one murder trial. Taylor[648] mentions the following cases in
illustration:
It was alleged that the absence of blood-stains on the prisoner’s
clothing was a strong proof of his innocence in the trial of
Sub-Inspector Montgomery for the murder of Mr. Glasse (Omagh Ass.,
July, 1873). In this case the weapon was a bill-hook which had produced
contused wounds on the head. There was blood on the floor about the
body, but the wounds were not likely to have been accompanied by much
spurting. Yet it was assumed that the assailant in this case must
have been covered with blood. Much stress was laid upon the absence
of blood-stains. On the first two trials the jury could not agree,
owing chiefly to the absence of blood-stains, but on the third trial
he was convicted and afterward admitted that he had removed the
blood-stains from the clothes with cold water. Also in the case of
Reg. _v._ Courvoisier (C.C.C., 1840) the accused, who was tried for
the murder of Lord William Russel, had no blood-stains on his clothes.
All the vessels of the throat of the deceased had been cut to the
vertebræ while he was asleep. It was contended most strongly that the
accused could not possibly have committed the crime, as he had no
blood-stains. But after conviction he confessed that he wore no clothes
when he committed the murder, and he only had to wash his hands and the
carving-knife he used. Again, in the case of Reg. _v._ Thompson (Durham
Wint. Ass., 1863) the defence mainly relied on the absence of blood on
the prisoner’s clothing. The wound in the throat of the wife of the
accused was five inches long, directed from left to right, dividing
all the vessels and nerves of the neck. The medical witness stated
justly that no such wound could be self-inflicted. It was rapidly
fatal. No weapon was found near the body. The prisoner was convicted.
The same author cites the case of a prisoner on whose trousers worn
soon after the murder no blood-marks were found, but the trousers
actually worn by him were found with blood upon them. Juries have even
acquitted the prisoner apparently only because no marks of blood were
found, though the other circumstances were explicable only on the
theory of murder.
It should be remembered in this connection that blood-stains may be
found on the clothing of many, especially on the coarse clothing
of working-people. This may be accounted for by the occupation,
flea-bites, accidental circumstances, or it may occur without
definite explanation. Such persons may be accused of murder and yet
the blood-stains be consistent with innocence. Too much importance
should not, therefore, be attached to them, even if the accused cannot
satisfactorily explain them and if he does not attempt to do so in
a suspicious way. That blood on the clothing even under suspicious
circumstances may be consistent with innocence is illustrated by the
case of a suicide by cutting the throat, in 1872, cited by Taylor.[649]
In this case the son first found his father dead, and thought that he
had broken a blood-vessel. He raised the body, staining his hands and
clothes, then went for help. At the inquest he was closely questioned
as to the presence of the blood-stains, but there could be no doubt
that the case was one of suicide.
In general, we may say that a murderer is much more likely to escape
without blood-stains in contused wounds, and more likely in the case
of punctured wounds than in incised wounds, for in punctured wounds
the bleeding is much less free and is less likely to spurt from the
wound. In the case of incised wounds he is most apt to escape without
stains if he is behind or to the side of the victim when he inflicts
the wound—in other words, when a part of the body of the deceased
was between the assailant and the wound inflicted. Furthermore, the
assailant is more likely to escape without blood-stains if there is a
single wound than if there are several, and each additional wound makes
it more likely that he will be spotted with blood.
The _examination of the ground or floor and the furniture_, etc., may
furnish some evidence as to the nature of the crime, and also help
the witness to answer the questions which may sometimes be asked,
_i.e._, AT WHAT SPOT WAS THE VICTIM WOUNDED? and WHERE DID HE DIE?
This question is sometimes settled by examination of the spot where
the deceased lay and the furniture, etc., about. Sometimes the floor
or ground and the furniture or surrounding objects at a distance give
the requisite evidence. The examination of the cracks and corners of
the floor and furniture should not be neglected, and Taylor instances
a case where the hair of a dog helped to clear up the case. If the
body has not been disturbed the most blood is usually found where
the deceased died. If the victim succumbs at the spot where he was
wounded, blood is found only in the immediate neighborhood, except for
arterial jets, which may be as far distant as two metres. The separate
blood-spots of an arterial jet are circular if the jet strikes the
object perpendicularly, oval or wedge-shaped with the larger end away
from the body if it strikes the object obliquely.
If the blood-stains are more diffused and are found in other places,
careful notice should be taken as to whether the different places
communicate with one another by traces of blood. If they do not
communicate, it goes to show that the body was moved after active
bleeding had ceased, that is, after death, but this indication is
not absolutely positive. If traces of blood do connect the larger
blood-spots, it is of interest and importance to know where the
deceased was wounded and where he died, also whether he moved or
if he was moved before or after death. This question is not always
capable of solution. Some injuries exclude the possibility of active
motion. Stupefying contused injuries of the head or an incised wound
opening a great artery are both inflicted where there is the greatest
hemorrhage, and the spot where the deceased was wounded and died should
be identical. In such cases a second large spot of blood, connecting
or not with the first wound, indicates that the body has been moved.
But if the wound does not bleed much or rapidly, the wounded person
may fall at a distance from the spot where he was injured, and death
occurs, as a rule, where there is the greatest amount of blood; for a
certain amount of bleeding occurs for a short time after the victim
falls or even after death. One can find in many places the signs of
arterial jets marking the movement of the deceased from one blood-spot
to another. This is quite different from the tracks caused by dragging
a bleeding body. All this it is important to notice, for the dragging
or passive moving of the body strongly indicates murder. Blood at a
distance may indicate the occurrence of a struggle, or that the body
was moved, or it may show the tracks of a murderer. As to the latter
point, _the imprints of the hands and feet_, whether bloody or not,
may indicate murder and establish the identity of the murderer. We
have already seen how they may occur on the deceased and indicate a
struggle, and thus be presumptive of murder. When the marks are made by
the naked foot, it is well to examine it by lining it off in squares,
and so to compare it with the imprint of the foot of the accused.
Simple inspection can sometimes give the required evidence. We may
even get an impression of such imprints in the snow. Imprints of the
boots or shoes worn by the accused compared with those imprints found
at and near the scene of the crime may sometimes help to clear up the
case, but this may perhaps be considered outside of the sphere of the
medical witness. Such and other signs of a struggle about one of the
blood-spots would indicate that the wound was received there, though
death may have occurred at another spot. In such a case it would be
well to examine to see if there was much blood where the body was
found, for if there was not it would indicate that the body had been
moved there after death, and thus be strongly presumptive of murder.
As furnishing some evidence which may help to distinguish between
suicide and homicide in the origin of wounds, the question may be
asked, WHAT WAS THE POSITION OF THE VICTIM WHEN INJURED OR DYING? and
also, WHAT WERE THE RELATIVE POSITIONS OF THE VICTIM AND ASSAILANT?
The position of the victim at the moment of the injury is sometimes
indicated by the position of the wound, the direction of its tract,
and the direction from the wound of the blood on the body and clothes.
On the neck or extremities the course and form of the wound may
indicate the position of these parts when the wound was inflicted,
for sometimes in flexions of these parts the skin lies in folds, and
a wound inflicted when these parts were so flexed would be irregular,
wavy, or zig-zag. Further, the position and movement of these parts
necessary to restore directness to the wound may indicate the position
of the parts when the wound was inflicted. The examination of the
relative positions of the wound in the clothes and the body may help
to indicate the position of the body when wounded. The position of
the blood on the body and the direction of the blood from the wound,
whether below or at the sides, etc., tends to show the position of
the body when bleeding. Thus if the body was at any time in the erect
position, some of the blood-stains will be vertically below the wound,
or if the victim was lying on the back then the stain would be at the
sides only and not below the wound, except such stains as indicate
that they were produced by arterial jets. Few suicides cut the throat
in the recumbent position; therefore it may be considered in the light
of an indication of homicide if the blood-stains show that the victim
was not erect after the wound was inflicted. It is well also to note
the form, direction, and obliquity of the blood-spot. This would
indicate, by comparison with the wound, the relative position of the
wounded person and the blood-spot, and thus show whether the body had
been moved or not, as, for instance, by the murderer for the purpose
of robbery. The force of the bleeding is also indicated by the form of
the spot, and this would indicate how rapidly death probably ensued.
This fact might thus help us to judge whether the victim probably died
where he was wounded, and whether other and remote blood-spots would
not be presumptive of murder. If the victim is found in night-clothes,
this fact would help to show that he was lying down when wounded. The
medical evidence as to the position of the victim when injured is,
therefore, circumstantial and not very positive; that in regard to the
_relative position of the victim and assailant_ is even less positive.
We presuppose in this question that the case is one of murder. We are
not to prove murder or refute suicide. We can rarely be _positive_ as
to the relative position of the assailed and the assailant. A wound
in the back may be caused by some one in front with an arm behind.
The direction of the wound would indicate this, for if the assailant
is right-handed and inflicts a wound on the back from in front, a
stab-wound would almost always be directed from left to right, an
incised wound from right to left, both from above downward. With a
left-handed murderer the direction would most likely be from right to
left and from above downward for a stab-wound, and from left to right
and from above downward for an incised wound. If the assailant were at
the back of the victim and wounded him in front, the direction of these
wounds would be the opposite of the above, _i.e._, from right to left
for a stab-wound and from left to right and from above downward for
an incised wound with a right-handed assailant and _vice versa_ with
a left-handed assailant. These wounds occur more commonly than those
of the back, and are especially noticeable in incised wounds of the
throat. In the case of these incised wounds of the throat inflicted
from behind, the direction from left to right and from above downward
resembles that of self-inflicted wounds in the same situation. As
a general rule, wounds are on the same side of the victim that the
assailant was; the facts given above help to show us the exceptions.
Thus a wound on one side is presumptive that the murderer was on that
side, or possibly at the front or back and only exceptionally on the
opposite side. The presence of wounds on one side only may help to
confirm the testimony of a witness that the victim was against a wall
or some other obstacle which protected the other side. The question of
the relative position of the combatants in duels and the nature of the
weapons used as shown by the wounds has sometimes come up, especially
in other countries, to determine whether the combat was regular and
fair.
In all cases of suspected suicide, but where a doubt exists between
suicide and murder, or even accident, _hereditary disposition and
organic affections_ of the body, such as alcoholism, incurable or
painful diseases, chronic inflammation of the brain and meninges or of
the genito-urinary organs—all such and hereditary predisposition may
support the idea of suicide.
IMPUTED OR SELF-INFLICTED WOUNDS.
Closely allied with the question of the suicidal or homicidal origin
of wounds is the question whether a wound imputed to another is
self-inflicted or inflicted by another. These wounds are seldom fatal.
In discussing the question whether a wound is self-inflicted or
inflicted by another, we have referred occasionally to suicidal wounds
where the circumstances were such as apparently purposely to imply
murder and impute the cause of death to some one else. This happens
more often in cases of unsuccessful suicide. Here we have recourse to
the same evidence that we have gone over in the present section which
helps to distinguish between a suicidal and a homicidal wound. The
case may be somewhat more difficult, as the unsuccessful suicide may
manufacture evidence against the accused and hide to some extent the
evidence of suicide. These cases can usually be decided, however, in
connection with the circumstantial and other evidence. The majority
of cases of imputed but self-inflicted wounds are very superficial,
often not below the true skin. Being self-inflicted they have many
of the characters of suicidal wounds. Thus they are usually situated
in front and on the left or right according as the wounded person is
right or left handed, and the direction is usually similar to that in
suicidal wounds. Such wounds are generally incised or punctured wounds,
seldom contused wounds, and in this respect they resemble suicidal
wounds. As exceptions to this rule, Bergeret[650] mentions some cases
where females in attacks of hysteria have inflicted severe contusions
on themselves, and have preferred charges of attempted murder against
innocent persons. Like suicides also the hands are seldom injured,
though they may be much so in resisting homicide.
In other respects, however, these wounds differ from suicidal wounds.
Thus they are not usually situated over a “mortal” spot, and they are
often numerous and _scattered_, sometimes parallel and sometimes not.
The wounds in the dress do not correspond even as often as in suicide.
In comparing cuts in clothing with those on the body, it is important
to find what articles were worn at the time the assault was alleged to
have taken place, and to make sure that the clothes examined were those
worn or alleged to have been worn. It may not be necessary that the
clothes examined should have been really worn, for if they were alleged
to have been worn and were not, the examination of them will almost
always show the deception or the self-inflicted nature of the wounds.
Then take careful note of the position, direction, form, and size
of the cut and the apparent sharpness of the weapon in the several
layers, and see if they correspond with one another and with the wounds
on the body in those various particulars. In imputed wounds the clothes
are generally cut when off the body and can seldom be done so as to
deceive a careful examiner. Several wounds cannot exist in the same
region of the body without some being bloody and showing the marks of
it on the clothes. Even a single wound of the clothes generally shows
blood on the inner surface if there is a corresponding wound of the
body underneath. In simulated and imputed injuries the blood-stain may
be on the outside of the clothing instead of on the inside, showing
that it was artificial and not natural. An impostor may either do too
much or too little, and the medical witness should be on guard against
both alternatives. Taylor[651] mentions a case which occurred in
London some time ago, in which there were _two_ cuts in the shirt near
together exactly alike in size, form, and direction, making it evident
that the weapon had gone through a fold of the shirt. This proved that
the shirt could not have been worn at the time it was cut, for if the
shirt was folded while on the body the weapon must have gone through
the fold and then through another layer of shirt, making three cuts
instead of two, or five instead of four, before it could have reached
the body. This and other facts made self-infliction of the slight wound
on the chest probable. The same author cites another case showing the
imperfect manner in which the cuts in the clothes are made in imputed
wounds, the clothes being off the body at the time. The case occurred
in Nottingham in 1872, the accused being charged with wounding the
plaintiff on the highway by stabbing him in the arm, though there was
no robbery or other motive for the act. The coat and shirt sleeve were
found cut, but there was no corresponding cut in the lining of the coat
sleeve. The charge was clearly false, and was trumped up by the youth
who was the plaintiff because he wished to leave the place where he had
been sent for private study.
In examining a case where the self-inflicted nature of imputed wounds
is in question, the following are some of the many points to keep in
mind in the examination and to be ascertained by the examination:
(1) The relative position of the plaintiff and the assailant at the
time of the alleged attack. This can be compared with the position
as stated by the plaintiff or other witnesses. (2) The situation,
direction, depth, nature, and number of the wounds. (3) The situation
and direction of blood-marks or wounds on the dress or person of either
or both. (4) The marks of blood and the quantity of it at the spot of
the alleged struggle. (5) The signs of a struggle and the various other
points of circumstantial evidence gone over in considering suicidal and
homicidal wounds.
Though a severe blow may cause a slight mark, it does not follow that
a slight mark implies a severe injury, else the exception is made the
rule. The inconsistency of the story of the plaintiff is generally so
palpable that imposture is evident, but prejudice and unjust suspicion
are often excited against those accused. Thus Taylor[652] states that
“a strong suspicion was raised against the then Duke of Cumberland, in
1810, in reference to the death of Sellis, when a skilful examination
of the wounds on the deceased would have shown that they might have
been self-inflicted.” The same author also cites the case of M. Armand,
a merchant of Montpelier, who at Aix in March, 1864, was tried for an
alleged murderous assault on, or imputed murderous strangulation of,
his servant. The excoriation on the back of the neck was so slight as
to escape the observation of some medical men, and it was evidently
self-inflicted, either accidentally or purposely, as the facts showed.
The assertions of a number of medical men were taken by the court to
support the servant’s story to the effect that his master had struck
him a severe blow on the back of his neck, rendering him insensible for
many hours from concussion of the brain. The evidence given chiefly by
Tardieu for the defence showed the story of the complainant to be a
fabrication, and the accused was justly acquitted.
WAS A WOUND ACCIDENTAL?
In answering this question we must distinguish accidental wounds from
those self-inflicted and those inflicted by another. These three
classes comprise all wounds. In case of a trial for murder it may be
alleged by the defence that the wound was caused by accident or that
it was due to suicide from a fall, falls being a common class of
accidental wounds. So we have to judge between accident on the one
hand and homicide and suicide on the other hand. The question arises
especially in cases where the injury causing death is one commonly due
to accident.
As to the QUESTION BETWEEN ACCIDENTAL AND SUICIDAL WOUNDS, they are
often easily distinguished, especially if the body has not been
disturbed. In suicide there is clear evidence of design, and the
circumstantial evidence helps to make the case clear. It may not always
be possible to decide, however, as an accidental wound may sometimes
resemble a suicidal or homicidal one. Accident is often shown by the
_nature_ of the wound. Thus it is rare for an accidental mortal wound
to be caused by a knife or similar weapon held in the hand and forced
into the body by a fall, the blow of an opening door, etc. But such
exceptional cases have been reported. Incised and punctured wounds
are, therefore, very rarely accidental, and most accidental wounds are
contused wounds or contusions.
Again, accident is often shown by the _situation_ of the wound, which
should be on an exposed part of the body unless the accident is due to
a fall from a height, when the wound may be almost anywhere. But such
injuries are easily shown to be due to falls. The fall, of course,
may be accidental, suicidal, or homicidal. Some wounds in exposed
parts forbid accident on account of their nature, _i.e._, deep incised
wounds of the throat. If the deceased has a life insurance, suicide
is less probable, as the insurance is not paid in case of suicide. In
fine, accidental wounds are distinguished from suicidal by—(1) Their
_nature_; accidental wounds are almost always contused, suicidal very
rarely so, only in cases of lunatics and delirious persons and where
suicide is accomplished by a fall. (2) The situation of the wound or
wounds indicates their origin. We have already studied the situation
of suicidal wounds and have also seen that accidental wounds are only
on exposed parts, except when the injury clearly indicates a fall from
a height. The evidence from the direction of wounds rarely applies, as
this is valuable only in incised and punctured wounds, which are seldom
accidental. Both kinds of wounds are usually few in number except in
case of a fall from a height or a crush, though sometimes suicidal
wounds are multiple.
The evidence from weapons, if there be any, points strongly to suicide.
The signs of a struggle are hardly consistent with either suicide or
accident. The only case in which they might occur would be where a
struggle occurred to prevent a suicide from throwing himself off a
height or before a vehicle or railway train. In such a case accident
would be excluded by the signs of a struggle, and the question would
lie between homicide and suicide. The examination of the clothes of
the deceased would furnish no evidence unless some letter or paper
were found stating the purpose of committing suicide. Little or no
evidence would be furnished by the position of the body when found
in cases which might otherwise be doubtful. Organic lesions or other
facts predisposing to suicide would furnish presumptive evidence
against the wounds being accidental. Of all these various points the
first, as to the nature of the wounds, is by itself the most valuable
and conclusive. But this gives us no assistance in clearing up a case
where it is doubtful whether a fall from a height or a crush by a
vehicle or railway train was accidental or suicidal. Some of the other
points mentioned may aid us in such a case, and also the fact that such
injuries are far more often accidental than suicidal. But in these
cases, also, certain circumstances may show that the fall was not the
result of accident.
Accidental wounds are generally caused by a fall or a crush, and
the fact of their accidental character is generally established by
the circumstances of the event. Certain accidental wounds present
characteristics which allow the true nature of the wounds to be
determined. But in some cases a suspicion may arise and the question
may be asked as to WHETHER THE WOUND WAS ACCIDENTAL OR HOMICIDAL. For
instance, if a person receives fatal homicidal injuries, and just
before or after death the body is thrown from a height or is run
over and crushed, it may be hard to determine the murderous element
among the many wounds. This is the case if the homicidal wounds were
contusions or were caused by blunt instruments, but rarely, if ever
so, if they are incised or punctured wounds or both. But even in the
former instance, a close examination of the lesions and of the locality
of the injury can often clear up the case. Thus in a case mentioned
by Vibert,[653] as cited by Hofmann after Taylor, a woman was found
dead at the foot of some stairs in a cave. She had died of a fracture
of the skull and of the spine, produced by the fall. But about four or
five feet above the level of the top step there was found on the wall
the fresh marks of an arterial jet of blood. Examination showed a wound
in the right temporal region which had opened the temporal artery, and
it was therefore thought that the woman was wounded at the top of the
stairway and then thrown down, which was afterward proved to be true.
In another case, reported by M. Tourdes, a man knocked down and killed
by an axe, which crushed his skull and caused the brain to exude, was
placed in a road frequented at night by heavy wagons. The head was
placed in the rut, but the coagulated blood and brain formed a puddle
which did not appear on the wheels or their track, and no bloody furrow
was caused by their passage. The same author mentions the case of a
woman plainly strangulated by the hands and then thrown into the ditch
of the fortifications of Paris.
It is especially with regard to fractures of the skull that the
question often comes up as to the accidental or homicidal nature of
the injury, as to whether it is due to a fall or a wound. Sometimes a
depressed fracture may show the form of the instrument. An extensive
comminuted fracture of the skull may indicate greater violence than
would be received from a fall from the little height which the
circumstances may allow. As to the slighter degrees of fracture,
the disposition of the fracture itself often shows less than the
form and site of the ecchymosis, the lesion of the scalp, and the
place and position of the body when found. In such cases the traces
of a struggle, the existence of other wounds, etc., may be of great
importance. In distinguishing between homicide and accident, as in
distinguishing between the latter and suicide, the most obscure and
difficult cases are those where the injury has been caused by a fall
from a height or by a crush.
This is illustrated by the case of Madame de Tourville, which is
quoted by Taylor.[654] She was killed in July, 1876, by a fall from a
precipice. Her husband, a lawyer, was accused of murder committed by
pushing her over a precipice in the Stelvio Pass. The place where her
dead body was found was at a considerable depth below, and the injury
was chiefly in the head, which had been crushed by the fall. The body
showed no evidence of intentional violence. The prisoner’s guilt was
established on the following points: (1) The false and inconsistent
statements made as to the occurrence; (2) the marks of the body having
been dragged some distance so that a part of the dress was found, in
a bloody condition, some way from the body; (3) there were marks of
blood on the prisoner’s hands and clothing. After a long trial he was
convicted, though the sentence was afterward commuted to imprisonment
for life. Of course, as we have already stated, if a person is
responsible for a fall he is also responsible for the results of the
fall. This applies to many of the contused injuries and deaths from
falls in prize-fights and drunken brawls.
We may sum up the points of evidence which help us to distinguish
between an accidental and a homicidal injury much as we did when the
question lay between accident and suicide. (1) The evidence from the
nature of the wound is not quite so conclusive as when the question
lies between suicide and accident. For contusions and contused wounds
are far more often homicidal than suicidal, and accidental wounds
are almost always of this class. If, however, the wounds are incised
or punctured, this fact points almost certainly to homicide. (2) As
to situation, a homicidal wound may be situated almost anywhere; an
accidental wound, except in falls from a height, only on an exposed
place. (3) The direction of the wound can seldom help us in the case
of contused wounds which, practically, are the only ones in question,
though it may possibly be incompatible with accident. (4) As to the
number of wounds, homicidal wounds are far more apt to be multiple
either in a small area or scattered in such a way that an accident
could hardly account for them all. (5) A weapon may give evidence more
often here than when suicide is in question, for a weapon may be used
to inflict contused wounds which may resemble those received in a fall.
The evidence furnished by a weapon or blood, hair, etc., on the weapon,
etc., is strongly in favor of murder. (6) The evidence from a struggle
is also more important because it is more often found. A struggle may
occur in homicide, and only in homicide, as a rule, so that signs
of a struggle are strong evidence of murder and against the idea of
accident. (7) The examination of the clothes and body of the deceased
may give valuable evidence, showing, as it may, signs of a struggle or
other marks of an assailant and indicating murder. (8) Examination of
the position and attitude of the body and of the spot where it lay and
the ground around may furnish more or less proof of murder, as in the
case quoted above. Thus the track of the murderer may be discovered
or the body may have been interfered with and moved or robbed, all
indicating homicide.
In any case, whether it is desired to distinguish accidental from
suicidal or homicidal wounds, those cases present the most difficulty
which result from falls from a height or crushes. But, as the case of
Madame de Tourville shows, the above given and other circumstances may
often show even then that the fall or the crush was not the result of
accident.
FALLS FROM A HEIGHT may, therefore, be the result of suicide, homicide,
or accident. The injuries are similar in all three cases. A fall of six
to eight metres causes, as a rule, numerous lesions, and shows such
a traumatism that the case usually excludes the possibility or, at
least, the probability that the wounds resulted from blows. Sometimes,
however, the gravity of the lesion is not proportional to the height
of the fall. Thus Vibert[655] relates the case of a man, afterward
employed for several years in the École de Médicine, who jumped from
the top of the column of the Bastile, a height of fifty metres. He
rebounded on to some canvas stretched at the foot of the monument, then
fell to the ground, and was able to get up and walk away. Curiously
enough, he killed himself later by jumping from the top of an omnibus
in motion. In the case of falls from a height, it is especially true
that with grave lesions internally the skin may be intact or only
slightly ecchymosed or eroded, or the ecchymosis may be only deeply
seated so as not to appear superficially. In the latter case, if life
had continued the ecchymosis might have shown itself at some spot on
the surface in a few days, but these falls from a height are fatal as
a rule. In falls from a height, besides ecchymoses, which may occur
where there are no other injuries or may fail where there are many
injuries, the _lesions_ consist of fractures of bones and ruptures of
internal organs, with or without surface wounds. The _fractures_ may
be of a number of bones, and especially of those which first touched
the ground, though the skull may be fractured at some part whether or
not it was struck in the fall. These fractures are often comminuted,
especially fractures of the skull and pelvis, and when the fall is from
a great height. Ruptures of muscles may occur with the fractures.
Ruptures of internal organs are not rare in such cases. According
to Vibert,[656] the order of frequency of rupture of the various
organs is as follows: liver, spleen, kidneys, lungs, heart, stomach,
intestines, bladder, brain. Rupture of the liver occurs especially on
the anterior and inferior surfaces and the bleeding is rather abundant.
The healthy spleen does not rupture readily, except from a severe
traumatism, but if it is hypertrophied it may rupture spontaneously
from muscular violence. The lung may be ruptured internally without
showing the rupture on the surface and with the ribs intact. Two such
cases are mentioned by Vibert,[657] and he refers to others mentioned
by Nelaton and Holmes. Rupture of the brain without fracture of the
skull is very rare, though cases have been observed and reported,
among others by Casper-Liman. In falls from a height the rupture of
the aorta, mesentery, diaphragm, and larynx have been noted. It should
be remembered in this connection that rupture of the liver, intestine,
bladder, etc., may be caused by contusions without sign of violence
externally, and such cases cannot, therefore, be attributed to falls
unless there are other signs of the latter.
In _crushes_ caused by a heavy vehicle, the lesions resemble in many
respects those due to a fall from a height. Thus we find fractures and
internal ruptures, but we more often and regularly find subcutaneous
ecchymoses and ecchymoses between the muscles. The skin is often
stripped up extensively and the injuries are generally limited to the
region injured. It is rare to find that the cause of the injury leaves
no trace on the skin, for it usually gives the form to the erosions
or ecchymoses. Sometimes, for instance, the marks of a horseshoe are
clearly visible. Ruptures of internal organs may occur here too when
there are slight external marks of violence or even none at all. Thus
Vibert[658] relates the case of a man with the head crushed, but with
no signs of injury to the trunk save a few erosions at the level of
the sternum, who had not only rupture of the kidneys, the liver, and
the spleen, but also of the lungs and of the heart. In the heart the
apex was completely detached and floating in the pericardium, which
was intact. There was no fracture of the ribs nor subcutaneous or
sub-muscular ecchymoses. The age of the subject was thirty-two, so
that the costal cartilages were not probably ossified, which may have
accounted for the absence of fracture of the ribs.
_Crushes by the fall of heavy weights_ resemble the latter class of
crushes, and differ from falls from a height in the fact that the
wounds are usually limited to one region. The lesions themselves are
more or less similar. Similar internal lesions may be caused by the
compression of the chest and body by the knee of a murderer, which may
occasion rupture of the internal organs, fractures of ribs, etc. Thus,
too, from the pressure of a crowd the ribs may be fractured and the
lungs injured. It is particularly in these cases of injury from crushes
or falls from a height that we may have most difficulty, as far as the
medical evidence goes, of distinguishing between accident, suicide,
and murder. But the various points and considerations mentioned above
will sometimes enable the medical witness to clear up the case. In
some cases the non-medical evidence, circumstantial and otherwise, may
be sufficient of itself, or at least in conjunction with the medical
evidence.
In falls from a less high place the difficulty is somewhat different,
for here there may arise the question between a fall and a contusion or
contused wound, and the question generally lies between accident and
murder, or, very rarely, between accident and suicide. We have referred
to both of these questions above, and from the facts mentioned the case
can often be solved.
OF MORE THAN ONE INJURY WHICH WAS THE FIRST INFLICTED?
We can sometimes tell the order in which wounds were received, but
the question is rarely answerable with certainty. If one wound is
mortal and one or more are not, whether the wounds are suicidal or
homicidal, it has sometimes been considered that the former must have
been inflicted last. But we cannot admit that as a general rule the
most grave wound was the last inflicted. For the murderer or suicide,
especially the former, may go on wounding after the infliction of a
mortal wound, especially as it is the exception, and not the rule,
to die instantly after a mortal wound. Several assailants may have
inflicted wounds at the same time, which would still further increase
the difficulty. The question might then arise, Which assailant had
inflicted the mortal wound or which had first inflicted a mortal wound?
Under such circumstances, it would not be easy to give a specific
answer. There are several signs which may indicate which wound was
first inflicted in certain cases. An instrument may become duller or
even bent or twisted after and on account of the first wound, and the
subsequent wounds would vary accordingly. The wound of the clothes
corresponding to the first stab-wound may be and often is only bloody
internally, while the second and following wounds are bloody on both
sides. The following case quoted by Taylor[659] from the _Annales
d’Hygiene_, 1847, p. 461, illustrates this point. A man received three
stabs from an assailant, one in the back at the level of the eighth
rib, traversing the lung and heart and causing rapid death, and two on
the left elbow, cutting the coat and shirt but only grazing the skin.
The first one was evidently the first inflicted, for both the wounds in
the clothing on the arm were bloody externally at the edges, although
there was no blood effused here. The correctness of this opinion was
confirmed at the trial.
The point of a knife arrested and broken off in a bone may show that
this was the last wound. The amount of bleeding may show which was the
first wound. Thus if several severe wounds have been inflicted, all
or several of which would naturally cause profuse hemorrhage, and one
showed signs of such hemorrhage while another did not, the former would
be likely to be the first wound inflicted. Or if one showed slight
hemorrhage where much would be expected, this fact would indicate that
it was one of the last inflicted. The absence of the signs of spurting
blood may tell which of two or more fatal wounds were first inflicted,
for this would indicate that this wound was inflicted when the heart
action was weakened by loss of blood or even after death, and the
other wound or wounds which did not present this sign would have been
the first received. In fact, if any of the signs are present about a
wound which we have seen to indicate that a wound was inflicted at any
time after death, this would show that this wound was not the first
received, and that the other or others were inflicted earlier.
Questions as to the CONSEQUENCES of WOUNDS NOT FATAL may often be
brought up in civil actions for damages. In certain countries the
question of the consequences as to _incapacity_ may determine whether
an injury shall be the ground of a criminal as well as of a civil
action. Thus in France an injury which involves an incapacity of twenty
days or more subjects the assailant to a criminal action. The term
“incapacity” in this instance refers to general incapacity and not
to incapacity for fine and professional work. The latter, however,
comes in under the civil action which may be instituted against the
assailant or those directly or indirectly responsible for the injury.
The amount of the incapacity, its causes, whether due wholly or partly
or not at all to the given injury, the probable duration of the
incapacity, the treatment which it has and will necessitate, and many
other such questions form part of the medical testimony required in
such cases. Sometimes with slight wounds the results, accompaniments,
and complications may prolong the incapacity very greatly, as also the
state of health and the habits of the wounded person, the neglect of
treatment, improper treatment, etc.
Any bodily or mental infirmity or ill-health which may result from an
injury and its necessary treatment in the past and future, all these
questions and many more unnecessary to mention may be required of the
medical witness. No general rules can be laid down for all such cases.
In giving his testimony the medical man must depend in any particular
case upon his knowledge, judgment, and experience.
We can seldom give a precise solution of the _question of survival_
to determine the succession or inheritance if several of a family die
together in an accident. In case of death from inanition, cold or heat,
or in drowning especially, if some have wounds more or less grave in
themselves, we can sometimes form an opinion. With wounds we cannot
often do so, although in case of murder, the nature of the wounds, the
position of the bodies, the examination of the spot of the accident or
tragedy, may sometimes help us to form an opinion.
INCISED AND PUNCTURED WOUNDS AND WOUNDS OF BLUNT INSTRUMENTS REGIONALLY
CONSIDERED.
The several varieties of wounds which we have been considering vary
considerably in their nature, their effects, their danger, and in
many other ways according to the region of the body in which they are
situated. Some of these varieties are common in one situation and
almost never occur in others. Although the nature of wounds found in
the several regions of the body is not as important for a medical
jurist as their danger and their influence in causing death, we will
now consider the differences they exhibit on account of the region in
which they occur.
WOUNDS OF THE HEAD.
These are often characterized by their apparent harmlessness and
their real gravity sooner or later. We might almost make the opposite
statement and say that those apparently grave are often virtually
harmless, though this would be true only in a limited sense and in
certain cases.
As to their _nature_, we find punctured wounds extremely rarely,
incised and lacerated wounds often, while contusions and contused
wounds are still more common. _Incised and lacerated wounds_ of the
head involve the scalp almost exclusively. These wounds heal remarkably
well, even when the attachment is merely by a narrow pedicle, owing
to the abundant blood-supply. Hemorrhage from the incised wounds is
often free, for the vessels cannot retract, but it is seldom dangerous
unless the wounds are very extensive. The only way in which they differ
materially from similar wounds elsewhere is in the greater frequency
of complicating erysipelas here than elsewhere. This is probably
owing to the presence of septic conditions, as the head is generally
dirtier than other parts of the body, and slight wounds especially
are neglected. If the scalp is shaved over a wide margin and cleaned
like other parts of the body, erysipelas is found little or no
oftener than with similar wounds elsewhere. The density of the scalp
is so great that the redness and swelling accompanying inflammations
is comparatively slight. If erysipelas follows slight wounds of the
head, there is some reason to suspect constitutional predisposition or
careless treatment. From infection of such wounds of the scalp abscess
or diffuse cellulitis of the scalp may develop as well as erysipelas.
The constitutional symptoms in such a case may be marked or even
severe, but the prognosis is favorable. In very rare cases necrosis of
the skull may result or the inflammation may even extend to the brain.
These incised and lacerated wounds of the scalp are usually accidental
or inflicted by another; they are rarely self-inflicted. _Contusions
and contused wounds_ are the most common forms of injury to the head.
These two kinds of injuries are almost invariably inflicted by another
or are accidental. We have already seen that contused wounds of the
scalp or over the eyebrow may closely resemble incised wounds in these
localities. This fact should be borne in mind, as careful examination
can usually distinguish them if they are fresh and until they begin to
granulate. These wounds are liable to the same complications as incised
wounds, in fact more liable, as the contusion makes the wound more
susceptible to inflammation and the edges are more apt to be infected
at the time of the injury.
One of the _results_ of contusions of the head is the extravasation of
blood, most often between the aponeurosis of the occipito-frontalis
muscle and the pericranium. These extravasations are usually in the
form of a hematoma. Such hematomata often present a hard circular or
oval rim with a softer centre, and may readily be mistaken for fracture
of the skull with depression. The diagnosis between hematoma and
depressed fracture is not usually difficult, however, for with hematoma
the ridge is elevated above the level of the skull and is movable on
the surface of the skull; also the wounded edges often pit on pressure.
With depressed fracture, on the other hand, the edge is at or about the
level of the rest of the skull; it is sharper, more irregular, and less
evenly circular. Contusions and the resulting hematoma may occasionally
end by suppurating, but this event is rare. Contusions and contused
wounds may occasionally show the marks of a weapon, indicating that
they were inflicted by another. Also the position of the injury will
indicate its origin, whether it is accidental or inflicted by another,
for the former would not naturally occur on the vertex unless the fall
was from a considerable height.
Another result of injuries to the head, especially of contusions and
contused wounds, is FRACTURE OF THE SKULL. This may be simple or
compound, depressed or not, etc. Fractures are serious inasmuch as
they imply a degree of violence which may do damage to the brain.
The fracture itself, especially if properly treated, affords a good
prognosis, irrespective of any brain lesion. One variety of fracture of
the skull offers an exception to this favorable prognosis, and that is
fractures of the base of the skull. These may be fatal directly from
injury of the vital centres at the base of the brain or soon fatal from
hemorrhage in these parts. Or the fatal result may be secondary to an
inflammation or meningitis which good treatment is often unable to
prevent. It should not be considered that these fractures are uniformly
fatal, for quite a considerable proportion recover. Fracture of the
base usually occurs as the result of a fall. The injured person may
land on the feet or buttocks, and yet receive a fracture of the base of
the skull, the force of the fall being transmitted through the spine to
the base of the skull. Fracture of the base of the skull usually occurs
from an injury to the vault, not by _contre coup_, but by extension
of a fissure found higher up in the skull. This extension takes place
in the same meridian line of the skull with that of the force which
produced the fracture, and in this way the base of the skull is
fractured in different parts according to the point and direction of
the application of the force. Thus in case the force compresses the
skull antero-posteriorly the fracture will pass antero-posteriorly
toward the base from the front or the back, whichever received the blow
(see Fig. 13). Fractures of the vault of the skull occasionally occur
opposite to the point struck; this may occur by _contre coup_, but not
always so, as not infrequently in such rare cases a close examination
may reveal an extension of a fissure from the point injured to the
opposite pole of the skull. The shape and rarely the size of a fracture
of the skull, especially if punctured in character, may show the shape
and more rarely the size of the instrument or object which produced
it. Apart from fracture of the base, the prognosis in fracture of the
skull is serious, mainly on account of the danger of inflammation,
which is greater in compound fractures, and also on account of the more
remote danger of irritation from depressed fragments causing epilepsy,
insanity, etc., at a later period.
[Illustration: FIG. 13.—Several Fractures of the Left Half of the
Base of the Skull, Running Parallel to One Another and Approaching One
Another, also Separation of the Mastoid Suture. The injury was caused
by a fall on the left side of the back of the head.]
A circumstance that Taylor[660] says is connected with fracture of the
skull with depression—namely, that the person, sensible as long as the
object producing the fracture remained wedged in, became insensible and
began to manifest other fatal symptoms as soon as it was removed—must
be extremely exceptional. It may be explained, if it occurs, by the
occurrence of hemorrhage after the object which occluded an open
vessel by its presence or its pressure was removed. For it should be
remembered that the symptoms of compression in a depressed fracture
of the skull are very rarely due to the compressing effect of the
depressed bone, but rather to an injury of the brain, intracranial
hemorrhage, or a local and temporary interference with the circulation.
[Illustration: FIG. 14.—“Terraced” Fracture of the Left Parietal Bone
near the Sagittal Suture, caused by the Lower Part of the Rim of a
Round-Headed Hammer. The blow was struck from the right side. ½ natural
size.]
We may truly say that wounds of the head are dangerous in proportion as
they affect the brain. The existence of affection of the brain may be
hard to tell from the appearances, for an injured person may recover
from the first effects of a comparatively slight wound and yet die
suddenly later.
=Concussion= is the name applied to one of the effects on the brain
of a more or less violent blow directly on the head or transmitted
indirectly to the head. Though the term “concussion” implies a
functional rather than an organic lesion, yet in the majority of cases
it is equivalent to laceration of the brain. With laceration of the
brain there is usually more or less effusion of blood which may be
limited to a very thin layer. Concussion may exist without laceration
of the brain. Even death has been known to occur from concussion of
the brain without any visible signs of injury to the brain, so that
the concussion must have been functional and the fatal result due to
shock of the nervous system. Fatal concussion does not, therefore,
necessitate the existence of compression or visible injury of the
brain. Concussion may sometimes be due to a violent fall upon the feet,
in which case the shock is transmitted through the spinal column to
the head with or without fracture of the base of the skull. It was in
this way that the Duke of Orleans, the son of Louis Philippe, died.
[Illustration: FIG. 15.—Fractures of the Skull caused by a Four-sided
Hammer. One caused by the Corner, the Other by the End of the Head of
the Hammer. ¼ natural size.]
[Illustration: FIG. 16.—Four-sided Fracture caused by a Hatchet-Shaped
Instrument, the Edges Formed by Depression of the Broken Outer Table of
the Skull.]
The _symptoms of_ concussion show all degrees of severity. Thus the
injured person may become confused and giddy with or without falling,
he may become pallid and nauseated and may vomit, but after a short
period he recovers gradually.
[Illustration: FIG. 17.—Fracture of Parietal Bone with Depression,
caused by the Blow of an Axe.]
With a more severe injury, with which there is generally some
laceration of the brain, the injured person falls and lies quiet
and relaxed, apparently unconscious, though often he can be partly
roused. Paralysis and anæsthesia are absent. The heart is feeble and
fluttering, the skin cold and clammy. The pupils, as a rule, react
to light, but otherwise vary considerably. Urine and fæces may be
passed involuntarily. As he begins to regain consciousness, vomiting
usually occurs. Consciousness usually returns within twenty-four or
forty-eight hours, when headache and indisposition to exertion are
complained of, and this may last for a long time. Occasionally the
symptoms instead of abating increase, and coma supervenes, often
indicating meningitis, encephalitis, or intracranial hemorrhage. In
other cases the person may die almost immediately on the spot where he
fell, while in still others apparent recovery takes place and death
occurs later either suddenly or after a reappearance of symptoms.
In such cases, _abscess of the brain_ may occur and be the cause of
the fatal result. These abscesses are the result of the injury, which
may be almost anything from a compound fracture to a slight contusion
not leaving any scar. The abscess may occur within a week[661] or not
until after months or years. This interval of apparent recovery may
lead to the false supposition that death was not due to the injury,
but to some intervening cause. It is well to bear in mind that about
half of the cases of abscess of the brain are not traumatic. A large
majority of these are due to suppuration in the middle ear, a few to
septic diseases or tuberculosis. The situation of the abscess often
distinguishes between the traumatic and non-traumatic varieties. The
traumatic variety is usually found beneath the injury or sometimes
directly opposite, where the brain is injured by a kind of focussing
of the radiated effects of the blow. The cases of abscess of the brain
due to ear disease are usually found in the temporal lobe of the brain
lying over the position of the ear or in the cerebellum behind it.
The uncertainty of the nature and the extent of the cerebral injury
in so-called contusion of the brain renders it necessary to be very
careful in giving a _prognosis_. Any injury should be considered
serious which has produced unconsciousness, for such an injury may
produce enough laceration of the brain to render serious danger
possible or even probable. We have seen that as a rule the symptoms
of concussion come on immediately, but it is possible that symptoms
at first so slight as to escape notice may become serious in a few
hours or days. A gradual hemorrhage may sometimes account for this.
The knowledge of certain acts performed or a conversation held at the
last moment before the injury may be retained after recovery from
concussion of the brain. This is not necessarily the case, for instead
of remembering up to the moment of the injury, the injured person may
remember only up to a certain time shortly before, or a part and not
everything may be remembered.
[Illustration: FIG. 18.—Wounds of the Vault of the Cranium caused by
Artillery Side-Arms, followed by Death shortly after.]
The _diagnosis_ of concussion of the brain _from alcoholism_ is
sometimes a matter of medico-legal interest or importance. Concussion
may be so slight as to simulate intoxication. The history often clears
the case up. The history of a blow or a fall or the presence of marks
of violence on the head indicates concussion, though the blow or fall
may not have caused the symptoms, which may be due to alcoholism. The
odor of the breath may indicate alcoholism, but here too we may have
both present and the concussion may be responsible for the symptoms.
Or again the alcohol may have been given as a heart stimulant after
the accident. This combination often occurs. If there is no odor in
the breath, the presumption is in favor of concussion. As mistakes are
still not infrequently made in diagnosis, those cases in which there
is any ground for doubt should be carefully watched for developments.
In general, the existence of concussion is more often overlooked than
the coexisting alcoholism, so that if there is any doubt in a given
case it should be treated as one of cerebral injury. The injury which
causes the concussion in such cases is often due to the alcoholism. We
may be able to verify this supposition if the injury is such as would
be likely to be caused by a fall. There may be nothing found in the
brain after death to distinguish between concussion and alcoholism. A
bruise on the head only indicates a probability of concussion, for the
bruise and alcoholism may both be present, the former perhaps due to
the latter. The presence of alcohol in the stomach would indicate the
existence of alcoholism.
Another effect of an injury which has caused concussion of the brain
is an _extravasation_ or _effusion of blood_. Extravasation of blood
in or on the brain is one of the commonest causes of death from injury
to the head. It may occur with or without marks of external injury. A
person suffering from such an extravasation of blood may recover from
the first effects of the injury, and at a varying time afterward the
symptoms may return and increase so as to result fatally. In such a
case the opening of the bleeding vessel may have become plugged until
some exertion, emotion, or excitement on the part of the injured person
has loosened the plug. A hemorrhage may have ceased from partial
syncope and return with a stronger heart action due perhaps to the
administration of alcohol. This effusion may occur on the surface of
the brain in connection with a superficial laceration of the brain or
just beneath or outside the dura mater and not involving the brain
directly. The latter cases are almost always due to the effects of
violence, though there is at least one case of apparently spontaneous
rupture of the middle meningeal artery. The violence which causes
a rupture of the branches of this artery may be so slight as to
leave no bruise or so severe as to cause fracture of the skull. The
most important symptom of such extradural hemorrhage is a period of
consciousness after recovery from the first effects of the injury,
then stupor may appear and deepen into coma. A subdural hemorrhage may
cause almost the same symptoms, though the injury is usually such as
has produced a depressed fracture. This hemorrhage is most often due
to the rupture of a number of small vessels under the fracture, though
if one larger vessel is ruptured it is most often the middle cerebral.
A thin layer of hemorrhage in connection with a superficial laceration
of the brain is of frequent occurrence with or without the other two
forms of intracranial hemorrhage. If the brain is lacerated we may have
convulsions in addition to other symptoms. Death occurring during or
soon after a prize-fight may occur from some of the above classes of
intracranial extravasations. It may be questioned whether the blows or
a fall caused the hemorrhage. It is generally due to a fall in such
cases, but may be due to blows, but the guilt is the same unless the
fall was accidental. As the result of severe traumatism the vessels of
the interior of the cerebrum may be ruptured or hemorrhage may occur
into the ventricles of the brain. In such cases the symptoms will
resemble those of ordinary apoplexy, only the cause is different from
the latter and the injury is usually so severe as to leave no doubt as
to the existence of a traumatism. The following question may arise in
cases of intracranial hemorrhage and especially in the latter class of
such cases, _i.e._, in cerebral hemorrhage:
WAS THE EXTRAVASATION OF BLOOD DUE TO DISEASE OR VIOLENCE?—It may
be alleged in defence that the hemorrhage was the natural result
of disease. Where the hemorrhage is extradural or subdural or in
connection with a superficial laceration of the brain, the cause is
almost always traumatic. We have referred to one case of extradural
hemorrhage from spontaneous rupture of the middle meningeal
artery.[662] Subdural hemorrhage may occur from _Pachymeningitis
hæmorrhagica interna_, but this condition is readily diagnosed on
post-mortem examination and often with considerable certainty during
life. A history of alcoholism, headache, impaired intellect, unsteady
gait, occasional losses of consciousness, stupor increasing to coma,
etc., indicates such a condition.
It is in cases of cerebral hemorrhage that there is the most difficulty
in discriminating between that due to disease and that due to injury.
It may be alleged that the hemorrhage was from diseased vessels, or
that the effects of a blow, which cannot be denied, were aggravated by
disease of the cerebral vessels or by excitement due to intoxication or
passion. Cerebral hemorrhage from disease is rare before 40 years of
age, except in alcoholics. When the hemorrhage is due to disease the
blood-vessels are diseased. The most frequent site of such hemorrhages
is the course of the lenticulo-striate artery in the ganglia of the
base or the white substance of the centrum ovale.
When injury is the cause of the hemorrhage it is usually found beneath
the point injured or directly opposite to this. External signs of the
blow are generally visible if it be severe enough to cause a cerebral
hemorrhage. The vessels may be perfectly healthy and the victim quite
young if the hemorrhage is due to an injury, also the ruptured vessels
may be plainly torn. The most difficult cases are those where there
is the history of an injury and at the same time such a condition of
disease of the cerebral vessels, etc., as would account for spontaneous
hemorrhage. Where the injury was slight in the case of alcoholics or
aged people the medical witness should be especially careful in stating
that a cerebral hemorrhage was due to the injury. Then, too, in the act
of falling from the occurrence of a cerebral hemorrhage due to disease
the head may be injured and show marks of violence. It should be borne
in mind that an injury to the head may be inflicted when disease of the
brain, vessels, or membranes already exists. In such a case a slight
blow might cause extensive hemorrhage, but as that which accelerates
causes, death, even though it might sooner or later have occurred in
the same manner without injury, is due to the injury inflicted.
From the above considerations we see that spontaneous cerebral
hemorrhage and that due to disease are not always easily distinguished
from that due to violence. In severe injuries the structure of the
brain is plainly bruised, etc., but the greatest difficulty exists in
cases of slight violence where arteritis of the cerebral blood-vessels
coexists. The spontaneous extravasation of blood in or upon the brain
from excitement does not usually occur except with diseased vessels,
old age, or alcoholism. It is rare, therefore, in the young and
healthy. If there is any doubt as to the origin of the hemorrhage, the
medical witness should state the cause most probable in his judgment.
Taylor[663] supposes the case of a man excited by passion, alcohol,
or both, who becomes insensible and dies after being struck a blow so
slight that it would not have affected a healthy person. If examination
reveals a quantity of blood effused into the substance of the brain,
there can be little doubt in the mind of the medical man that the
excitement was the principal cause of the effusion. On the other hand,
if a severe blow or a violent fall on the head had been received in a
personal conflict with another and it is found that death was due to an
effusion of blood upon the surface, there can be little doubt in the
mind of the medical examiner that death was due to the blow, which
would satisfactorily account for the conditions found without reference
to coexisting excitement, etc. In fact, in all cases where a question
is raised as to the cause of the hemorrhage, it is most important to
consider whether the violence was not sufficient to account for the
hemorrhage without the coexistence of disease or excitement. It is
also most important to bear in mind that after severe injuries, as
after a fall, causing extensive fracture of the skull, followed or not
with extravasation of blood, the injured person may walk about and die
some distance from the place of the accident and where no chance for
a similar accident exists. In this way the suspicion of murder may be
occasioned, as illustrated in the following case cited by Taylor:[664]
A man was accused of the murder of his companion, who was found dead in
a stable with fracture of the temporal bone which had caused rupture of
the middle meningeal artery. The accused stated that the deceased had
been injured by falling from his horse the day before. After the fall,
however, the deceased had gone into a public-house, where he remained
some time drinking before returning to the stable. The extravasation
had here taken place gradually, as is characteristic of hemorrhage from
the middle meningeal artery, and perhaps the excitement due to the
drinking had influenced it.
THE DATE OF AN EFFUSION OF BLOOD may sometimes be a matter of
importance in determining whether a given extravasation of blood in or
on the brain was caused by a recent blow or had existed previously. The
color and consistence of these effusions indicate whether they are old
or recent; the precise date we cannot state, but the information we
can give is often all that is required. The color of recent effusions
is red, which changes after some days to a chocolate or brown, which
generally turns to an ochre color (see Plate I.). This latter color
may be met with from twelve to twenty-five days after the injury. The
consistence of the coagula also becomes firmer with age, and as the
coagula become firmer they are more or less laminated and the expressed
lymph may lie between the laminæ or around the coagula.
[Illustration: MEDICAL JURISPRUDENCE—PLATE I.
EXTRAVASATIONS IN SEVERAL PORTIONS OF THE ARACHNOID, WITH HEMORRHAGES
IN NEIGHBORING PORTIONS OF THE BRAIN. DEATH IN FOUR DAYS.
CEREBRAL ABSCESS. EPILEPSY, PARESIS. DEATH 3¼ YEARS AFTER THE INJURY.
RECENT AND OLD CEREBRAL EFFUSIONS.]
On account of the many layers of the brain coverings, a rough diagram
of the coverings as given by Taylor[1] may be of much use to the
medical expert in illustrating his evidence so as to make it clear to
the court (see Fig. 19).
=Wounds of the brain= vary very widely in their immediate results
according to the part of the brain injured. Thus sometimes a slight
wound of the brain may be instantly fatal and often a severe wound in
another part is not so. Extensive wounds may occur especially in the
frontal lobes with remarkably slight disturbance. If a person with a
wound of the brain survives the first effects of the injury the danger
of inflammation remains. This danger may not be removed for a long
time, for the inflammation may develop very slowly, not showing itself
for from three to ten weeks or even later. Thus Taylor[665] cites
the case of a child who was accidentally shot through the brain. The
symptoms of inflammation did not appear until the twenty-sixth day and
death occurred on the twenty-ninth day.
[Illustration: FIG. 19.—Diagramatic Representation of the Skull and
Membranes of the Brain for Exhibition in Court. _a_, Skull with outer
and inner tables and diploë; _b_, dura mater; _c_, arachnoid membrane;
_d_, pia mater.]
=Wounds of the face= heal remarkably well on account of its great
vascularity. If severe they may leave great deformity or disfigurement,
which may be the ground of a civil suit and thus require the testimony
of a medical expert. If the wound involves the orbit or its contents it
may be more serious, either from a fracture of the thin upper or inner
wall of the orbit, separating it from the brain, or from extension of
a secondary inflammation of the contents of the orbit to the brain.
Wounds of the eyebrow may cause supra-orbital neuralgia or amaurosis
from paralysis of the upper lid. Some fractures of the nose, especially
those due to severe injury near the root of the nose, may be more
serious than they appear. For in such cases, of which the writer has
seen several, the fracture is not confined to the nose, but involves
also the ethmoid bone and its cribriform plate forming part of the base
of the skull. In such a case a fatal meningitis is a common result.
[Illustration: FIG. 20.—Double Fracture of the Thyroid and Cricoid
Cartilages of the Larynx, from the Blow of a Flat-Iron.]
=Wounds of the neck= are very rarely accidental, more often homicidal,
but most often suicidal. In nature they are most often incised wounds.
As we have already seen, the kind and condition of the weapon used is
often indicated by the character of the wound. We have also seen that
in many cases a suicidal wound of the neck can be distinguished from a
homicidal one with more or less probability or even certainty. Wounds
of the neck are often dangerous, and they may be rapidly fatal if they
divide the main vessels, especially the carotid arteries. Wounds of the
larynx, trachea, and œsophagus are grave and often fatal from entrance
of blood into the air-passages or from subsequent œdema or inflammation
occluding the air-passages. Wounds of the sympathetic and pneumogastric
nerves may be fatal, and those of the recurrent laryngeal nerves cause
aphonia. The situation of the average suicidal or homicidal cut-throat
wound is in front, generally across the thyro-hyoid membrane, sometimes
dividing the cricoid-thyroid membrane, and not at the side of the neck
where the great vessels lie and would be more easily divided. The
force is expended, as a rule, before the great vessels are reached.
The epiglottis may be cut or detached and the incision may even reach
the posterior wall of the pharynx, but the majority of the suicidal
cases recover with proper treatment. The homicidal cases are more often
fatal from division of the great vessels, though, as already stated, in
either class of cases a fatal result may occur if the air-passages are
opened from the entrance of blood into them and the consequent asphyxia.
CONTUSIONS of the neck may be so severe as to cause unconsciousness
or even death. The latter may be due to a reflex inhibitory action,
as in cases of death from a blow upon the pit of the stomach. As a
result of such contusions we may have a fracture of the larynx usually
confined to the thyroid and cricoid cartilages (see Fig. 20). This
may be followed by hemorrhage from the larynx, some of which may
pass down into the trachea and threaten death from asphyxia. Later
emphysema often develops throughout the tissues of the neck, and there
is great danger of œdema of the larynx. The prognosis is serious unless
tracheotomy is performed early or the case is closely watched. It is
most serious where the cricoid cartilage had been fractured, as this
requires a greater degree of violence. Whereas incised wounds of the
throat are most often suicidal, contusions are most often accidental
or inflicted by another. Among the latter class of injuries may be
included the so-called _garroting_, by which a person is seized
violently around the throat, usually from behind, and generally with a
view to strangle and rob. In such cases the larynx or trachea may be
injured in the same way as by a contusing blow.
WOUNDS AND INJURIES OF THE SPINE AND SPINAL CORD.
Injuries of the spine resemble more or less closely those of the
head. FRACTURES OF THE SPINE generally occur in combination with
dislocation, as fracture-dislocation. Thus displacement is generally
present and causes a fatal compression or crushing of the cord. When
the cord has once been crushed at the site of the displacement of the
fracture-dislocation there is no hope of its ever healing. Therefore
the lower end of the cord is never again in functional connection with
the brain. These injuries are more rapidly fatal the higher up they
are. If the injury is above the fourth cervical vertebra death is
nearly immediate, for then even diaphragmatic breathing is impossible,
and the injured person dies of asphyxia. Fracture of the odontoid
process of the axis, which regularly occurs in hanging, may occur
from falls on the head, etc., and is not always immediately fatal.
Thus in one case[666] the person lived fifteen months and in another
case sixteen months. In the latter case the fracture was due to the
patient turning in bed while his head was pressed on the pillow. In
some cases it may be questioned how far this injury may result from
disease of the bones or ligaments. Therefore a careful examination of
these parts should be made after death, which will usually enable
us to answer this question, which may be brought up by the defence.
It is hardly necessary for our purpose to enumerate the symptoms of
fracture-dislocation of the spine. Of course the patients are almost
always unable to walk and so are bed-ridden. A marked feature of
fracture-dislocation of the spine is the length of time intervening
between the injury and the fatal termination, and yet the injury is
wholly responsible for the death of the injured person. This delay may
last for months or even for years with careful treatment. But sooner or
later the case generally ends fatally, though not necessarily so. Where
the cord has been entirely crushed the result is almost always fatal;
where the cord is not so injured recovery may and often does occur.
According to Lutaud, fractures of the spine are sometimes followed
by secondary paralysis coming on after healing of the fracture. At the
outset we can seldom give a definite _prognosis_, which can only be
given after watching the developments of the case. The prognosis is
more favorable in fracture of the arches alone or when the injury is in
the lower part of the spine and not very severe. The commonest cause
of fracture-dislocation of the spine is forced flexion of the spinal
column. Injuries to the spine are generally the result of falls or
blows on the spine, especially in its lower part. Lutaud[667] states
that after forced flexion of the spine without fracture paraplegia may
sometimes occur, which is attributed to forced elongation of the cord.
This paraplegia, which may seem to be grave, is completely recovered
from as a rule.
Incised or punctured wounds of the spinal cord are rare, as it is so
well protected except in the very highest part behind. Here between
the occiput and the atlas and between the latter and the axis, and to
a less extent between the axis and the third cervical vertebra, the
cord is more exposed, owing to the narrowness of the laminæ. It is here
that _pithing_ is done, which is almost instantly fatal, as the medulla
oblongata and upper part of the spinal cord are the parts injured,
and they contain the respiratory and other vital centres. Pithing may
be done with such a small needle-like instrument as to leave scarcely
any trace. Only a slightly bloody streak may persist, which may appear
superficial if the instrument is introduced obliquely. Such a mark
in this location with no other apparent cause of death should always
lead to an examination of the upper part of the cord, which will
always reveal the cause of death in such cases. Pithing is practised
especially in infanticide.
As with the brain, so with the spinal cord, we may have CONCUSSION due
to the shock of a contusing blow. Concussion of the spinal cord, as of
the brain, may be fatal without showing scarcely a mark of violence
externally or internally. As the cord is so well protected from injury,
it must be extremely rare to have concussion of the cord without some
actual lesion of its substance. As concussion of the cord is not often
the result of the injuries of which we are treating, but rather of
railroad injuries and the like, it will not be considered at length
in this connection. As a result of a blow or fall on the spine or
communicated to it, hemorrhage may occur in the substance of the cord
or around it between or outside its membranes. In very rare cases such
a hemorrhage may occur spontaneously as the result of disease, of which
the writer has seen one case. It may be associated with concussion
or laceration of the cord. It may destroy life directly by extension
or indirectly by leading to a spreading inflammation. Hemorrhage in
or about the cord causes a gradual compression of the cord, and in
cases of fracture of the spine often adds to the compression due to
the displacement of the bones. In hemorrhage into the substance of the
cord paralysis comes on early or immediately and may be complete while
symptoms of irritation fail. The latter symptoms are most marked in
meningeal hemorrhage in which paralysis is delayed in appearance and
generally incomplete. The products of an inflammation due to an injury
may compress the spinal cord in the same way that hemorrhage does.
Wounds and injuries of the varieties we are considering, affecting the
spine and spinal cord, are generally accidental, less often homicidal,
and almost never suicidal.
WOUNDS OF THE THORAX AND THORACIC ORGANS.
=Wounds of the thorax caused by incising, puncturing, or blunt
instruments.= These wounds are most often punctured wounds; contused
wounds are common and incised wounds are not rare. They are perhaps
most often homicidal in origin or at least inflicted by another, and
the accidental origin of these wounds is probably the least common.
Incised or punctured non-penetrating wounds of the thoracic wall are
rarely grave. Bleeding, as a rule, is not serious, though it may be
quite free. Such wounds may be accompanied by emphysema, though not
penetrating, owing to the movements of the chest and a valve-like
action of the edges of the wound. Contused wounds of the thorax are
more dangerous, especially if the violence was great, owing to the
complicating fracture of the ribs, rupture of the thoracic viscera, etc.
FRACTURE OF THE RIBS is a common result of contusions of the chest.
It is more dangerous when due to a direct blow or injury, as then the
splintering occurs internally and may wound the lungs, heart, or large
vessels, while with fracture from indirect violence, from compression
of the chest, the splintering of the ribs occurs externally. Fracture
of the upper ribs requires more force than that required to fracture
the lower ones, and consequently the former is the more dangerous. The
diagnosis of fracture of the ribs is generally quite easy by means of
crepitus felt or heard, false motion, local tenderness, etc. FRACTURE
OF THE STERNUM may be serious if depressed on account of the wounding
of the viscera behind it. Devergie[668] cites such a case where the
depressed portion of the sternum produced a transverse non-penetrating
wound of the heart about an inch in length, which had caused death in
thirteen days. Simple fracture of the sternum without displacement of
the fragments is rarely serious unless injury of the thoracic viscera
is produced by the same violence. Wounds or injuries of the thorax
are grave or not according as they penetrate or injure the thoracic
viscera or do not do so. A wound may just penetrate the thoracic wall
without wounding the thoracic viscera, and is then serious as a rule
only when followed by inflammation. In fact, many of the penetrating
wounds of the thorax wounding the viscera are only grave on account
of consecutive inflammation. We have already seen that various
characteristics of wounds of the thorax, especially of stab-wounds,
enable us to determine the kind of weapon used, its size, sharpness,
etc., and sometimes to identify the weapon itself. In much the same way
we can often determine whether the wound was suicidally or homicidally
inflicted. The cause of death in wounds of the thorax may be directly
due to the wounding of one or more of the thoracic viscera, or it
may be due to the inflammation occasioned by it. Wounds of the lower
part of the thorax may involve at the same time the thoracic cavity
proper and its contained viscera, the diaphragm and the abdomen and
its viscera. This is the order in which the different parts would
be met with in a wound from behind forward; the order might be the
reverse of this in a wound from before backward. Penetrating wounds
of the thorax may involve the lungs, heart, or great blood-vessels.
Of these, the lungs are most often injured, which is easily accounted
for by the greater size of the lungs. In =wounds of the lungs= the
immediate danger is from hemorrhage. The hemorrhage appears externally
through the wound and from the mouth, being coughed up. Where the
lungs are injured by a blow, fall, or crush without external injury,
blood appears in the mouth only. The blood coughed up from the lungs
is bright red and frothy, and it may also be frothy at the external
wound. Hemorrhage from the external wound may be slight, especially if
the wound is oblique and acts as a valve. In wounds of the lungs most
of the blood may collect in the pleura or in the lungs, and thus, by
compression from without or by displacement by the blood within it,
prevents air from entering the lungs and produces asphyxia, which may
be fatal. More or less dyspnœa usually occurs at first. Emphysema is
generally present in the cellular tissues, but this latter symptom
may also occur at times with non-penetrating wounds of the chest. If
death does not occur speedily from hemorrhage by compression of the
lungs or heart, there are good hopes of saving the patient, but the
prognosis should be reserved. For even when the first effects of the
wound of the lung are survived, the patient may die from the effects
of inflammation, recurring hemorrhage, or a too sudden relaxation of
regimen. Thus, for instance, if too much food, talking, or exertion are
indulged in the case may on this account terminate fatally, and such
aggravating causes of death may mitigate the sentence.
=Wounds of the heart= are among the most fatal. Although it was once
considered, and is usually thought now by laymen, that wounds of
the heart must be necessarily and instantly fatal, the facts are
otherwise. If the wound is small and oblique life may be prolonged,
and cases are recorded[669] in which wounds of the heart were not
directly fatal, and in some of which recovery would have probably
resulted if not for other diseases. Cases in which the heart wall
was wounded but not penetrated, and in which healing took place,
are not very rare.[670] Thus Callender removed a needle from the
substance of the heart. But there is perhaps only one case[671] on
record in which a wound penetrating the cavities of the heart was
recovered from. It is the rule rather than the exception that wounds
of the heart, penetrating or not, are not immediately fatal. Thus
in a series of twenty-nine cases of penetrating wounds mentioned by
Devergie,[672] as collected by Ollivier and Sanson, only two ended
fatally within forty-eight hours, the rest in periods ranging from
four to twenty-eight days. This delay in the fatal result has been
attributed to the arrangement of the muscle fibres crossing one another
and tending to close the wound, or at least to make it smaller. As to
the various parts of the heart wounded, the right side, especially
the ventricle, is most often wounded. Thus out of fifty-four cases
of wounds of the heart, Taylor[673] states that the right ventricle
was wounded in twenty-nine cases, both ventricles in nine, the right
auricle in three, and the left auricle in one case. This greater
frequency of wounds of the right side of the heart is easily accounted
for by its more exposed position anteriorly, just beneath the chest
wall in a part of its extent. The rapidity of death depends largely
upon the site and extent of the wound. Lutaud[674] states that out of
twenty-four cases of wounds of the right ventricle only two were fatal
within forty-eight hours, and out of twelve cases of wounds of the left
ventricle three were not immediately fatal. Wounds of the auricles are
generally fatal immediately, especially if the cavity is extensively
laid open. It is the general opinion that wounds of the auricles are
most rapidly fatal, next those of the right ventricle, and lastly
those of the left ventricle. This difference is probably due to the
comparative thickness of the walls of these parts. Thus the wall of
the left ventricle is so thick as to tend to close a wound unless it
be extensive. In wounds of the heart death rarely occurs from external
hemorrhage, which may be quite slight or even altogether wanting where
the wound is due to a crush or fracture of the ribs. Death is usually
due to the compression of the heart by the blood in the pericardium.
This usually causes syncope, or a slighter pressure may be fatal by
causing cerebral or pulmonary anæmia or shock. Death may occur suddenly
in this manner or not until after some time. Thus in penetrating
stab-wounds little or no blood probably escapes at first, in most
cases, but it may ooze or, later on, suddenly burst out into the
pericardium. Therefore after a wound of the heart the patient does not,
as a rule, die immediately, as formerly and often at the present time
erroneously supposed. This fact is of little importance as a rule in
surgery, for the patients generally die sooner or later, but it is of
importance in medical jurisprudence, for upon it may hang the solution
of questions of murder, suicide, or justifiable homicide. It also
accounts for the fact that the injured person can exercise voluntary
power after the injury. Thus Watson[675] met with a case where a man
ran eighteen yards and died six hours after a stab-wound of the right
ventricle. The coronary artery was divided and the pericardium was
filled with blood. Also Boileau met with an accidental penetrating
stab-wound through both ventricles in a soldier who ran two hundred
yards, then fell and died in five minutes. A boy admitted to Guy’s
Hospital in 1879 lived forty-two hours with a bayonet-wound transfixing
the right auricle, the septum, the left ventricle, the mitral valve,
and entering the left auricle.
Minute wounds of the chest are sometimes made by needles, etc., in the
region of the heart with the intention of killing infants or children.
Taylor[676] also mentions the case of a fatal wound of the heart from
a needle, the result of accident. We have already cited the case of a
needle lodged in the heart wall and removed by Callender by operation.
That the puncture of the heart by a small instrument is not necessarily
serious is proved by the experiments of Senn,[677] by which he found
that “the heart can be punctured with a perfectly aseptic, medium-sized
aspirator needle without any great immediate or remote danger.”
In cases of RUPTURE OF THE HEART the question may come up as to whether
it was the result of disease or violence. We have already seen that
rupture of the heart may occur from falls or crushes without marks of
violence to the chest. In general, we may say that in rupture of the
heart from violence the right side and base are most often involved,
while in rupture from disease the left ventricle is generally ruptured,
especially near the apex. The exciting causes of rupture of a diseased
heart are often violent emotions or exertion, which may both be present
in a quarrel with another and cause rupture without direct violence.
The cause need be but slight if the heart is diseased, whether the
cause is a natural one or outward violence. Rupture from disease may
therefore excite suspicions of murder, but those cases can usually be
satisfactorily solved by examination of the organ post mortem. A slight
degree of violence may cause rupture of a diseased heart about ready
for rupture from natural causes. When a diseased heart ruptures during
a quarrel, the symptoms of rupture of the heart may be observed to come
on suddenly before and without the infliction of any violence.
=Wounds of Arteries and Veins=, especially within the thorax.—Wounds
of large trunks are generally speedily mortal. In the chest we may
occasionally meet with wounds of the intercostal or internal mammary
vessels or the vena azygos veins. These wounds are often serious and
may be fatal. We have already seen that blood in the large cavities of
the body, like the chest, is commonly not coagulated, or at least the
greater part of it. We have already seen, too, that after wounds of the
carotid artery the victim may preserve the power of locomotion for a
short time, but not the power of struggling. This fact may be important
to help distinguish between murder and suicide. In such wounds of the
carotid the voice may be lost, as the trachea is often divided. Death
from wounds of large vessels may be due to loss of blood, and if this
danger is passed the case may still terminate fatally, as in a case
where the brachial was tied for injury and death occurred in three days
from gangrene. The wounds of comparatively small vessels may prove
fatal from hemorrhage, etc.
In wounds of blood-vessels death may occur from the _entrance of air_
into them. In some cases where this is supposed to have occurred it is
quite probable that death was really due to hemorrhage. A considerable
quantity of air may enter the circulation, especially the arterial
circulation, without a fatal result. When death does occur it is owing
(1) to “mechanical over-distention of the right ventricle of the heart
and paralysis in the diastole,” or (2) to “asphyxia from obstruction
to the pulmonary circulation consequent upon embolism of the pulmonary
artery.”[678] Senn found that fatal air embolism could hardly occur
spontaneously in a healthy jugular vein, as the walls collapse readily
from atmospheric pressure.
=Wounds and Ruptures of the Diaphragm.=—These may be due to weapons,
fracture of the ribs, falls or crushes, and disease. They also occur
as the result of congenital malformation, though these cases seldom
survive long. These injuries are generally homicidal or accidental in
origin. As a rule, the viscera are wounded at the same time, or, if not
wounded, at least herniated, and may thus become strangulated. It is
therefore hard to estimate the danger in such cases, but the prognosis
is at all times serious. The most serious cases of such injury to the
diaphragm are due to violent contusions or falls when the stomach and
intestines are full. The hemorrhage is usually slight, but hernia of
one or more of the abdominal viscera usually occurs in such cases,
and is said to be more readily produced during inspiration when the
fibres are on the stretch. According to Devergie, rupture of the
diaphragm with hernia is more common on the left side in the central
tendon in front of the crura and at the junction of the left muscular
leaflet. Also on either side of the ensiform cartilage and especially
on the left side there occurs an area of the diaphragm which may be
congenitally weak or even absent, and here too rupture and hernia are
likely to occur. _Phrenic_ or _diaphragmatic hernia_ occurs especially
after lacerated wounds, even after the wounds have apparently healed.
If hernia occurs long after the injury was inflicted, it may be asked
whether the wound was the cause of the hernia, and so of death. This
can only be determined by examination. Almost any or all of the movable
abdominal viscera may be found in a diaphragmatic hernia. It was once
supposed that this accident would be immediately fatal, but this is
far from the truth. Devergie relates the case where a person lived
nine months with the stomach and colon in the chest and died from
another cause. Thus a person may have a phrenic hernia and die from
another cause, or having had a rupture or wound of the diaphragm he may
suddenly acquire a diaphragmatic hernia by reason of a blow or sudden
exertion, or the latter may strangulate an existing hernia. A person
with a diaphragmatic hernia may have the power of moving or walking,
but is more or less incapacitated owing to the compression of the lungs
which exists and the consequent dyspnœa, etc.
WOUNDS AND CONTUSED INJURIES OF THE ABDOMINAL WALL AND VISCERA.
Such wounds and injuries of the abdominal wall may be incised,
punctured, or due to blunt instruments, etc. They are usually homicidal
or accidental, seldom suicidal except in delirious patients or
lunatics. The cause of death in such cases may be due to hemorrhage,
shock, etc., or to secondary inflammation, which is especially likely
to occur in penetrating wounds. The kind of weapon used may often
be judged from the nature of the wound. Incised and non-penetrating
punctured wounds are usually simple and not grave, but may be otherwise
from hemorrhage from the deep epigastric artery, or from inflammation
in or between the muscles, or in the subperitoneal connective tissue.
In the latter case peritonitis may occur, but is rare. A ventral hernia
may, however, result later on, as also from a cicatrix, especially if
it is transverse. In such cases the question arises whether the natural
results of the wound were aggravated by unskilful or improper treatment
or even wilful neglect on the part of the patient or practitioner.
CONTUSIONS of the abdomen are more serious often than those of the
chest, for there is less power of resistance. We have already seen
that death may occur from a contusion of the abdomen too slight to show
a mark of ecchymosis or a serious injury internally. This has been
attributed by some to an effect on the solar plexus or reflexly on
the cardiac plexus causing a fatal inhibition. Lutaud and others have
expressed the doubt whether the cases reported by Travers, Allison,
Watson, Cooper, Vibert, and others were carefully examined, and have
inferred that some visible organic change must have been present. Some
such cases, however, have been examined with especial reference to this
point, and no physical injuries and no other cause of death elsewhere
has been found. There is no ground, therefore, for a jury to doubt that
a contusion of the abdomen was the cause of death because there are no
visible marks of injury.