Again, it is a well-known fact that the blows severe enough to cause

rupture of the abdominal viscera may sometimes leave no trace of

violence in or on the abdominal wall. On the other hand, it must be

remembered that effusions of blood may be found post mortem in the

sheaths of muscles without indicating violence, so that blood may be

found effused in considerable quantity in and around the abdominal

muscles without violence having been done. In such cases, therefore, we

should note whether abrasions or ecchymoses of the skin are absent or

not. If they are absent and there is no other evidence of a blow, the

medical witness should hesitate to attribute such an effusion of blood

between the muscles to an act of violence.

As in the case of the chest, so wounds of the abdomen are serious, as

a rule, mainly as they involve the abdominal viscera. The viscera may

be wounded by a penetrating wound or by rupture, and the fatal result

is due sometimes to internal hemorrhage or to shock, but generally to

secondary septic peritonitis, which may be fatal in a few hours or

only after days or weeks. Occasionally wounds of the abdominal viscera

undergo spontaneous cure without surgical interference and with or

without medical treatment. But as a rule they are fatal unless they

receive proper surgical treatment. A wound of the abdominal wall may

be penetrating without wounding any of the viscera. Such wounds may be

fatal if they are infected, otherwise they usually heal readily and

without danger unless they are extensive and the abdominal contents

are exposed to the air. The gravity of penetrating wounds varies

somewhat with the particular viscus or viscera injured. It is well not

to examine wounds of the abdomen by the finger or probe too freely

unless a laparotomy is anticipated; for a simple wound or penetrating

wound without wounding of the viscera may thus be infected. Enough

examination is necessary to diagnose between a simple and a penetrating

wound of the abdominal wall.

RUPTURE OR WOUNDS OF THE ABDOMINAL VISCERA.

THE LIVER is most often wounded of any of the abdominal viscera, with

the possible exception of the intestines, because of its size, and it

is most often ruptured partly because of its size, but mostly owing to

its friable consistence. Such injuries most often involve the right

lobe, as it is much the larger of the two principal lobes. The anterior

surface and inferior border is the most frequent site both of wounds

and ruptures of the organ. Ruptures rarely pass entirely through

the organ, but are generally not more than an inch or two in depth.

They are usually directed antero-posteriorly or obliquely, rarely

transversely, and the lacerated granular edges are not much separated

as a rule (see Fig. 21). Rupture of the liver may be due to a blow,

crush, or fall, or even to sudden muscular action if the organ is large

and fatty. Thus Taylor[679] relates the case of a woman who died after

child-birth of uræmic convulsions, and in whom there was quite an

extensive hemorrhage into the liver beneath its capsule, and apparently

due to violent muscular contraction. As we have already seen, the liver

may be ruptured without the abdomen showing the marks of external

violence. Rupture or wound of the liver is one of the causes of the

fatality of wounds and injuries of the abdomen. The fatal result may

be and often is due to hemorrhage; in other cases it is due to shock

or the occurrence of peritonitis. Wounds of the liver heal readily

and hemorrhage is arrested at once, as a rule, by the approximation

of the edges. There may be little blood in and about the wound, but

it collects in the right iliac region or in the pelvis and is not

wholly coagulated. Unless the wound or rupture involves the vena cava,

portal vein, or a large branch of either of these, the hemorrhage is

apt to be slow and the victim may survive hours or even days, except

for active exertion or repeated violence. Two cases illustrating the

slowness of the hemorrhage have occurred in Guy’s Hospital. In one[680]

the man, showing no urgent symptoms at the time, was sent away, and

died a few hours later in a police-station. In this case the liver was

ruptured nearly through its thickness, and a basinful of blood had

been effused, causing death. In the other case,[681] which occurred

to Wilks, the patient survived the accident ten days, and Taylor[682]

cites a case which was reported to have ended fatally eight years after

the accident. As a rule the injury is fatal, without treatment, within

forty-eight hours. Not being immediately fatal as a rule, the victim of

a rupture or wound of the liver can walk about, and may be capable of

more or less severe muscular exertion after the injury, though the fact

of such exertion has sometimes been used by the defence to prove that

the rupture was not due to the particular violence in question.

[Illustration: FIG. 21.—Ruptures of the Liver from a Fall from a

Considerable Height, causing Immediate Death.]

_Wounds and ruptures of the gall-bladder_ result in the effusion

of bile. While rupture of the liver is not necessarily followed by

peritonitis, rupture of the gall-bladder with the effusion of bile

generally causes peritonitis, and is fatal in this way and not from

hemorrhage. Rupture of the gall-bladder may be favored by the presence

of gall-stones, but the result is still attributable to the injury.

SPLEEN.—Ruptures of the spleen may be due to a bruising violence

in this region, and here too the skin may not show the marks of the

contusion, though this fact is still employed by the defence to try

to disprove the connection between the injury and the result. It is

important to remember, from a medico-legal point of view, that an

enlarged and softened spleen may be ruptured from a comparatively

slight muscular exertion. This might occur in a sudden movement to

avoid a blow, and the charge of manslaughter might be affected by

the mode of the production of the injury and the previous abnormal

condition. Only direct violence is liable to rupture the healthy normal

spleen. Rupture and wounds of the spleen may be and generally are fatal

from hemorrhage, owing to the vascularity of the organ; more rarely are

they fatal from shock. Peritonitis is not a result to be expected.

The hemorrhage accumulates in the lower and left side of the abdomen or

in the pelvis, and coagulation is imperfect if present at all.

KIDNEYS.—These are occasionally ruptured from violence, but more often

from accident. Wounds of the kidney are rare, owing to the depth from

the surface at which they lie. They are more accessible from behind. A

wound from behind is generally extra-peritoneal unless it perforates

the organ; not so a wound from in front. Accidents in which the lumbar

region is forcedly flexed are most apt to be followed by injury to the

kidney. The injury may cause no prominent symptoms, but usually lumbar

pain and tenderness, frequent micturition and hematuria, and in severe

cases the symptoms of hemorrhage and shock are present. The injury may

be speedily fatal from hemorrhage or collapse, or more slowly fatal

from peritonitis, when the peritoneum is involved, or from abscess

and septic infection, or from uræmia if the other kidney is diseased.

Slight injuries are generally recovered from. As is the case with the

liver and spleen, so after injuries of the kidney the victim may walk

about, etc., unless there is copious and immediate hemorrhage.

THE BLADDER may be wounded directly through the hypogastrium, vagina,

or rectum; it may be punctured by a broken fragment of the pelvis,

especially the pubis, or it may frequently be ruptured from blows,

crushes, or falls. The latter accident occurs especially where the

bladder is distended. The bladder may also rupture spontaneously from

over-distention, which may or may not be favored by disease of the

bladder wall, in which case rupture occurs more easily. Medico-legally

the question may arise whether the rupture was spontaneous or due to

injury. In this connection it should be remembered that the injury may

leave no external mark of violence, and a case is recorded in which the

bladder was ruptured by a fall in wrestling; but the question can be

determined only by an examination of the bladder. If the wall of the

bladder is thinned by the pressure of a calculus or from other causes,

or if it is weakened by tubercular, syphilitic, or carcinomatous

deposits or ulcerations, it may be spontaneously ruptured from

slight distention or a slight degree of violence may rupture it. If

violence has been employed it is responsible for the rupture, though

the diseased condition may act as a mitigating circumstance; not so

a distended bladder, as the latter is not abnormal. In spontaneous

rupture from over-distention without disease of the bladder wall,

stricture, hypertrophied prostate, or some such condition must be

present to account for the over-distention. Spontaneous rupture of

the bladder can, therefore, only occur when either disease of the

bladder wall or obstruction of the urethra is present. No condition

excludes rupture from violence. If there is an injury followed by

the symptoms of rupture of the bladder and death and the bladder and

urethra are healthy, there can be little doubt that death was due to

the injury. Wounds or rupture of the bladder may be extra-peritoneal

or intra-peritoneal. Rupture from disease of the bladder wall occurs

at the site of the diseased and weakened spot, which is most often at

the base of the bladder. Rupture of the bladder from violence occurs

most often on the postero-superior wall, running downward from the

urachus, in which case the peritoneum would be involved. A punctured

wound of the bladder wall may be so minute that the leakage is very

slow and the customary symptoms may be obscured, or the opening may be

valvular in character, perhaps allowing escape of urine only when the

bladder is not distended. The _symptoms_ consist of pain, inability

to micturate, and the presence of blood in the little fluid which can

be drawn by a catheter. Fluid injected is not all returned and the

bladder cannot be distended. After a time varying from a few hours to

a few days, depending upon the size of the opening and the condition

of the urine, peritonitis or peri-vesical cellulitis is set up, the

former being generally fatal, the latter not necessarily so. Prompt

surgical treatment may save the patient’s life by avoiding peritonitis.

Extra-peritoneal ruptures are far less dangerous than intra-peritoneal,

as in the former case cellulitis and abscess in the cellular tissue

around the bladder, which may subsequently be treated by operation

and drainage, take the place of peritonitis in the latter case, for

which prevention is the only safe treatment. In extra-peritoneal

rupture death, if it occurs, is generally due to septicæmia; in the

intra-peritoneal variety it is due to peritonitis. These cases of

injury to the bladder may die suddenly and speedily from shock or from

peritonitis in three to seven days, or not until fifteen days or so. In

punctured and incised wounds the urine escapes more slowly, peritonitis

develops less early, and death is longer delayed. Hemorrhage in injury

to the bladder is not usually serious; the blood is found partly in

the bladder, partly in the pelvis, where the fluid extravasated by

peritonitis is also found. The victim of a wound or rupture of the

bladder may often walk about for some time after the injury.

STOMACH AND INTESTINES.—Punctured wounds, or, more rarely, incised

wounds of the abdomen may involve these organs, or they may be ruptured

by blows, crushes, and falls, or from disease. Stab-wounds of these

viscera may be multiple from a single stab, the instrument traversing

one coil, perhaps, and then wounding others, though this is less often

the case than with gunshot wounds. Ruptures too may be multiple,

though less often so than wounds. The ileum is most liable to rupture,

though several cases of rupture of the jejunum are on record. Like

the bladder, the stomach and, to a less extent, the intestines are

more liable to be ruptured when distended. Ruptures of the stomach or

intestines are seldom attended with much hemorrhage, while wounds may

occasionally cause a serious and fatal hemorrhage from the wounding of

a large blood-vessel. The principal danger lies in the leakage of the

contents of the stomach and intestines, which almost always sets up a

septic peritonitis. This may sometimes become localized and go on to

spontaneous cure, though as a rule it becomes general and is fatal. In

such cases early operation may avoid the fatal peritonitis. A punctured

wound may be so small as to be closed by the mucous membrane, avoiding

the escape of the contents of the gut. Or a wound may not entirely

penetrate the wall of the stomach or intestines, which only gives way

some days, perhaps, after the injury, though the injury is entirely

responsible for the delayed result. These injuries are sometimes

fatal immediately or very speedily from shock, while in other cases

of very extensive injury there may be almost no shock, and the victim

is aware of no serious injury. It is an important point to remember

medico-legally that spontaneous rupture of the stomach or intestines

may occur owing to ulceration due to disease. This can be determined

by a careful examination of the wall of the stomach or intestines at

the site of the rupture. A slight injury may also cause rupture if the

wall of the gut is weakened by disease, as the disease causes greater

liability to rupture. Here too it is to be remembered that a severe

injury causing rupture may leave no mark of violence on the abdominal

wall. The power of walking or other muscular exertion after such

injuries of the stomach or intestines is not infrequently preserved, as

recorded in numerous cases.[683] The prognosis in such injuries of the

stomach and intestines is always extremely grave.

INCISED, PUNCTURED, AND CONTUSED WOUNDS OF THE GENITAL ORGANS.

These are not common as medico-legal cases. Self-castration or

mutilation is sometimes practised by lunatics, idiots, or even

intoxicated persons. Thus a man who, while intoxicated, cut off his

genital organs and died the next day from the effects of hemorrhage was

seen by Demarquay.[684] Circumcision in infants is also sometimes fatal

from phlegmonous inflammation.[685]

Incised, lacerated, or contused wounds of the female genitals may be

fatal from hemorrhage from many small vessels. Deeply incised wounds

of the female genitals proves wilful and deliberate malice; accident

is out of the question and suicide is improbable in such cases. But we

sometimes have to determine between accidental, self-inflicted, and

homicidal wounds of these parts, as accidental wounds may occasionally

resemble those made by design and so may furnish more or less

difficulty, unless all the circumstances are known. Thus Taylor[686]

relates the case of a child in whom a sharp-pointed stick entered and

passed through the posterior wall of the vagina as she fell from a

tree. The stick was removed by a woman, and the child died in a little

over a day from peritonitis. Unless the circumstances were known, this

case might have caused suspicion of homicide.

Lunatics, idiots, and drunkards sometimes inflict on themselves wounds

unlike ordinary suicidal ones. In other cases the various points we

have enumerated in a previous section to distinguish between suicide,

homicide, and accident may be applied to solve the case.

Contused wounds, such as kicks, etc., of the female genitals may

be fatal from hemorrhage due to the laceration of the parts.[687]

Like the wounds of the eyebrows, contused wounds of the vulva may

sometimes resemble incised wounds owing to the sharp bony surfaces

beneath. Careful examination allows a discrimination to be made from

incised wounds. If hemorrhage occurs a long time after the alleged

violence, it is probably due to natural causes, especially in cases of

metrorrhagia, etc. It may be alleged in defence that contused wounds

of the female genitals were inflicted post mortem, but besides the

other features which we have already seen help to distinguish between

ante-mortem and post-mortem wounds, we may add that kicks and other

contusions of the vulva, if fatal, are so from hemorrhage or effusion

of blood, and no post-mortem hemorrhage is enough to cause death.

INCISED, PUNCTURED, AND CONTUSED WOUNDS OF THE EXTREMITIES.

These may be fatal if a large blood vessel or vessels are opened, or

sometimes if a compound fracture or wound of a joint becomes infected.

They may also in some cases be fatal from shock, from the severity

of the injury. As a rule they are the cause of civil suits, not of

criminal ones. The various injuries may cause disability for a longer

or shorter time, or even permanently, and more or less deformity may

also remain. This may be the case with fractures, especially if they

occur near the joints, in which case great caution should be exercised

in giving an opinion or prognosis. It is a common mistaken idea of the

laity that a fractured or dislocated limb can be made in every case as

good as before the injury. On the contrary, they not infrequently leave

a slight deformity and impairment of function, sometimes even under the

best treatment. Dislocations may also leave a lasting disability or

weakness, often owing to the carelessness of the injured person.

Wounds of an artery or vein, or both, may result in an aneurism or

an arterio-venous aneurism. Wounds of nerves may cause paralysis and

anæsthesia of the parts supplied. Wounds of muscles or tendons may

cause weakness or complete loss of motion of particular joints. Wounds

of the soft parts, if infected, may lead to cellulitis and phlegmonous

inflammation, which may result in much injury. Wounds of joints, if

penetrating, are serious, for without the proper treatment they may

result in suppuration in the joint, disorganization of the joint,

and final ankylosis. Before the use of antiseptic treatment such

wounds were not uncommonly fatal. Fractures, simple or compound, or

contusions of bone especially in young subjects, may be followed by

osteo-periostitis and its consequences, which may require a long time

for recovery after the fracture is entirely recovered from, and a still

longer time before the limb can be used. These and many other of the

various results of wounds and injuries of the extremities, causing

deformity or disability, or both, can often be cured or improved by

surgical treatment or operation.

THE MEDICO-LEGAL CONSIDERATION

OF

GUNSHOT WOUNDS.

BY

ROSWELL PARK, A.M., M.D.,

_Professor of Surgery in the University of Buffalo_; _Attending

Surgeon to the Buffalo General Hospital_; _Fellow of the German

Congress of Surgeons_; _of the American Orthopædic Association_;

_of the American Genito-Urinary Surgeons’ Association_; _of the

New York Academy of Medicine_, _etc., etc._

GUNSHOT WOUNDS.

GENERAL CONSIDERATIONS.

FEW medical men there are who have long engaged in practice who have

not been compelled to take part in some medico-legal controversy in

cases of accidental or alleged homicidal gunshot wounds. So soon as

death occurs the surgeon ceases to work as such, but may continue to

work as a medical jurist, and in preparation for this event must be

ready to answer any questions bearing upon the case which, though

possibly ridiculous in surgery, are or may be necessary in law. He

may be called upon to testify as to the precise nature of a wound

inflicted upon the body of a man seen before or after death; as to the

means by which it was inflicted; whether the purport was suicidal or

homicidal; how much blood was lost; whether the weapon was near to or

at a distance from the body when fired; whether it were possible that

the deceased could have fired it himself; whether after the reception

of the wound the person could have moved or performed any act—in other

words, whether death was instantaneous. He may be asked also as to

genuine or spurious blood-stains, whether genuine blood-stains were

human or from some other animal; whether possibly they were from the

body of the deceased. He will be expected to tell from what direction

the bullet or missile was fired; which the wound of entrance and which

of exit, and many other things possible concerning the circumstances

under which death occurred. It is unnecessary to state that questions

of this nature call not only for conventional surgical skill, but for

the highest degree of shrewdness and general information, as well as

sometimes for expert knowledge with regard to small-arms and their

ballistics.

It has been well said that the first duty of a medical jurist is to

cultivate a habit of minute observation. When this is combined with a

knowledge of what the law requires and with the results of a technical

education, he will be able to meet all or nearly all of the scientific

questions which may be asked of him. A learned judge once said that

“a medical man when he sees a dead body should notice everything.”

Certainly he should make a minute scrutiny of the body to note whether

there are upon the dress or hands of the deceased marks of blood, or

whether blood-stains are noted in different parts of the room; whether

the body or any part of it is cold or warm; whether the limbs are cold

or rigid or pliant, since by these means the accurate date of death may

be more accurately determined.

EXAMINATION AND DESCRIPTION.

In determining facts attending a suspicious case of gunshot wound,

there should be noted, if known, 1st, the exact time of death, as

well as of infliction of the wound; 2d, location and attitude of the

body; 3d, condition of clothing; 4th, anything of importance in its

environment; 5th, external appearance of the body, as well as state

of countenance; 6th, exact description of all marks of violence and

of blood-stains; 7th, the presence of cadaveric rigidity and the

surface upon which cadaver has been lying, as well as its age and

condition of general nourishment; 8th, time when deceased was last

seen alive or known to have been alive; 9th, time after death at which

examination is made; 10th, all physical circumstances corroborating

or arousing suspicions of suicide or homicide; 11th, account of an

accurate internal post-mortem examination, in which direction of

the bullet or missile is noted, along with a careful description of

parts disturbed or injured in its course, large vessels or nerves cut

across, effusions of blood, and in every way as accurate a description

as possible of the exact damage done. To this also should be added a

minute scrutiny of other parts, in order to establish clearly that

death was due to the alleged injury, or on the other hand that it may

have resulted from natural causes, and that the injury in question was

only a consecutive and contributing cause. Especially should there be

examined those organs in which occur the most common causes of death,

namely, the brain, the heart and great blood-vessels, and the viscera.

Moreover, if an operation has been performed the post-mortem examiner

should be prepared to speak with reasonable positiveness as to whether

said operation was, in the first place, necessary if life were to be

preserved, and, in the second place, whether death were due to the

injury proper or to the attempt to save life thus made necessary.

For the determination of all this, obviously the best time for the

performance of the examination is the earliest possible moment after

death. Nevertheless, bodies are sometimes exhumed for this purpose, and

much information is obtainable even after a considerable interval of

time.

If death has been caused by a bullet which has not passed through the

body, but lodged, it should by all means be obtained, since evidence

of the greatest value may inhere in it. Moreover, in first noting the

position of the body, the direction of the wound, or the location of

a blood-clot upon the floor or clothing or elsewhere, may indicate to

the surgeon or other astute person the point at which the bullet may

be found concealed or buried in some soft or hard object. This bullet

should be recovered, if possible, at all events, although if taken

from the body itself the evidence it conveys may possibly weigh more

heavily than if removed from some object outside the body. The exact

number of gunshot wounds with a minute description and location of each

should be committed to paper at once, as well as any statement, if at

all reliable, concerning the number of shots fired, since valuable

deductions may be reached as to the number of bullets which have passed

through or which have lodged within the body. It is well sometimes,

also, before dissecting out the bullet-wound, to insert first a stiff

and then a flexible probe or something which shall, if possible,

follow the bullet-track, since occasionally a question comes up of

the direction in which it was fired. Even though surgeons well know

that such questions are impossible of satisfactory answer, owing to

the manner in which a bullet is diverted in its course by the various

tissues of the body, it will nevertheless create a good impression

as to the thoroughness and exactness of an examination should it be

brought out, in answer to questioning, that this had been done. Many

an excellent surgeon has been surprised upon the stand by the question

from one of the counsel as to whether he knew that some certain writer

had stated that it was always well, in trying to determine the course

and direction of a bullet, to put the patient or the body, as the case

might be, in the exact position in which it was when the shot was

fired, providing this be known. The accomplished surgeon knows that

this is a matter of very trifling import, but the witness’ status

will be much better established with the jury if he can show himself

familiar with this possible method of examination.

When a suspected person is brought before a magistrate, accused of

homicidal attempt, it is very likely that the judge will require a

written statement or opinion from the surgeon in attendance as to

the extent and danger of the victim’s injuries, and especially as to

whether these are of a character dangerous to life. The meaning of

these words is left entirely to the sagacity of the surgeon. A mere

naked declaration of this fact is insufficient. He must, if called

upon by the court, give his grounds for his belief, and these may be

rigorously examined by counsel. He will also probably be asked as to

the presumable duration of life and possibly the effect of operation.

Thus the prisoner’s immediate liberty or restraint may depend upon the

surgeon’s words. Perhaps the only advice which can be offered here

is to qualify between injuries directly dangerous to life and those

in which life is endangered merely by possible complications, such

as sepsis, gangrene, etc. Still, aside from wounds which are either

fatal or may be nearly completely recovered from, there is another

quite large class of those causing grievous bodily harm in which it

is a question for the jury always to decide what was the intent of

the accused. A medical witness may thus in such a case be of great

assistance to the court by giving an account of the injury devoid of

technicalities, and of its possible consequences. It should also always

be stated, if known, whether the patient was under the influence of

liquor or any narcotic at the moment of injury.

In the examination of wounds either of the living or dead body, it

should always be determined for medico-legal purposes whether there

is about them fluid or coagulated blood or ecchymosis, that is,

livid discoloration of the skin from effused blood. The color of the

ecchymotic spot will give a valuable clew as to the time between the

infliction of the wound and death. Putrefaction of such a wound must

not be mistaken for gangrene. In giving reports on such cases care

should be taken to distinguish between facts and inferences. In fact,

the inferences had better be kept unreported or confined to a separate

statement.

Should there be any possible suspicion of a combination of poisoning

and gunshot wound, the stomach contents should be carefully preserved

and sealed up in the presence of witnesses before turning over the

same to the analytical chemist, whose receipt for the package, with

a careful description of the same, will probably have to be placed

in evidence. Any fact on the condition of the stomach with regard to

digestion is always worth noting. In the case of Reg. _v._ Spicer

(Berks Lent Assizes, 1846) a most important point hinged on the

examination of the stomach. The body was found at the foot of a

stairway. The prisoner stated that after he and his wife had had their

dinner he heard a fall. The woman had died instantaneously and the

death occurred about the dinner-hour. Upon examination the stomach was

found empty, without a trace of food. It was, therefore, clear that a

part at least of the prisoner’s story was untrue.

Evidence as to whether the wounds were superficial or deep may be

of value. If the edges are swollen or large, or if granulation or

cicatrization have commenced, it is evident that the person must have

lived some hours or some days after their reception. The same is true

of suppuration, adhesion, or gangrene. It must also be remembered in

this connection that very few gunshot wounds will show much change in

less than ten or twelve hours save that due to the extravasation of

blood. Should the question come up as to whether a gunshot wound had

been inflicted before or after death, we may remember the principal

characteristics of a wound inflicted during life, which are more or

less eversion, more or less hemorrhage with diffusion of blood into the

tissues, and the presence of clots. In a wound made after death little

or no blood is effused, unless it come from some vessel very near the

surface, in which case it will be venous in character and will not

coagulate as does that which is poured out of a wound in the living.

The track of the bullet also will not be found filled with coagula.

In these respects a little will depend upon whether the body has lost

its animal heat or not. The gunshot puncture of a divided artery in a

dead body will present a very different appearance from one inflicted

before death, even though it be the cause of death. Bleeding after

death is exclusively venous, and there does not occur extravasation

of blood in the cellular tissues, nor does it coagulate. Questions of

this character come up sometimes in the case of multiple wounds or

injuries, and it is, at times, of importance to be able to determine

whether the assault or injury has been continued after death. Changes

in color of an ecchymosed spot rarely begin until after the expiration

of twenty-four hours, when its dark margins become lighter, and as time

goes on the whole area passes through successive shades of violet,

green, and yellow; its area may also increase sometimes to remarkable

proportions, but the central portions are always darker than the

periphery, the darkest spot corresponding to the centre of violence.

Ecchymosis is longer in disappearing in the old than in the young. Its

various features also will vary a little in accordance with the tissues

bruised.

Gunshot wounds pertaining to spurious suicidal attempts are usually

found not to involve vital parts, while they will have most of the

characteristics of injuries inflicted from a weapon near at hand. The

skin or the clothing will show powder-marks, and if a wad is a feature

of the cartridge used, it may be found in one place or the other. In

these cases there is also relatively more laceration and bruising,

while sometimes the hand which held the weapon may be blackened or

burnt by the discharge of the same. Self-inflicted wounds, in other

words, must necessarily partake of the character of near wounds.

EVIDENCE FROM THE SITUATION OF THE WOUND.

It has been generally noted that suicidal wounds are for the most part

confined to the front or lateral parts of the body; gunshot wounds

of this character being found usually in the region of the heart,

the face, and the temples. The presence of an injury to these parts

is not necessarily indicative of suicide, but the existence of such

injuries in other parts of the body is at least negative evidence of

homicidal attempt. Moreover, Orfila has observed that it is not so much

the situation as the direction of the wound which gives evidence for

or against the presumption of suicide. The question has been raised

whether it were possible to have a gunshot wound without external

evidence. There has been recorded more than one case where a bullet

entering through the open mouth has penetrated the brain without

passing through the vertex of the skull and has killed instantly

without leaving any external mark.

It is very necessary to establish, if possible, the direction of such a

wound, and this may be coupled with a knowledge of the right-handedness

or the left-handedness of the person who inflicted it, or may shed

light in this way upon some personal peculiarity which may lead to

the detection of the guilty person. Thus it is said of Sir Astley

Cooper that in one instance he remarked that a certain wound could

not have been inflicted except by a left-handed person, and that his

observation led to the detection of the murderer. It has been stated

that for the detection of the weapon or instrument used it should

be placed first in one hand of the deceased and then in the other,

while the other extremities are so manipulated that it may be clearly

determined whether suicidal attempt were possible or no. There is

ordinarily little difficulty experienced in distinguishing suicidal

from accidental wounds. In the former case extraneous signs and

circumstances point more clearly to the intent of the deceased than do,

perhaps, the peculiarities of the wound itself. This is to be settled

mainly by the evidence of those who find the body; in other words, by

circumstantial evidence.

In suicides ordinarily one wound only is met with. At any rate,

probably one only that has destroyed life. Consequently the presence of

several wounds, each of which was necessarily fatal, constitutes almost

conclusive evidence of murder, the strength of the same depending upon

the necessary fatality of more than one of these. Thus it is hardly

conceivable that a suicide should shoot himself through the heart

and through the brain; the coexistence of two such wounds would be

almost conclusive of homicide. The existence of multiple wounds is a

rather strong presumption of insanity or drunkenness of the person who

inflicted them. Men who kill when under the influence of liquor not

infrequently inflict injuries enough to be several times fatal.

The coexistence of wounds made by cutting weapons, as well as firearms,

is not unknown. These are occasionally suicidal, ordinarily they

betoken murderous attempt. If suicidal the deceased will ordinarily be

found to have been a lunatic.

But evidence is to be obtained also from signs and circumstances

separable from the wound itself. Thus the position of the body may be

such as to invalidate the theory of accident or suicide. The position

of the weapon, too, is something to be noted with great care. Whether,

for instance, this be firmly held within the hand of the corpse, or

whether it had been simply placed there after his death; whether it be

found where it would seem to have been most naturally dropped after its

discharge, or found somewhere where it could scarcely have been placed

or thrown by the deceased; whether it be found at such a point that it

is clearly evident from other signs it could not have been dropped by

the deceased, since death must have been caused too quickly for him to

have traversed the intervening space.

EVIDENCE FROM THE WEAPON AND PROJECTILE.

Evidence of great value may be obtained often from the weapon itself.

First of all, from the position in which it is found, as stated above;

second, from a careful examination of itself. It should be noted

whether there be any blood upon it, and whether this be so fresh as

not to have caused any rust; whether it may possibly be so smeared

with blood as to indicate a hand-to-hand conflict; or whether any part

of the weapon may have been used as a club or bludgeon, as would be

shown by the presence upon it of hair entangled in dry blood. When such

blood is removed from the weapon it should be carefully examined with

the microscope, since from the detection and identification of hair or

fibres of fabric evidence of the greatest value may be adduced. Next

it should be ascertained whether a weapon shows signs of having been

recently discharged or whether it be evident that it could not have

been so, and such determination of the time element as may be afforded

by a study of this kind should be contrasted with that made after a

study of the wound. If the weapon be a revolver or a repeating arm of

any kind, it should be determined if possible how many cartridges or

bullets have been fired, and whether at or about the same time, and

this information should be compared with the evidences obtained from

the body and from the room or locality in which the suicide or murder

occurred. If, for instance, it be determined that three cartridges

have been fired and but two bullet-wounds are found in the body, an

examination of the room may show where went the third bullet. Next the

calibre of the weapon should be noted and the weight of the ball which

it discharged and its dimensions should be compared with any which

may be found in or about the body. The weight of the bullets attached

to cartridges of various sizes and makes is usually stamped upon the

packages in which they are sold, or can readily be obtained from the

makers of the same. A bullet taken from a body weighing after its

removal more than do the other bullets undischarged in the weapon by

which an injury is alleged to have been inflicted is rather presumptive

evidence against the injury from that source.

CAN A BULLET LOSE IN WEIGHT BETWEEN THE TIME WHEN IT LEAVES THE BORE

OF A GUN AND ITS DISCOVERY IN A BODY?—Here springs up a question upon

which some very interesting evidence has been adduced in different

trials. To discuss this matter completely the question should be

divided into two, the first being:

DOES A BULLET SUFFER LOSS OF WEIGHT DURING ITS COURSE THROUGH THE PIECE

AND THE AIR BEFORE IT COMES IN CONTACT WITH THE BODY?—A personal

letter received from Captain Charles Shaler, of the Ordnance Department

of the United States Army, in reply to certain questions, tends to

fully settle that a lead bullet suffers a certain loss of weight in the

barrel due to the friction between the bullet and the bore; this is

known as “leading” and varies according to circumstances. “Patching”

the bullet is often resorted to in order to reduce the leading;

lubrication is also practised. The fusing of a bullet takes place

especially with lead bullets. A ball which has been partly fused in

the bore will lose the fused portions in the bore or in flight, and

will move irregularly on account of the resulting irregularity of form.

A .45-calibre, 500-grain service bullet, lead alloyed with tin, was

weighed without lubricant and was found to weigh 500.5 grains. It was

then lubricated in the cannelures and was fired into a butt composed of

three barrels placed end to end and filled with sawdust. Tho bullet was

recovered, no lubricant being found in the cannelures, and re-weighed,

the weight obtained being 485.5. The loss of weight was, therefore,

15 grains or three per cent, some of which may have been due to the

bullet penetrating the sawdust. A German-silver “jacketed” .30-calibre

bullet, weighing before firing 231 grains, fired without lubrication,

when recovered and re-weighed was found to have suffered a loss of

weight of one-half grain or one-quarter of one per cent. The other part

of the main question is:

DOES THE BULLET LOSE IN WEIGHT IN ITS COURSE THROUGH THE BODY?—This

is, of course, intended to pertain only to those instances in which

there is no evidence of splitting or division of the bullet, and

refers only to the effect of friction or attrition. June 5th, 1878,

in Saratoga County, Mrs. Jesse Billings was accidentally killed by a

bullet. Her husband was arrested and tried for murder. On the first

trial he was acquitted. A second trial, however, was held, and some

very interesting expert testimony was brought out on matters pertaining

to these questions. The medical evidence is published in full by Dr.

Lewis Balch, of Albany, in the Transactions of the Medical Society

of the State of New York for 1881. The rifle from which the bullet

was supposed to have been fired was found in a well, and was sworn to

have belonged to Jesse Billings. In it was found a cartridge of the

type known as the Commercial Long No. 44. This gun became an important

factor in the case, and most of the evidence as to whether it was the

weapon with which the murder had been committed was referred to the

medical experts. The defence in the first trial claimed that all the

lead fired was found in Mrs. Billings’ head. On the second trial the

same claim was not made, but that it was a smaller bullet than a .44

and its weight less than 220 grains; that in consequence this rifle

could not have been that from which the shot was fired, for it only

called for a .44 ball, and that it would have thrown a bullet with

such force that it must have gone entirely through the head. They

further claimed that powder-marks and grains of powder were found in

the window-sash, showing that the weapon was fired near the window, and

that the hole in the glass was not large enough to admit a full-sized

.44 ball. The verdict was mainly won upon these statements. A question

for the medical experts to answer was, what would be the effect upon

the skull of a .44-calibre ball fired from a Ballard rifle, the ball

weighing 220 grains and the charge of powder being 28 grains? also what

would be the effect upon the ball? Experts from the Ordnance Corps and

from the rifle factories were able to testify that the bullet found

in Mrs. Billings’ head was originally a .44-calibre ball; also that

its markings showed the peculiar left-handed twist used in rifling

this particular arm. The defence maintained that it could not have

been a .44, claiming that the hole in the window-pane showed that. The

original window produced in court was no criterion, since from repeated

handling the hole made by the bullet had become enlarged and changed

in shape. Both of the experts for the defence believed that the ball

could not make a hole smaller than itself when passing through glass.

This necessarily supposes that the ball after being fired is the same

calibre as before, which, as shown above, is not always the case. So

Dr. Balch fired forty-five rounds from the Billings rifle with 220

grains of lead and 28 grains of powder. The shots were fired through

glass set in sashes, the glass being 28×13¼, double thick and American

make. The rifle was discharged at varying angles and at distances

varying from two to seventy feet, and he obtained one shot where the

hole made would not admit a full-sized ball. His summary was as follows:

Balls unable to pass through 1

Balls partly passed 3

Balls passed 18

Cartridge passed 21

Glass broken out 2

—

Total 45

Other rounds were fired from a Colt’s navy revolver, old style, .36

calibre, at distances varying from ten to twenty feet. The holes made

were so large that the barrels and ramrods could be passed without

touching. The examination of the one instance noted above where the

aperture in the glass was smaller than the ball is explained by Balch

as follows: “A ball conoidal in form, passing with great velocity,

strikes glass, penetrates, but does not break the glass at the point of

entrance. The point struck is instantly disintegrated, and so rapid is

the stroke that it has not time to call upon the surrounding particles

for support; hence the smallness of the hole. As glass is made it

varies in elasticity; some parts which are to be cut into panes cool

faster than others. A bullet striking the portion of the glass which

has cooled quickly strikes an object which will yield somewhat to the

force; in doing this a hole will be made smaller than if that more

brittle had been struck. Furthermore, all rifles taper more or less

from breech to muzzle, that is, the muzzle will measure one or more

thousandths or hundredths less than the breech. The bullet being forced

through the narrow aperture yields to the pressure and becomes smaller.

The gun under consideration was measured at the New York Armory, and

found to be .44 at the breech or chamber and .423 at the muzzle.

Considering these various facts, statements that a ball of known size

will make a hole through glass smaller than the size of the ball when

fired do not admit of doubt as to their verity. Some statements bearing

on this same point contained in a recent letter from Captain Shaler, of

the United States Army, deserve mention here. The following experiment

was made in Washington by Captain Lyon in October, 1880:

“Noticing a statement in a newspaper to the effect that a ball fired

from a rifle would, in passing through glass, make a round hole smaller

than the diameter of the ball used, the following experiment was made:

“Service ammunition used, in a calibre .45 Springfield rifle to

penetrate glass.

═════════════════════╤═══════════════════╤════════════════════════

Time Fired. │ Size of Hole made │ Remarks.

│ in Glass, inches. │

─────────────────────┼───────────────────┼────────────────────────

1 │ 0.570 │

2 │ 0.550 │

3 │ 0.600 │

4 │ 0.600 │

5 │ 0.575 │

6 │ 0.575 │ The frame holding the

7 │ 0.590 │ glass was placed 25

8 │ 0.620 │ yards from the muzzle

9 │ 0.600 │ of the gun.

│ │

Average size of hole │ 0.586 │

Calibre of bullet │ 0.458 │

│ ────── │

Difference │ 0.125 │

─────────────────────┴───────────────────┴────────────────────────

“From the above it will be noted that there is no uniformity in the

size of the holes and that they all exceed the diameter of the bullet.

“These experiments were supplemented by some made recently in which

a sash containing six panes of ordinary window-glass was placed

at twenty-five yards from the firer and the glass was successively

penetrated (a separate pane being used in each case) by bullets from a

service .45-calibre Springfield rifle, a .30-calibre Springfield rifle,

a .45-calibre Colt’s revolver and a .22-calibre revolver. In every case

the hole made was much larger than the bullet making it.”

With reference also to the effect of a ball being smaller than its

original diameter after it leaves the piece, Captain Shaler states:

“All very compressible bullets forced by inertia lose a certain amount

even though they also gain force by slugging. Forcing by inertia tends

to shorten the bullet and increase the diameter, while slugging tends

to lengthen the bullet and reduce its diameter. Whether the bullet is

smaller after it leaves the piece depends upon the bullet used and the

method of forcing employed.”

To return to the Billings case, it was claimed that the bullet was

also too small. It weighed 165 grains, 55 less than when it was fired

from the rifle. Balch found in firing at human skulls, the subjects in

all the trials but two being placed in a sitting posture, sometimes

with a sash like the Billings window in front of the subject, that the

ball lost lead in accordance with the resistance it met with and the

amount of bone ploughed in its passage. These experiments conclusively

prove that the weight of a ball taken from a body after being fired,

it having traversed a bone in its flight, is by no means evidence of

its weight before firing; in other words, a ball always loses some

lead when passing through bone. With the same rifle as that produced

at the trial he made a series of experiments in the dissecting-room,

endeavoring to make a bullet enter the skull at the same point and in

nearly as possible the same direction as in the case of the murdered

woman. In six such experiments there were varying losses of lead, all

the bullets used being the same general weight. In two trials the

distance was but ten feet from the muzzle, yet more lead was lost

than in any of the other four. The least loss recorded took place at

the longest distance, thirty-five feet. This in part accounts for the

loss of lead, for at ten feet the bullet has not acquired its greatest

penetrating power, for he showed by experiment that a 220-grain bullet

fired at a human skull will lose more lead than was missing from the

Billings bullet, thus disposing of the question raised by the defence

that a ball could not have weighed 220 grains before being fired.

Just how to account for the missing lead has never been clearly

established. We have to remember that a few grains may be left in

the bore of a rifle, especially if rusty; that in passing through

glass another portion is lost, and finally it is scarcely conceivable

that any bullet should penetrate an adult skull, especially in

the neighborhood of the mastoid processes, without losing quite a

perceptible percentage of its mass by friction.

It was also claimed by the defence that the ball taken from Mrs.

Billings’ head had been fired from a weapon of low velocity, which

was held to account for the fact that the ball failed to pass out of

the skull. The rifle when tested at the Government Arsenal showed

a mean velocity of 999 feet per second. Had it been as high as was

supposed by the defence, namely, 1,300 or 1,400 feet, the argument

that a bullet driven with this force would always go through the skull

would have more weight, but with the velocity found by actual test the

energy of the ball was lessened to nearly one-half of that supposed.

The bullet which killed Mrs. Billings did not pass entirely through

the skull. It ploughed into the opposite side and broke before it a

triangular piece of bone which broke the skin externally. This shows

the resistance of external fascia against perforation. A study of the

lines of fracture in this particular case proved very interesting, but

perhaps would be somewhat irrelevant here. A measurement of the skull

and of the bullet-track through it shows the former to have been of

more than ordinary thickness and density, and the channel ploughed in

the bone by the bullet along the base of it to have been nearly two

inches in length. Dr. Balch gives the following conclusions to his very

interesting evidence: 1st. A leaden ball passing through bone loses

lead in proportion to the amount of bone traversed. 2d. If the petrous

portion of the temporal bone be the part struck by the ball and struck

squarely at the base, that portion of the bone is crumbled or broken in

such exceedingly fine pieces as to defy restoration. 3d. That if the

ball struck any part of the skull the petrous portion will be broken,

but can be usually recognized and generally put together again. 4th.

That a ball of given calibre fired through glass may make a hole

enough smaller than the full size of the ball before firing to prevent

an unfired ball of like calibre passing.

In all this kind of experimentation upon cadavers for the purpose of

eliciting evidence by reproducing as nearly as possible ante-mortem

injuries, we must not forget that Casper has strongly insisted that

“it is extremely difficult to break up the organic cohesion of dead

organs.... If we endeavor to fracture the skull of a dead adult we

shall find that an amount of force which if applied in life would

indubitably produce fissures if not fracture, or complete crushing

of the skull, leaves the dead skull quite uninjured.... The most

powerful blows struck down upon the body, laid down horizontally, were

without result, and only after repeated violent blows were we able to

produce perhaps one or a few fissures in the occipital or parietal

bone, or in the temporal bone (squamous portion), and usually in the

latter. We were unable to produce more considerable effects, such as

complete smashing of the skull or fissures of its base, even in one

single instance. The dead skull seems to have considerably more power

of resistance, and after its removal fissures of the bone were more

easily produced by similar blows” (Vol. I., p. 245). And again: “The

result of my experiments on the dead body in regard to gunshot wounds

could only be to make more complete the proof of the resistance of

the dead corporeal tissues, in contradistinction to the tissues when

alive. After I had already learned this peculiarity from my experiments

with contused wounds, this peculiar resistent property was found to be

confirmed in a most remarkable manner” (“Forensic Medicine,” Vol. I.,

p. 271).

If the number of bullets known to have been fired, or, more important

still, which have been found exceeds the number which could have been

discharged from the weapon in question, a very large element of doubt

and uncertainty is introduced which must be quieted by other and more

circumstantial evidence. Should two different weapons be in question,

it is very necessary to establish from which of them the bullets have

been discharged. This can be done mainly by weight and evident calibre

of the bullets, or some other peculiarity; possibly in disputed cases

even by analysis of the metal.

=Wounds by Shot-Guns.=—In most of what has been said it has been

supposed that the injury has been inflicted by an arm of the kind

commonly described under the terms pistol, revolver, or rifle. Gunshot

wounds are, however, occasionally inflicted with shot-guns and a charge

of shot varying in size from small bird-shot up to that generally known

as buck-shot. It is characteristic of such missiles that they separate

after their discharge from the gun, and a determination of the degree

of their separation is approximately a determination of the distance

of the mark from the muzzle of the weapon. In suicide or accidental

discharges of a shot-gun the muzzle is so near the body that the charge

of shot acts very much as would a single bullet of the size of the

bore of the gun, and near wounds thus inflicted, while necessarily

large, have about them a minimum laceration and disturbance of tissue,

so that perhaps only by their size could one say, viewing the wound

alone, that the weapon used had been a shot-gun. On the other hand, at

a distance of a few feet the shot begin to separate to such an extent

that there is much more laceration of tissue, and after separation to

an indeterminate, because variable, number of feet we get such marks

as individual shot may make. This distance is indeterminate because it

is predicated on the size of the gun, the dimensions of shot, and the

weight of the charge of powder. The writer, for instance, has recently

seen one case where the muzzle of the gun could not have been more than

two feet away from the surface of the foot at which it was discharged,

the consequence being a round and very slightly ragged hole through the

mid-tarsal region from dorsum to sole.

It is possible for a single grain of shot to produce death. Such a

case is related by Ollivier d’Angers: a thief scaling a wall received

at a distance of fifteen paces a charge of shot from a fowling-piece;

he fell dead immediately. The charge had struck him in the breast,

centring over a space of three or four inches, but one shot had

penetrated the aorta over the attachment of the sigmoid valves, and

another had traversed the entire wall of this vessel.

POWDER-MARKS.—A very important part of evidence in case of near wounds

of gunshot character pertains to the powder-marks upon the clothing

and skin. Naturally every one knows that when a weapon is discharged

near a given surface there will be more or less powder-marking upon

that surface, the same being due to particles of gunpowder which are

incompletely or not at all consumed, and which are black because

of the charcoal they contain; but the circumstances under which

powder-marks of a given character can be inflicted are so extremely

variable that no statistics or information of value in a general

way can be given. Thus the fineness of the marks will depend upon

the fineness of the powder, and the area covered and the depth of

the marking upon the same, upon the distance of the muzzle from the

surface; and the only way to make out the exact distance of the muzzle

from the surface at the time of the infliction of a given wound is to

use the same weapon, if possible, with cartridges or charges out of the

same lot as that used at the time of injury. Distances could, perhaps,

be stated in round numbers, but their value would only be remotely

approximate, and in a given case the best evidence is to be obtained by

experiment with the fire-arm in question.

=Dimensions of Perforations.=—At different times a great deal of

weight has been attached to the dimension of the perforation through

such objects as wood, glass, or even through the bones of the body,

made by the bullet which is supposed or known to have destroyed

life. Wrong inferences have been drawn sometimes from a study of

undischarged bullets or cartridges similar, at least before firing,

to that which has been taken from a given body. It has been stated,

for instance, that such a bullet was too large to have passed through

such an aperture or to have made such a hole, or that it was so much

smaller than a certain hole that it was not the particular missile

which made that perforation. Upon this matter has hinged a great deal

of uncertainty and consequently a good deal of study. The size of

opening which a bullet of given calibre will make through wood depends

upon the distance of the weapon, the firing charge, the velocity of

the bullet, the extent to which its shape has been altered by passing

through the given barrier, by the heat of the explosion, by the impact

of the air upon the heated and consequently softened metal, and by the

density and thickness of the wood, as well as by the resistance which

it may have offered mainly from its being fixed in place or movable.

There is, however, ordinarily less question about the size of a similar

hole through a piece of glass or bone. It is generally supposed that

a bullet passing through a window-pane will shatter it. This depends,

however, mainly upon the perfection of fixation of the glass in its

resting-place. If for purposes of experiment panes of glass be tacked

into a shutter and bullets be fired at them from varying distances,

they will be practically invariably shattered. It is, however, quite

different if the pane of glass be firmly fixed in a frame by means of

putty which has become old and hard, and especially if the window-frame

itself be closely fitted in the casing. Under these circumstances a

bullet will often make a clearly punched hole, or one with very few

radiating lines of fracture. Experiment, therefore, to secure evidence

should be made under circumstances exactly parallel to those which

necessitate such evidence.

EVIDENCE FROM EXAMINATION OF THE DEAD BODY.

=Fractures.=—Considerable evidence of great interest with respect to

the effect of a bullet-wound upon the skull and the possibility of

fractures being produced at the base by _contre coup_ will be found in

the statement of the case of The People _v._ Elisha B. Fero, published

by Dr. Charles T. Porter, of Albany, in the _Journal of Psychological

Medicine_, April, 1870. Mrs. Fero was murdered while in her bed and

was found to have been bruised about the head and body, her husband

claiming that the deed was that of a robber who had attacked them

both. He was found with slight bruises or scratches about the face and

black marks as if from burnt powder between the middle fingers of his

right hand. The first autopsy appears to have been carelessly made,

but a flattened conical ball weighing twenty-six and one-half grains

was found lodged in the middle of the right cerebral hemisphere. It

had not gone completely through the brain. Its base fitted the shells

of the metallic cartridges used in Fero’s revolver. Eight days after

death a second examination was made, after which the head was removed

and preserved in 95% alcohol. A theory of the prosecution was that

Mrs. Fero was murdered by her husband; that he shot her, as well as

struck her numerous blows upon both sides of the head and its front

and back with some broad, heavy, and elastic body, making fractures

found on autopsy. Not the least interesting part of the testimony

is that referring to the condition of tissues alleged to have been

bruised after long preservation in alcohol. The expert testimony in

this case appeared to show that such fractures as were found, without

reference to the fact of external bruises, were due to the unskilful

manner in which the skull-cap was removed. In this connection it

is well right here to emphasize the fact that fresh fractures can

be produced in the skull by too forcible or injudicious efforts

to remove the calvarium when making autopsies, or that fractures

previously existing can be extended or complicated in the same way.

Shaw in his “Manual of Anatomy” says: “The question whether there has

been a fracture of the cranium previous to death is sometimes more

difficult to decide than a person not accustomed to make dissections

might imagine. If the fracture has occurred immediately before the

patient’s death, there will be found coagulated blood upon the bones

and in the fissures. If the patient has survived for some time, there

will be marks of inflammation and, perhaps, pus in contact with the

skull, but if a fracture has been made in making the examination,

which sometimes happens in even very careful dissectors’ hands, the

blood in the fracture will not be coagulated, nor will there be any

effusions around the portions. In Beck’s _Medical Journal_, Vol.

XXII., p. 28, Mr. Alcock some time since stated in a public lecture in

London that he had known a fracture of the base of the skull produced

by the awkward and violent tearing of the upper portion by the saw in

penetrating enough to divide the bones, and this to be mistaken by the

inexperienced operator for fracture of the skull producing death. Being

a medico-legal case, it might have led to melancholy consequences had

not the error been detected by an observer.” That an extensive and

often complicated fracture by _contre coup_ can occur as the result of

gunshot injuries of the skull is a fact well known to all surgeons of

experience and laid down in all text-books and illustrated in all large

museums.

In view of these well-known facts, it would always be well to insist

in cases of this kind that the saw alone should be used and not the

hammer nor the chisel. When a cranial bone is fractured blood is

poured out from the ruptured vessels, as is always the case with any

bone. Its amount varies indefinitely with the number and size of the

ruptured vessels, the activity of circulation, the length of time a

person lives, etc. The blood may collect in circumscribed masses or

become infiltrated in the surrounding tissues, although usually both

phenomena are observed. The extent to which infiltration takes place

depends upon the quantity of blood and the nature of the surrounding

tissues. In loose tissues like those about the orbit infiltration is

much more rapid and extensive.

=Examination of the Weapon.=—French medical jurists have tried to

indicate how we may determine the time elapsed between the death of a

person and the discharge of a weapon found near the body, but exact

statements in this matter are utterly out of the question. Certain

facts bearing on the subject are these: When recently discharged there

will be found adhering to the barrel of the piece and consisting of the

fouling of which sportsmen complain, a quantity of potassium sulfid

mixed with charcoal. This is shown by its forming a strong alkaline

solution with water, evolving an odor of hydrogen sulfid, and a dark

precipitate with a solution of acetate of lead. Depending upon the

degree of exposure to air and moisture, after some hours or days this

sulfid becomes converted into potassium sulfate, which forms a neutral

solution with water and gives a white precipitate with acetate of lead;

but if a considerable time has elapsed since the discharge of the piece

oxid of iron (iron rust) with traces of sulfate may be found (_Ann.

d’Hygiene_, 1834, p. 458; 1837, p. 197; 1842, p. 368).

WAS THE WEAPON FIRED FROM A DISTANCE OR NEAR BY?—A gunshot injury

from a bullet implies at least one wound, namely, that of entrance,

and perhaps another, that of exit. It does not always happen that the

bullet passes through the body. The appearance of the wound of entrance

is usually one of irregular circular puncture, its edges perhaps

slightly torn or lacerated, with a purplish or dark areola, varying in

width from a line or two to one-half inch. When the weapon is fired

close to the body there are likely to be more or less powder-marks,

and possibly actual burning from the heat and flame of the gunpowder.

If the part of the body injured had been covered by clothing at the

time, the marks of powder and of burning would probably be confined to

the same. Bleeding is usually slight and occurs more commonly from the

wound of entrance than from that of exit. Regularity of either of these

wounds depends in large measure upon the angle at which the bullet has

struck the surface. When striking very obliquely the wound may be more

oval or the bullet may have ploughed a furrow or a channel, by a study

of which the relative position of the assailant and the assailed at

the moment of injury may, perhaps, be determined. It is of importance

to determine if possible the approximate distance at which the bullet

was fired, since the question of self-defence, for instance, may hinge

upon evidence of this character. The charge of powder and the weight of

the bullet being known, one may sometimes estimate this distance by the

depth of penetration or the appearance of the bullet. Still, the nature

of the tissues must figure largely in such consideration. Many suicides

who shoot themselves in the head show only one wound of entrance and

none of exit.

=Experiments Testing Powder-Marks.=—Powder-marks and burns from

weapons ordinarily used will scarcely appear when the distance has

exceeded ten or twelve feet. LaChese, of Antwerp, found that in

firing a gun even from a distance of only four feet the skin was only

partially blackened.

As the result of experiments made with a Ballard rifle, old style, .44

calibre, with bullets of 220 grains and 28 grains of powder, Dr. Balch,

of Albany, found that powder-marks were made at distances as follows:

At two feet, particles too numerous to count, with some of the

lubricant blown upon the board;

At four feet the same;

At six feet the same;

At eight feet, nine grains of powder;

At ten feet, five grains of powder in one case and six in another.

That these were powder-grains were shown in court by picking some

of them out, placing them on a glass, and igniting them with a

galvano-caustic point. From those at ten feet no distinct flash could

be elicited; from those obtained at eight feet distinct flashes were

seen (Trans. New York State Med. Soc., 1881).

In the celebrated case of Peytle, brought in 1839 for the murder of his

wife, who had been killed by two bullets entering near the nose, the

eyebrows, lashes, and lids were completely burned, and a large number

of powder grains were imbedded in the cheeks. Experiments being made

in order to ascertain the distance necessary to produce these effects,

it was found that the weapon must have been held within a distance of

twelve inches.

=Wounds of Entrance and of Exit.=—A great deal has been written in

time past about the peculiarities of the wounds of entrance and of

exit, much of which cannot be maintained under expert criticism. It is

true that the wound of entrance will usually be well defined, the skin

slightly depressed and appearing as above noted. It is true also that

powder-marks will appear about this wound rather than that of exit.

Usually, too, the orifice of exit is larger, less regular, its edges

everted slightly, with more or less laceration of the skin, and quite

free from any powder-marks or evidence of burning. The depression at

the border of the wound of entrance differs after some days, by which

time the contused margins slough away, and its appearance is daily

changed by a process of granulation providing the individual recover

or live long enough. According to Dupuytren, the hole in the clothing

is smaller than that made by the same bullet in the skin. These are

all points worth remembering when fitting bullets into wounds which

they are supposed to have made; but the conditions under which gunshot

punctures occur are constantly varying, and the significance of local

markings is mainly the product of experience, care, observation,

and reasoning. Thus the shape of either of these wounds will depend

naturally upon the integrity of the bullet and its original shape

and dimensions. Matthysen’s experiments give the following: A pistol

fired at twelve paces distance, with a ball 15 mm. in diameter, made

a wound in chest of 8¼ mm. diameter, and at its point of exit at the

back one of 10 mm. In two experiments at the same distance as above,

the entrance wound was 4 mm. larger in diameter than that of exit, and

when a larger ball with a diameter of 17 mm. was used the same results

were preserved, both wounds being less in size than the ball which made

them. A spherical ball will usually cause more loss of substance than

a conical, while the latter will cause usually more irregularity of

outline and may even give the wound of entrance a slit-like appearance.

Complications may also occur from other sources; a single wound of

entrance may give rise to two or more wounds of exit due to splitting

of the bullet, or if the bullet have been divided and the larger part

lodged in the bone, only the smaller portion passing out, the wound

of exit may in reality be much smaller than that of entrance. Again,

a bullet may split into fragments before striking the body, and of

these one may enter the body, or one or more of them lodge. Multiple

wounds are possible even from one bullet, as when it passes through

two different parts of the body. Again, when two wounds, for instance,

are discovered, one of them may be regarded as that of exit, when in

reality they may be two wounds of entrance, neither bullet having left

the body. So while it is possible in some cases to decide which is

which, too much dependence should not be placed upon appearances of

this kind, least of all until after a careful autopsy has been made.

=Course of the Projectile.=—When a bullet traverses a body the two

apertures may be nearly opposite to each other, although the bullet

may not have taken a direct course between them, having been deflected

by tissues of varying density in its course. This leads to the mention

of the effect of animal tissues upon the course of bullets, with which

works on military surgery deal extensively.

The following is a remarkable illustration, yet authentic, of a

devious path of a ball. In a duel with pistols between two students

at Strasburg one fell, apparently mortally wounded in the neck, but

recovered without feeling any inconvenience from his wound. It was

found that the bullet had struck the larynx and had gone completely

around the neck. It was taken out by simply making an incision over it.

Other instances may be cited where bullets have made a circuit around

the head, thorax, or abdomen. The ball may make a half circuit of the

body and lodge or emerge at a point opposite that at which it entered,

thus leading one to suppose that it must have passed directly through

(Wharton and Stille).

As the writer of a chapter on the effect of projectiles of small-arms,

in the Third Surgical Volume of the “Medical and Surgical History of

the War of the Rebellion,” p. 709, says: “Such bullets attain great

range and effectiveness as oppose least frontage of resistance to air;

their velocity consequently is greater. Rotation upon their long axes

tends to give them steadier flight and more direct course. By their

pointed apices they pierce more easily the structures opposed to them.

Such bullets, owing to the elasticity of the skin, make a wound of

entrance perhaps a trifle smaller in diameter than themselves, while

spherical balls are more likely to carry a portion of the integument in

with them.”

The differences of structure and density of the muscle tissues and

their aponeuroses encountered by a bullet in its passage materially

influence the directness of its course unless its velocity be very

great, while round bullets are the more easily deflected from their

course. The track of a small conical bullet passing swiftly through

a muscle is more cleanly cut than that made by a round bullet, but

in all gunshot wounds there is usually found a regular canal, with

lacerated walls, with more or less destruction along the area of

injury, shading off concentrically until lost in healthy tissue. There

is always loss of substance dependent on muscle tension or direction

of the bullet, whether transverse or obliquely to the direction of

the muscle fibres; the more fibrous structures are torn and lacerated

or simply perforated, mainly owing to their different tension at the

instant; their openings seldom correspond to those of the muscle

tissues or those upon the surface of the body, because of the constant

change in the relation of the parts due to muscle action. This makes

it often difficult to follow the course of a bullet with accuracy. The

irregularity of a bullet-track due to these causes constitutes one of

the great sources of danger, since cavities and pouches thus formed

give lodgment to foreign matter driven in with the bullet, by retention

of which a fertile source of sepsis is maintained. Gunshot injuries

of bone may be classified as contusions, simple fractures, partial

fractures, penetrations, perforations, and complete fractures with more

or less comminution or loss of substance, all of these, of course, in

the surgical sense compound. These are all manifestations of mechanical

force acting in accordance with established laws. On autopsy these will

be ascertained, while one or more portions or all of a bullet may be

found imbedded in or attached to some bone. The best illustration of

such accidents will be found in the “Medical and Surgical History of

the War of the Rebellion.”

Such questions as pertain to the position of the wounded person when

shot or that of his antagonist, and other similar inquiries, can only

be settled by reference to particular circumstances of individual

cases. Position of the wound may help a little. A bullet-wound directly

in the centre of the top of the head could scarcely be received by a

person standing unless his assailant occupied an elevated position. If

accompanied by evidence of severe blows by which the deceased might

have been knocked down, it might show that he had been shot after

falling.

=Wounds by Small Shot.=—Small shot rarely traverse the entire body

unless discharged from such proximity as to make a clean, round

opening. Paley relates the following instance: A boy was shot in the

neck by the accidental explosion of his own gun, No. 8 shot. He died

instantly. He was lying forward of the muzzle so that it was nearly in

contact with the skin of the neck. A large round hole was produced, in

diameter one and one-half inches, whose edges were slightly darkened

by powder. The wound of exit at the back of the neck, at the third

vertebra, was a mere slit in the skin scarcely an inch in length with

the diameter placed vertically. The smallness of this aperture may

have been owing to the greater part of the charge being lodged in the

body. Dr. Lowe states that in some experiments it was found that a

round aperture might be produced by a discharge of small shot at a

much greater distance than that assigned by Dr. LaChese, namely, ten

to twelve inches. Even admitting such exceptional instances, it will

scarcely ever occur that a wound from a small shot can be mistaken for

one produced by a leaden bullet.

De Vergie has shown that when the ball enters a portion of the body

well covered with fat, this often protrudes between the edges of the

wound and may alter its character. If clothing have been carried in

some shreds of it may show upon the wound, and such fragments of

texture will nearly always characterize the wound at once as that of

entrance.

=Wounds by Blank Charges.=—Experience has shown that no matter with

what the piece is charged, it is capable, when fired close by, of

producing a wound which may prove fatal. Thus a gun loaded with wadding

or gunpowder only may cause death. A portion of clothing may be carried

into the wound and lead to death from hemorrhage, or death may occur

from many secondary causes, such as tetanus or sepsis. Accidents so

frequently occur from weapons discharged in sport, not loaded with

ball or shot, that it is worth while to bear this in mind. It has been

observed, for instance, that persons attempting to commit suicide have

forgotten to put a bullet in the pistol, nevertheless the discharge

of the weapon into the mouth has sufficed, from the wadding alone,

to produce a considerable laceration and hemorrhage (Taylor). Many

fatal accidents have taken place by the discharge of wadding from

cannon. LaChese has ascertained by experiment that a piece charged with

gunpowder alone is capable of producing a penetrating wound somewhat

resembling that produced by gunshot, when the piece is large and

fired within six feet of the body (_Ann. d’Hygiene_, 1836, p. 368).

This arises from unexploded grains of powder acting as pellets of

small shot. Sweet has experimented with pistols loaded with gunpowder

and wadding in order to determine the effect of their discharge at

different distances. At twelve inches he found that the clothing was

lacerated and the skin abraded, but the wadding did not penetrate; at

six inches the clothes were lacerated and the wadding penetrated to

the depth of one-half inch; at one and one-half inches from the chest

the wadding passed into the thoracic cavity between the ribs, and at a

second experiment carried away a portion of the ribs.

It is probable that an ordinary wadding such as loosely wrapped paper,

rag, or similar material, especially as prepared by one not accustomed

to military use of a weapon, would not produce a wound which would

resemble that made by a bullet, and it is doubtful whether such a wound

could be produced at a greater distance than six inches from the body.

It is on record that in Paris, in 1858, a circus cannon of four inches

bore, loaded with three ounces of grain powder retained by a wad of

old theatre bills loosely folded together and rammed home with only

moderate force, was discharged in the direction of the boxes at a

distance of about one hundred and fifty feet. A man seated in one of

these boxes opposite the muzzle of the gun, leaning forward, his arms

crossed upon the handle of his umbrella, had his arm broken above the

elbow immediately upon its discharge. Several portions of wadding

were found beneath the place where the man sat, but no marks existed

upon his clothing nor upon the anterior part of the arm, which must

have been inaccessible to any projectile that did not first strike

the forearm. It was concluded that the fracture had been caused by

the violent and sudden starting of the man backward, which must have

brought his arm against the hard part of the partition. An experiment

tried with the cannon proved that any wadding that could be made with

paper was dispersed in passing, or lost all power of mischief, at much

less distance than one hundred and twenty feet (_Annales d’Hygiene_,

1859, p. 420, Wharton and Stille).

=The Mannlicher Rifle.=—It may be of interest here to note the effects

of the rifle-bullets used in the most recently invented improved

arms. The last new projectile used in the German army, 1892, with the

Mannlicher rifle, has an inner core of lead inclosed in a casing of

steel or firm metal, which prevents the lead, even when softened by

heat, from becoming deformed and enlarged by contact. The weight of

the bullet is much less than any of the old, but to its higher rate of

velocity and its pointed shape, which is preserved, must be ascribed

its greater perforating power. Owing to this immense velocity and the

small surface of contact, it meets with little resistance on striking

a person, has no time to stretch the various tissues it encounters,

causes little or no commotion of the neighboring parts, and merely

punches a hole, carrying the contused elements before it clear out

of the wound without seriously damaging the surrounding wall of the

bullet-track. This absence of contusion must lead to more frequent

deaths from hemorrhage, while when this arm is used we shall hear very

little of deflection or deviation of the bullet from its path, since

it has sufficient power to pass directly through any part of the body

which it may meet on its way. The result in battle will be a reduction

of the list of wounded, but a terrible augmentation of that of the dead.

IDENTITY FROM A FLASH OF GUNPOWDER.

Taylor states the following: “Among the singular questions which have

arisen out of this subject is the following: whether the person who

fires a gun or pistol during a dark night can be identified by means

of the light produced during the discharge. This question was first

negatively answered by a class in physical science in France, whereas

later a case tending to show that their decision was erroneous was

subsequently reported by Fodere. A woman positively swore that she

saw the face of the prisoner, who fired at another during the night,

surrounded by a kind of glory, and that she was thereby enabled to

identify him. This statement was confirmed by the deposition of the

wounded party. Desgranges, of Lyons, performed many experiments on

this subject, and he concluded that away from every source of light

the prisoner who fired the gun might be identified within a moderate

distance; if the flash were very strong, the smoke very dense, and the

distance great, the person firing the piece could not be identified.

The question was raised in England in the case of Reg. _v._ White at

the Croydon Autumn Assizes, 1839. A gentleman was shot at while driving

home on a dark night, being wounded in the leg. When he saw the flash

of the gun he saw that the piece was levelled toward him, and the

light of the flash enabled him to recognize at once the features of

the accused. In cross-examination he said he was quite sure he could

see the prisoner and was not mistaken as to his identity; but the

accused was skilfully defended and he was acquitted. A similar case was

tried at the Lewes Lent Assizes, 1862, Reg. _v._ Stapley. The prisoner

shot at the prosecutor on a dark December evening, and the latter

swore that he distinctly saw the prisoner by the flash of the gun and

could identify him by the light on his features. His evidence was

corroborated and the man was convicted. A case is also quoted, Rex _v._

Haines, in which some police officials were shot at by a highwayman

during a dark night. One of these stated that he could distinctly see

from the flash of the pistol that the robber rode a dark-brown horse

of remarkable shape, and that he had since identified the horse at a

stable in London. He also was positive that the prisoner had on a rough

brown great-coat.

There seems to be enough evidence in this direction to show that

identification under these circumstances is occasionally possible.

GENERAL MEDICO-LEGAL CONSIDERATIONS.

The result of the wonderful advance in the practice of surgery

made during the past fifteen years has been in a large measure to

revolutionize the treatment of gunshot wounds, and inasmuch as the

result of many homicidal attempts will depend in large measure upon

what the surgeon can do for the victim of assault, it may not be amiss

to very briefly epitomize in this place something of what modern

surgeons believe with regard to the best treatment of bullet-wounds,

expressed in a general way. They have learned, among other things,

that the harm which a bullet does is done by it during its flight, and

that after it has come to a stop it is, _per se_, an almost invariably

harmless foreign body. This is practically always the case unless it

has carried in with it foreign material which may serve as a source of

septic infection.

In time past there has always been a strong feeling, which had,

however, nothing scientific to justify it, that every gunshot wound was

a poisoned one. Of late, since bacteriology has attained the proportion

of a science, it has been held that bullets were necessarily sterilized

by the heat of the discharge of powder behind them. Very recently

Dr. B. Von Beck, Medical Director of the 14th German Army Corps, has

made experiments upon the amount of heat imparted to leaden and other

bullets after firing. After making an allowance for specific heat and

the conductivity of the different metals used, he found that even when

the projectiles encountered resistance from three to four times greater

than that offered by the human body the results were as follows:

Temperature of leaden bullets of .45 calibre, when recovered, 69° C.;

of .30 calibre, covered with steel, when recovered, 78° C.; of .30

calibre, covered with copper, when recovered, 101° C. He states that

these experiments disprove the theory that certain lesions in wounds

can be in any way attributed to the heat imparted by the bullet.

While these experiments prove that the bullets may be heated to the

above degrees when recovered, they by no means prove that they are so

heated at the time when they inflicted the wound. During the year 1892

some very interesting experiments were carried on by Dr. Lagarde, of

the Army Medical Department (_New York Medical Journal_, Oct. 22d,

1892, p. 458). He experimented by deliberately infecting bullets and

then firing them into cotton, and animals as well, studying the effect

both on the bullets themselves and upon the animals. Some of these

bullets were taken from the original packages, while others had been

intentionally rolled in dirt. The experiments were carefully carried

out and appear reliable, and the conclusions given by the author, which

interest us here, are as follows:

(1) The vast majority of cartridges in original packages are sterile

or free from septic germs because of the disinfection and absolute

cleanliness observed in the process of their manufacture.

(2) The majority of gunshot wounds are aseptic because the vast

majority of the projectiles inflicting them are either sterile or free

from septic germs.

(3) The heat developed by the act of firing is not sufficient to

destroy all the organic matter of the projectile, the cherished notions

of three centuries or more to the contrary notwithstanding.

The results as set forth justify the assumption that a septic bullet

_can_ infect a gunshot wound. The average bullet-wound, however,

is sterile so far as infection from the bullet is concerned, and

in accordance with this view of its usual innocence there need be

no longer the clamor for removal of the missile which the fears of

previous generations have nearly always called for; and the best

practice among _military surgeons_ of to-day is rather to let the

bullet remain where lodged than to make a more serious wound for its

removal. Exceptions to this rule occur only in cases where operation

is called for on account of injury done by the bullet while still in

motion. It is also held to be a violation of simple physiological

and surgical rules to probe or carelessly search for a bullet whose

location cannot be made out from a study of signs and symptoms in a

given case. The act of probing breaks up blood-clot, often brings on

fresh hemorrhage, is in a majority of cases unsatisfactory, frequently

introduces specific elements from without, and really gives little, if

any, more information than can be gathered from a study of the case

without the use of the probe. If every ordinary bullet-wound which did

not call for immediate operation because of injury to some essential

or vital part—such as a large blood-vessel or nerve-trunk, or some of

the viscera—were antiseptically and hermetically sealed at the very

outset, there would be a much smaller percentage of death from gunshot

wounds, either in civil or military practice, than now obtains. And it

might be a matter upon which to go to the jury whether violation of

such rules, to-day, does not mitigate the offence of the accused.

Recent discoveries in so-called cerebral localization have instigated

numerous operations upon the skull and brain for the relief of

pressure, as from blood-clot, or for removal of depressed bone or a

bullet which twenty years ago would have been impossible. The brain is

no longer the _terra incognita_ of the past generation of medical men,

and it is now often possible for the surgeon to intervene in such a way

as to save life in cases previously considered hopeless; in fact, such

is now his duty when consent can be gained, and it should be held that

he is culpable when deficient in general knowledge in this respect.

In wounds of the thoracic cavity it should now be held that so long

as air has entered through a bullet-wound there are cases where free

incision, even with removal of ribs, can scarcely increase the dangers,

while permitting opportunity for much more accurate exploration and

determination of life-saving methods. The experiments of numerous

investigators, the writer included, have shown that bullet-wounds of

the heart need not be always and invariably fatal, and have afforded

an element of hope from the possible surgery of even this organ. The

writer looks forward to the time when some accomplished yet daring

surgeon, getting the right patient at the right time and in the right

place, _i.e._, where conveniences are at hand, shall, in some case of

perforating wound of the pericardium or of the heart itself, resect

some portion of the anterior thoracic wall, lay open the pericardium,

maintaining meanwhile artificial respiration if necessary, and suture

a wound in the heart-substance, thereafter closing the pericardium

and external wound, and save life which would otherwise be surely

sacrificed. With others he has done this upon animals, hence why may it

not be done in man?

In the mean time for, first, the recognition and, second, the surgical

treatment of perforating wounds of the abdominal viscera, American

surgeons have won for themselves the greatest credit, and an already

long list of successful laparotomies after gunshot wounds of the

intestines, with intestinal suture or resection, has shown the very

great value of this procedure, even though it has kept some would-be

murderers from the gallows.

These lines are inserted here because the time and effort which

surgeons have devoted to this kind of surgery deserve only the highest

encomiums and encouragement from the legal profession, although to our

deep regret they have not always met with the same.

OF THE VARIOUS CONDITIONS WHICH COMPLICATE GUNSHOT WOUNDS AND MAKE

THEIR RESULTS UNCERTAIN,

=Delirium Tremens= is one of the commonest and must always be

regarded as one of the most serious. It is well known to surgeons

that a slight injury even, and often a severe one, is enough to

provoke manifestations of this character in intemperate persons. The

medico-legal question under these circumstances is this: Would the

same amount of injury have been likely to cause death in a person of

ordinary health and vigor? The law as applied to these cases has been

stated by Lord Hale: “It is sufficient to prove that the death of a

person was accelerated by the malicious acts of the person, although

the former labored under a mental disease at the time of the act. The

intent of the accused may often be judged by the character of the wound

and the means of its infliction. Drunkenness of the victim admits of

no excuse when his assailant is aware, or ought to have been aware,

of the condition of his victim. It is held that the assailant ought

to have known that violence of any kind to such a person is likely to

be attended by dangerous results. It is known also that a wound which

accelerates death causes death.” The commissioners who were appointed

to define criminal law on the subject of homicide have thus expressed

themselves: “Art. 3. It is homicide although the effect of the injury

be merely to accelerate the death of one laboring under some previous

injury or infirmity, for although if timely remedies or skilful

treatment had been applied, death might have been prevented” (Taylor,

p. 327).

=Death from Surgical Operations Necessitated by Gunshot Wound.=—The

modern treatment of serious or so-called penetrating gunshot wounds

where the cranium, thoracic viscera, or the abdominal viscera,

especially the intestines, have been perforated one or more times,

calls for surgical procedures which are of severity and danger in

proportion to the gravity of the wound which necessitates them, and

which, while they often save life, must necessarily often fail. Indeed,

such operations may prove fatal upon the operating-table, _i.e._,

patients may die before the conclusion of the operation. The question

may, therefore, arise whether the person who inflicted the wound should

be held responsible for his act, or whether by the intervention of

the surgeon the responsibility may not at least be shifted from the

shoulders of the accused. The law in this respect is explicit and

regards such operation as the outcome of necessity and a legitimate

part of treatment, so that if it be undertaken in good faith, with

reasonable care and skill, the accused will be held responsible, be the

result what it may. The question of necessity and the plan of operation

are left to the judgment of the surgeon in charge. Considering the

responsibility involved in such cases and the possibility of a suit

being raised, we should always advise the operator to secure the

counsel of other surgeons or practitioners in his vicinity. The

verdict of such a counsel of talent will always stand. According to

Lord Hale, when death takes place from an unskilful operation under

such circumstances, and not from the wound, the responsibility of

the prisoner naturally ceases, but the burden of proof that such has

been unskilfully performed rests naturally with the defence. It is

much better also in these cases that the primary responsibility be

borne by one surgeon from the beginning of the case, though he may

associate with himself as many others as he chooses, since the ends

of justice have more than once been defeated by a division of such

responsibilities. Should it be made to appear that the surgeon in

charge has not availed himself of such means as are supposed to be in

the hands of every competent practitioner and has neglected ordinary

antiseptic precautions, it would not be difficult to show that the

operation had been unskilfully performed, and the prisoner would

naturally get the benefit of such defence. At the present date of

writing there exists a large class of the profession who still continue

to do surgery according to the views and practices of twenty or thirty

years ago, and who, while perhaps carrying out some of the forms of

antiseptic surgery, are still ignorant of its fundamental principles

and consequently guilty of neglect, since there is now no reason why

all should not practise them. The writer holds to the view that if it

can be shown that these precautions were not adopted when others would

have adopted them, it constitutes criminal neglect.

On the other hand, circumstances may arise where a simple or a more

serious operation would have saved life, as, for instance, in cases

of hemorrhage, and where a surgeon from timidity or carelessness

has failed to take the necessary steps. Such neglect as this should

inure to the benefit of the accused, but when at any time it can be

shown that the possible benefits of operation have been offered to

the deceased before his death and have been declined, the surgeon at

least is relieved of all further responsibility. Among the dangers of

operations under these circumstances are of course to be reckoned those

pertaining to the use of anæsthetics. The surgeon in charge, however,

is responsible for the selection of his assistants, at least when

assistants are at hand, and must be regarded as equally competent in

this as in other features of the operation; and even though the patient

die from collapse or the anæsthetic, the burden of proof must rest with

the defence to show that it had been unskilfully administered.

NOTE.—The assistance which the microscope may afford in the

procurement of evidence in cases of gunshot wound is beautifully

illustrated in the expert testimony reported by Dr. James, of St.

Louis, in the presidential address before the American Society of

Microscopists, in Washington, August, 1891, printed in Vol. XIII. of

its Transactions. It occurred in St. Louis, in the case of The People

_v._ Vail, who had a pistol in his pocket at the instant when his wife

fell from a wagon against him, knocking him, as he claimed, against

the wheel of the wagon, the pistol being discharged by accident. By

a minute study of the fibres of the various textures making up his

overcoat and of the effect of the explosion of powder upon textile

fabrics almost in contact with it, he was enabled to establish the

accident and secure the acquittal of the accused.

DEATH

BY HEAT AND COLD,

INCLUDING

INSOLATION IN ITS MEDICO-LEGAL ASPECTS.

BY

ENOCH V. STODDARD, A.M., M.D.,

_Emeritus Professor of Materia Medica and Hygiene in the University

of Buffalo_; _Member of the Medical Society of the State of New York

and of the Central New York Medical Association_; _Fellow of the New

York Academy of Medicine and of the American Academy of Medicine_;

_Late Surgeon 65th Regt. N. Y. Vols._; _Late

Health Commissioner, Rochester,

N. Y._; _etc., etc._

DEATH BY HEAT AND COLD.

TEMPERATURE OF THE BODY.

The production and regulation of heat in the body is a problem by

no means elucidated. We consider heat production to be of internal

origin, by a complex process involving tissue metamorphosis, chemical

changes in nutrient elements, muscular movements, etc. Heat regulation

is accomplished, not only by variation in the loss of heat by the

body, but by what is more important, variations in the amount of heat

generated. It is an accepted physiological conclusion that there exists

in the body a thermotaxic nervous mechanism which controls its normal,

as well as its abnormal, manifestations of heat.

The average temperature of the body in health is 37° C. (98.6° F.), in

the axilla. Taken in the vagina or rectum, .9° C. (1.3° F.) higher is

noted. The daily average range of variation is about 1° C. (1.8° F.).

In disease or injury considerable variations occur; very high, as well

as very low, temperatures are met. In severe neuroses and some forms of

malarial disease a temperature of 42.2° C. (115° F.) has been recorded,

and after an injury 71° C. (122° F.).[688]

Very low temperatures are reported in several cases of acute

alcoholism, accompanied by exposure to cold, where a temperature of

28.8° C. (75° F.) in the rectum was noted, recovery following.[689]

Such extreme temperatures, though authentic, are exceptional.

Very high temperatures in febrile conditions are borne because

remitting; and low temperatures, subject to periods of elevation,

are met in wasting and other conditions. Very high and very low

temperatures are also noted, just before death, in acute diseases and

conditions specially involving the nervous system.

The degree to which the temperature may be raised without destroying

life has been investigated by Berger, Bernard, Chossat, and others.[690]

Their experiments show that if an elevation of temperature of the body

7.20° C. (13° F.) be maintained for any length of time in warm-blooded

animals, death ensues. Depression of the temperature of warm-blooded

animals 12° C. (20° F.), or even less than these degrees below the

normal, results fatally. Portions of the body may be frozen and yet,

under appropriate treatment, recover. But freezing of the whole body

must necessarily prove fatal.

Great differences in ability to endure extremes of heat and cold

appear among different nations and in different individuals. The very

young and the very old are unable to bear exposure to extreme cold.

In both, the capacity for heat production is low and the vital powers

are soon enfeebled to a critical degree. The healthy adult can, with

proper precautions, safely endure great extremes of heat and cold.

The experience of arctic explorers in the expeditions of Kane, Nares,

Greely, and others has demonstrated the power of endurance, for a

considerable period, of a temperature from 90° to 100° F. below the

freezing-point. On the other hand, laborers employed in pottery and

other establishments, using ovens raised to 148° to 315° C. (300° to

600° F.) or higher, are often exposed for some time without injury to

temperatures approaching these intense figures.

EFFECTS OF EXTREME COLD.

Legal inquiry into the conditions of death from cold occurs almost

entirely in cases of unintentional exposure. Cold has been employed,

however, with homicidal intent. The depressing influence of continued

low temperatures is observed in the death-rates of cities, in winters

of protracted severity, where the proportionate mortality among

infants, the aged and enfeebled shows marked increase. While age is a

prominent predisposing and contributing factor, other causes exist.

Exhaustion from severe and prolonged exertion, deprivation of food,

intoxication, former illness, and other conditions of depression lessen

the powers of the body to resist cold. Thus an exposure which might be

safely borne in perfect health might result fatally in the same person

in conditions of depression just referred to (Case 1).

Investigation may be demanded in case of the death of

A. Young children.

B. The injured.

C. The insane.

=A. In Young Children.=—This may be in the new-born or older children.

In the _new-born_ exposure to cold soon causes death, as warmth is

essential to the life of the young being. The length of time necessary

to a fatal issue is modified by several conditions. In the immature or

prematurely born infant the resisting power is much less than in the

child born at full term and otherwise healthy. In cases of suspected

infanticide by exposure the question of the maturity of the child at

birth is to be decided. Careful examination of the place in which the

body was discovered should be made as to its lack of warmth; and the

degree of external cold at the time of probable exposure should be

recorded. The circumstances as to whether the exposure was inadvertent

or accidental, as in cases of premature or unexpected delivery, or

whether from intentional and deliberate purpose or from culpable

neglect, should be carefully considered. The post-mortem examination

should decide whether the appearances and conditions of the body are

those peculiar to death from cold (Case 2).

Death may occur from culpably careless exposure to cold, as a

contributory if not as a direct cause, in such conditions of

enfeeblement. Criminal neglect to provide medical attendance, food, and

other essentials has been proven in some cases of the so-called “faith

cure” or “prayer cure.” Exposure may be resorted to with deliberate

homicidal intent. It may, in some cases of death, become an important

legal question to decide whether a studied and persistent neglect of

this nature may not have been followed, with the purpose of getting rid

of a troublesome care (Cases 2 and 3).

=B. Exposure of the injured or wounded=, thereby inducing some

grave condition or complication which under proper care would have

been avoided, may raise an important question in injuries inflicted

by another, with or without criminal intent. It is undeniable that

serious or fatal results may follow a slight wound, otherwise trivial,

where the injured person was subjected, accidentally or intentionally,

to extreme cold for a considerable period. While such cases are

comparatively rare, they may demand investigation.

=C. Exposure of the Insane.=—While it must be admitted that the

insane subject is usually indifferent to matters of temperature, death

from exposure to cold may call for special examination. Carelessness,

incompetence, or wilful neglect on the part of nurses or keepers of

insane hospitals, or deliberate criminal intent in such or others

having the care of or an interest in the death of an insane person may

lead to a judicial inquiry.

Sudden death has been reported as occurring, in several cases, _after

the ingestion of large quantities of cold water_ when the person was

greatly heated. It is somewhat difficult to explain all such cases

reported on a single line of causation. Some observers have attributed

death to syncope or asthenia by the shock produced, in the sudden

effect of the cold upon the sympathetic nervous system inducing heart

failure. This seems the most natural explanation.

Others consider the causative factor to be the formation of thromboses

in the capillaries of the brain, lungs, and other organs, inducing

active and obstructive congestions causing death by apnœa or coma.

Others regard these cases as similar to “heat apoplexy.”

SYMPTOMS.

Under the influence of external cold, the vessels of the skin are

contracted and the internal splanchnic areas dilated. Thus the surface

of the body contains less blood and the internal organs a larger

proportion. This vascular change is one of the important factors in

maintaining the uniform temperature of the body. The thermometer,

placed in the mouth, in such conditions frequently indicates a rise of

temperature. This is probably due, not only to the increased volume

of blood collected in the internal organs, but also to an increased

production of heat through a thermogenic action.

In exposure for a time to severe cold the nose, ears, cheeks, hands,

feet, and other portions of the body, after the first appearance of

dusky lividity, become bloodless and white, lose sensation, and become

congealed; a condition known as “frost-bite.” From this, recovery

without injury is possible under appropriate treatment, by which the

temperature is gradually raised and the circulation restored. Where

the latter result is not secured, the part becomes gangrenous and is

ultimately removed by a process of inflammation and sloughing.

If the application of cold be protracted and the temperature

extreme, the loss of heat becomes rapid and symptoms of depression

of the heart’s action appear. Painful sensations of the surface and

other portions of the body are experienced, succeeded by impaired

sensation and anæsthesia. The skin acquires a dusky, reddish, and

livid appearance, with the formation occasionally of vesicles or

blisters. With the lessened sensation stiffness of the limbs appears,

due to failing muscular contractility. The congestion of the central

portions of the nervous system induces a condition of advancing stupor,

resulting in complete coma with ultimate suspension of respiration and

the heart’s action.

Death from exposure to cold may be rapid or slow. In cases of recovery

the period of reaction is a critical one. The depression of the heart

is apt to continue, and gangrene of parts of the body is likely to

occur. Ulcers and sores healing with difficulty develop in some cases.

TREATMENT.

In the treatment of those who are suffering from the effects of extreme

cold, the restoration of the congealed or “frost-bitten” portions of

the body should be gradually accomplished. Raising the temperature

rapidly is liable to induce the death and destruction of the affected

parts. Ice or snow should, at first, be rubbed upon the frozen part,

to be succeeded later by cold water. The patient should be placed in

a cool room and distant from the fire or source of heat. As soon as

warmth begins to return the part should be enveloped in wool, cotton,

or some substance of poor conducting powers. If the whole body be

chilled, frictions of the surface with stimulating lotions are of

benefit, wrapping the person in woollen or fur coverings or garments

afterward.

Hot coffee or alcoholic stimulants are of value as restoratives, but

the latter are to be avoided during an exposure to cold.

POST-MORTEM APPEARANCES.

The appearances indicative of death from cold are sufficiently marked

to enable one to decide whether exposure to cold was the chief

determining cause of death, provided that a careful consideration of

the circumstances of season, temperature, place, and other conditions

be also had.

In the examination of a body in a case of apparent death from cold, the

limbs and internal organs may be found frozen. It must be remembered

that this occurs after, not before, death; and the frozen condition

must not be mistaken for “rigor mortis.”

In cases where a body is found, in freezing conditions of atmosphere,

showing commencing putrefaction, the death must not be hastily

attributed to cold, which prevents putrefaction. It is evident that if

cold was the cause of death the temperature of the body had been raised

since that event, or, more probably, death occurred from other causes

and the body remained some time before becoming frozen.

The finding of a body in the snow or frozen in severe weather must not

preclude the search for other causes of death, such as apoplexy, etc.,

which may have occurred anterior to the freezing.

Observers generally have agreed upon the presence of certain

post-mortem conditions in cases of death from cold.

EXTERNALLY.—Upon the skin are found dusky reddish patches, irregular

in outline, which are in sharp contrast with the general pallor of the

surface. Krajewskey,[691] Ogston,[692] Dieberg,[693] and others, in the

several series of cases reported by them, all describe this condition.

The skin otherwise is pale.

INTERNALLY.—The viscera, including the brain, are congested. The heart

contains a large quantity of blood in the cavities of both sides, and

the large vessels leading from it are also full. The color of the blood

is a bright red, resembling its arterial hue. This condition has been

generally noted and described; but some excellent observers have not

referred to it.

EFFECTS OF EXTREME HEAT.

The application of moderate heat to the surface of the body causes

dilatation of the cutaneous capillaries. In such application the

exhalant and perspiratory function of the skin is increased, by which

means a rise in general body temperature is prevented. If, however,

severe physical exertion accompany the exposure, a more pronounced

result is induced and a depressing effect upon the nervous system

becomes manifest. If the degree of heat be raised and the exertion

increased and prolonged, marked depression ensues. Under circumstances

of quiet and rest a high degree of temperature is borne by man without

depression or discomfort, but with continued and severe muscular effort

the rise in animal temperature is productive of distress and depressing

conditions. In the Turkish or Russian baths, in the healthy subject,

a temperature of 48.8° to 54.4° C. (120° to 130° F.) produces profuse

perspiration but no depression, and a plunge in or affusion of cold

water is not only borne with impunity but is acceptable. In conditions

of heat accompanied by physical exhaustion, such sudden exposure to

cold would prove extremely dangerous.

In the condition of rest, exposed to external heat, the tendency to

elevation of body temperature arises from the external causes alone,

which in no way specially modify the nutritive functions. But in the

second condition the internal processes of nutrition, which have been

subject to great stimulation, are suddenly embarrassed by suppression

of the compensating activity of the cutaneous surface, and severe

organic and nervous derangements follow.

In the summer season the temperature rises to 32.3° C. (90° F.) and

even much higher in certain localities. During the prevalence of such

heat, the mortality among young children, the aged and enfeebled is

very marked; these two periods of life being very susceptible to the

depressing effects of heat. A high temperature is easily borne if the

air be pure and the atmosphere be not saturated with moisture. Telluric

electric conditions also have a modifying influence, undoubted though

obscure.

In certain occupations an intensely heated atmosphere is endured with

impunity for a considerable time, provided the air be maintained in a

condition of purity and water be supplied to the person exposed. The

stokers upon ocean steam-ships, where a forced draught is employed, are

subjected to extreme heat, sometimes reaching 60° C. (140° F.). Resort

to forced and continuous ventilation of the stoke-rooms, with short

hours of duty, renders tolerance of the high temperatures possible.

SUNSTROKE.

The terms “_sunstroke_,” “_insolation_,” “_coup de soleil_,” are

applied to conditions induced, not alone by exposure to the rays of

the sun, but rather by a combination of great heat with other exciting

causes. They are used to designate attacks occurring in very hot

weather after exposure to solar or other sources of extreme heat.

The striking and usual phenomena are exhaustion, unconsciousness,

stertorous respiration, and death, occurring by syncope, within a

few moments or hours. In a number of cases the symptoms of cerebral

apoplexy with death by coma are present.

In others, the condition seems one of complete exhaustion. The majority

of cases seem to be a combination of these several conditions, with

death resulting from syncope.

The ordinary phenomena of the attack are pain in the head, hurried

respiration sometimes stertorous, violent beating of the heart with

failing of its power, oppression within the chest and, occasionally,

nausea and vomiting. The pupils are sometimes dilated and sometimes

contracted, but in all cases exhibit lessened sensitiveness to light.

The suddenness of the attack modifies the symptoms developed.

PATHOLOGICAL CONDITIONS.

These are exhaustion with syncopic tendency and a rapid rise in the

temperature of the body to a point destructive to the activity of the

nervous centres. This is accompanied by an abnormal condition of the

blood, resulting from loss of its watery portions, with retention of

effete products and impaired aeration. A tendency to general stasis,

specially marked by congestions of the lungs and brain, is present.

The change in the blood is a very important factor. In some cases, not

fatal at the outset, this induces a septic condition.

The greatly elevated temperature of the body undoubtedly produces

certain modifications which type it, in some respects, as a febrile

disease; but this, with the septic tendency due to blood changes, is

not sufficient to designate it as a purely “_thermal fever_,” as some

have claimed. It is something more than this.

Sunstroke occurs more commonly in tropical than temperate

climates;[694] and usually in the day-time, at the period of greatest

solar activity, those attacked being engaged in labor involving

considerable exertion. It occasionally, though rarely, occurs at night.

The military service affords abundant opportunity for observation. Here

the seizures are on the march, rarely in camp. Fatigue, prolonged and

extreme exertion, ill-adjusted clothing and accoutrements, with the

deprivation of cool water, are fully as active factors as the heat of

the sun. The death-rate ranges between forty and fifty per cent, the

mild cases being excluded. Death in some cases is marked by syncope,

in others by apnœa, though the majority seem to die by a combination

of both, as in most cases the pulmonary congestion is more or less

pronounced. Undoubtedly the character of the symptoms and mode of death

are influenced, in many cases, by individual tendencies leading to

apoplectic conditions or to cardiac or other complications.

TREATMENT.

This must be adjusted to the pathological conditions of the patient.

As already indicated, two classes of cases are met: one marked by

exhaustion, with tendency to death by syncope; the other, a state of

or tendency to cerebral congestion or apoplectic conditions. Exactly

opposite methods of treatment are demanded. In the first, frequency

and feebleness of the heart’s action, with faintness of the heart

sounds and embarrassment of respiration, indicate the tendency to

death by nervous exhaustion, and must be met by placing the patient

in a condition of absolute rest and quiet in a cool place. Stimulants

must be promptly administered, though cautiously on account of the

tendency to nausea and vomiting. Hypodermic injections of alcohol or

ether, or rectal enemata of turpentine, alcohol, or other stimulants,

afford means of securing speedy effects when the stomach is irritable.

Carbonate of ammonia and other cardiac stimulants are recommended.

Depleting agents, or such as prove depressing, are to be avoided. In

some cases, hypodermic injections of small doses of morphine prove

beneficial. Individual cases must modify therapeutic procedures.

In the second class of cases the tendency to cerebral congestion

indicates sedative and depleting procedures. Blood-letting has been

recommended by some authors, if employed with extreme judgment and

discrimination.[695] Cold applied to the head and also to the whole

body by rubbing with ice[696] or by effusion and the wet sheet, or

other means, is indicated if the temperature is high (104° to 105° F.).

Active catharsis, by promptly acting purgative enemata, is also to be

resorted to in most cases. The convulsions occurring in some cases are

successfully modified and controlled by inhalations of small quantities

of chloroform.

POST-MORTEM APPEARANCES.

These, though not clearly characteristic, are pronounced. In some cases

no distinct conditions are found.[697] Local congestions are present in

nearly all cases. Upon the skin are found petechial and livid spots,

pallor being occasionally noted. Ecchymoses and subserous hemorrhages

are also common. These conditions have been described as resembling

those of spotted typhus (Levick).

Rigor mortis is marked and occurs early, putrefaction beginning soon

after death. The lungs are highly congested and often œdematous, and

effusions of serum are frequently found in the pleural cavities.[698]

The heart is usually changed in color and consistence, with the left

ventricle contracted and the aorta empty, while the right ventricle

and pulmonary arteries are dilated and engorged. The blood is fluid

and dark.[699] The large vessels of the pia and dura are full of

dark blood. Congestion of the cerebral mass is not always noted. The

ventricles contain serum; and extravasations of blood into the cervical

sympathetic ganglia and vagus are sometimes found. The kidneys are

usually moist and œdematous; the liver and spleen congested and dry.

BURNS AND SCALDS.

For all purposes of practice it is unnecessary to draw any distinction

between a burn and a scald, for in reality none exists, except as

regards the nature of the causative agent. In some cases requiring

investigation, this may prove to be a matter of much importance.

=Definition.=—A =burn= is an injury produced by the application to the

body of a heated substance, flame or radiant heat.

A =scald= is an injury produced by the application of a liquid at or

near its boiling-point.

APPEARANCES AS INDICATING ORIGIN.

A hot body may produce a burn of any intensity, ranging between

reddening of the skin and complete charring of the tissues, according

as its temperature is elevated and the period of contact prolonged: the

shape of the object and its size being indicated by the form of the

burn. Metallic substances heated to a temperature of 100° C. (212° F.)

are capable of producing redness and vesication and other injurious

effects. At this temperature the albuminous elements of the blood and

other fluids undergo coagulation. Some bodies require to be heated to

redness, or nearly so, in order to produce a defined burn.

Very hot and partially-fused solids cause burns of greater severity

than where the heated body is of a character favoring prompt removal.

In such cases their adhesion to the skin involves the tearing away

of the superficial portions of the derma in their removal, or they

by their adherence prolong the contact of the heated body, thus

intensifying their destructive action.

=Metals in a state of fusion= produce burns which cannot be easily

distinguished from those caused by solid bodies. Such burns are classed

as scalds. Their effects may vary in any degree between slight redness

and complete destruction of the tissues with charring. Burns caused by

melted solids are less regular in form and outline than those caused by

heated solids. They are usually of greater severity on account of the

high temperature to which they have been raised.[700]

=Boiling Water.=—Scalds by boiling water may be so slight as to

produce redness only, or they may be so severe as to cause marked and

characteristic symptoms. Those noted in severe cases are an ashy hue

of the skin, accompanied by a soaked or sodden appearance and the

production of blisters. Occasionally these features are not easily

distinguished from those of burns from other sources. Blackening of the

skin and charring of the tissues never result from burns by boiling

water. As in all burns, a large surface involved renders an early fatal

issue probable. In severe cases, not necessarily fatal, gangrene of the

parts injured sometimes occurs. Most of those met with are accidental,

yet cases of scalding by hot water with intent to injure are not

uncommon, aside from injuries and death resulting from explosion

of boilers, bursting of steam-pipes, etc. Occasional instances are

recorded of death of children, the insane or feeble persons by

inadvertent immersion in a bath of hot water (Case 21).

Severe and fatal burns of the mouth, fauces, and larynx in young

children occur from _inhaling steam_ or swallowing boiling water from a

teapot or kettle in an attempt to drink (Case 5).

=Burns by burning oil= produce effects and appearances similar to those

by melted metals.

=Burns by flame= are specially characterized by scorching of the

surface. Hairs upon the part actually burned are scorched and usually

also those in the vicinity of the burned patches. Such conditions

could not result from scalds by hot water, boiling oil, or from a hot

body only.

=Burns by petroleum= or its derivatives resemble the burns from flame,

except that the injured portions of the body are not only scorched but

blackened and are usually burned more severely than by flame alone, as

the clothing holds the burning substance in contact with the parts. The

odor of the agent is also very noticeable.

=Burns by Acids and Corrosive Agents.=—The injury produced by a

mineral acid, the caustic alkalies, etc., has frequently been the

source of judicial inquiry. “Vitriol-throwing,” as it has been termed,

has been and occasionally is resorted to with malicious intent to

injure. No case of death resulting directly and solely from this cause

is recorded, but grave injuries, involving loss of sight, etc., have

resulted. A case is referred to by Taylor[701] where sulphuric acid

was poured into the ear of a woman while asleep by her husband. Death

ensued, after six weeks, from disease of the brain resulting indirectly

from the use of the acid.

The appearances of a burn by a mineral acid are distinguished from heat

burns with little difficulty. The eschar which results is not dry and

leathery, as in a burn by heat, but soft and readily sloughing away.

There is no redness around the site of the injury, the color of the

burn being uniform, and no blisters are formed. There is no blackening

of the skin and the hairs are not scorched. The color of the skin

around the injured portion may afford valuable evidence of the nature

of the agent employed. Nitric acid produces a yellow stain, sulphuric

acid a dark brown, and chlorohydric acid a brownish-yellow stain.[702]

The clothing also is capable of affording characteristic evidence by

the discolorations produced; and the destructive agent employed may be

determined by a chemical analysis of the fabric.[703]

It is not possible to distinguish a post-mortem from an ante-mortem

burn by an acid when no vital reaction has taken place.

THE CLASSIFICATION OF BURNS.

A classification of burns according to the severity of the injury

inflicted is the most practical course. Upon this plan, burns may be

divided into four general classes:

I. Burns in which the skin or subcutaneous cellular tissues only are

injured.

II. Burns which involve the muscles, nerves, and blood-vessels.

III. Burns involving the internal organs and bones.

IV. Burns in which the other three classes are variously mixed.

CLASS I.—The skin in cases such as may occur from a brief contact with

a hot body or water near the boiling-point shows a slight redness or

scorching with no enduring mark. Pain is considerable.

CLASS II.—In the mildest cases the cutis is destroyed in its whole

thickness, and the parts injured are occupied by eschars of a

yellowish-gray or brownish color. The surrounding skin is reddened,

and the formation of blisters occurs either immediately or after an

interval of a few hours. In these cases a shining cicatrix remains

after the healing, without contraction of surrounding parts. In the

severer cases the subcutaneous cellular tissue and underlying muscles

and nerves are destroyed. The blackish eschars formed are insensible

and separate by suppurative process, leaving a granulating surface

below. Extensive redness of surrounding tissues, with more or less

vesication, is usually noted. The resulting cicatrices, together with

the skin and adjoining structures, are prone to contraction, resulting

in considerable deformity, according to location and extent. So great

is the deformity in injuries of the extremities, or even some parts of

the head and trunk, that extensive surgical operations become necessary

to relieve it.

CLASS III.—Burns of this class are so severe that an immediately

fatal issue is usually the result. Such instances involve a prolonged

exposure to flame or to a source of intense heat. The appearances

described as belonging to the preceding class are in part found here

with the addition of charring or carbonizing the parts destroyed.

EFFECTS OF BURNS.

The effects of burns may be considered as I., _Local_, and II.,

_Constitutional_.

=Local Effects.=—In different instances the effects vary in accordance

with the extent and severity of the burn. Redness, blisters,

destruction of the cuticle and of the subcutaneous cellular tissue,

blackening of the skin, scorching of the hair, and roasting of portions

of the body are met with in varying degrees. In some severe cases all

these are found upon a single body. The redness produced varies in

intensity and extent, according to the nature of the agent producing

the burn, its form, and the length of time the part was exposed.

Very soon after the infliction of the burn a special line of redness

appears between the burned parts and the uninjured skin. This _red line

of demarcation_ is formed by intensely injected vessels and becomes a

very important medico-legal sign in some cases. The vesication may be

single or multiple, consisting of one or two large and full blisters

or a number of large and small ones, scattered over the portions

burned, some unbroken and still holding their contents, others broken

and denuded of cuticle or with breaks from which their serum has

escaped upon the surrounding parts. In some cases of burning _cracks

or fissures_ in the skin occur, due to the effect of the heat, making

it dry and brittle and causing it to rupture by the movements of the

patient (Case 8). These fissures are most frequently noted in proximity

to the joints.[704] They resemble wounds, and it occurs occasionally

that it is important to accurately distinguish their character. In

some cases the skin only is fissured; in others the subjacent tissues

are also involved. This difference depends upon the depth of the burn.

In the first condition the skin splits, leaving the subcutaneous fat

exposed, which in some instances is partially melted by the heat and

flows out over the edge of the crack upon the surrounding skin (Cases

8, 13). The blood-vessels in such cases usually are not burned and,

owing to their elasticity, remain stretching across the fissure (Case

14). The smaller may be seen by careful examination with a lens:

they should always be looked for. In the second class of injuries

the vessels are involved in the burn and break with the cracking of

the skin. The importance of careful observation of these fissures is

emphasized in cases of apparent wounds associated with burning. It may

be necessary to decide whether the wounds are the result of the action

of heat as above described or were caused by some sharp instrument or

weapon. Careful inspection of the edges of the wounds will show whether

they are ragged, as the result of fissure, or clean-cut by some sharp

instrument. The absence of evidences indicating hemorrhage upon the

surrounding parts and the detection of uncut blood-vessels extending

across the fissure will establish the differential diagnosis. Wounds of

the above character resulting from the action of fire may exist on the

same body with wounds of actual violence. It is important, therefore,

in all cases to examine each wound with special care and record its

position, shape, depth, and other characteristics.

=Constitutional Effects.=—As in all sudden and violent injuries, the

effect of a severe burn upon the nervous system is very marked. This

is manifest in the symptoms of “shock,” with pallor and coldness of

the surface of the body, a feeble pulse, chills or shivering, and a

tendency to collapse. In other cases, proving immediately fatal, these

symptoms are followed by obstructed respiration with death from coma

succeeding. In other cases convulsions precede death, while in such as

are not immediately fatal a reaction more or less imperfect ensues upon

the first constitutional symptoms.

Death from cerebral congestion or effusion may result before any

definite evidence of reaction appears. In some instances pulmonary

congestion or œdema occurs, with or without pleural effusion,

terminating in death before reaction. This period usually covers

the first two days. In some cases immediate death results from

the depression produced by the severity of the pain. During the

subsequent two weeks a period of inflammatory reaction succeeds, when

inflammations of the thoracic and abdominal viscera, with ulcerative

processes in some organs, are developed and induce a fatal termination

(Cases 10, 11, 16).

CAUSES OF DEATH.

The causes of death are due to several conditions. This fact

is explained in part by the relation which exists between the

cerebro-spinal and sympathetic nervous systems, and of the nervous

supply of the surface to that of the internal organs, which in cases

of extensive injury proportionately modify the conditions of the

visceral organs. As death in burning results from various causes, it is

convenient to consider them under two classes:

1st. Those _immediately_ fatal.

2d. Those fatal _after an interval_.

The FIRST DIVISION would include cases in which the deprivation of

fresh air and the presence of asphyxiating products of combustion

(carbon monoxide and carbon dioxide) were the immediate causes of death

by _suffocation_ or _asphyxia_ (Cases 9, 18).