ASSAULTS, HOMICIDE, AND WOUNDS
=Assault.=--Every act of attack upon the person of another is an
assault in law, whether it injure or not; nor is it necessary that the
act done take effect. Spitting on anyone is an assault. No provocation
by word, whether written or spoken, can justify an assault, though it
may mitigate the offence. If a medical man unnecessarily strip a female
patient naked, under pretence that he cannot otherwise judge of her
illness, it is an assault if he himself take off her clothes (R. _v._
Rosinski, 1 Mood C.C. 12). So, where a medical man had connection with
a girl fourteen years of age, under the pretence that he was thereby
treating her medically for the complaint for which he was attending
her, she making no resistance solely from the _bona fide_ belief that
such was the case, this was held to be certainly an assault, and
probably a rape (R. _v._ Case, 1 Den. 580; 19 L.J. [M.C.] 174). Such an
act is now held to constitute a rape.
=Battery.=--This includes beating or wounding. A touch of the finger,
however slight, is included under this term.
=Homicide.=--In Scotch law homicide is held to be committed only where
a distinctly self-existent human life has been destroyed. Destruction
of an unborn child, however short a time before delivery, may be
criminal, but is not homicidal. In the same country criminal homicide
is divided into two classes:
(1) Murder. (2) Culpable Homicide.
1. _Murder_ is constituted in law by any wilful act causing the
destruction of human life, whether plainly intended to kill, or
displaying such utter and wicked recklessness as to imply a disposition
depraved enough to be wholly regardless of the consequences. Murder may
be the result of personal violence, poison, or by the committal of some
other serious crime, as where anyone causes the death of a woman in the
attempt to procure criminal abortion, rape, or by the exposure of an
infant which results in its death. The use of weapons is not essential.
2. _Culpable Homicide._--The name applied in law to cases where the
death of a person is caused or materially accelerated by improper
conduct of another, and where the guilt does not come up to the crime
of murder:
(_a_) Intentional killing of another in circumstances
implying neither murder on the one hand, nor justifiable
homicide on the other--_e.g._ if a person exceed
moderation in retaliation for an injury, or kill another
when the danger to which he was exposed is passed.
_Every charge of murder is held to conclude a charge of
culpable homicide, and the jury, if they see cause, may
find that culpable homicide only has been committed._
(_b_) Homicide, by the doing of any unlawful, or any
rash and careless act, from which death results, though
not foreseen as probable--_e.g._ using firearms in
a public street, &c.
(_c_) Homicide, resulting from negligence or rashness
in the performance of a lawful duty--_e.g._ a
signalman on a railway forgetting to alter the points,
and thus causing a collision, and loss of life. In
England this would amount to manslaughter.
=Justifiable Homicide.=--Self-defence; hanging a prisoner properly
sentenced to death; killing another to prevent murder, if prevention
can avail in no other way. In self-defence, the person killing must be
in _reasonable dread_ of death at the hand of his adversary.
In England there is--1. Murder; 2. Manslaughter; 3. Justifiable
Homicide.
Murder, according to Lord Coke (3 Inst. 47), is constituted “where
a person of sound memory and discretion unlawfully killeth any
reasonable creature in being, and under the King‘s peace, with malice
aforethought, either expressed or implied.”
In England the killing must be committed with malice aforethought.
Malice may be expressed or implied.
In Scotland malice aforethought is not necessary (5 Irv. 525, and 40
S.J. 92, and 5 S.L.R. 20).
The law in both countries appears to differ more in terms than in
practice. In England, if an injured party live for one year and a day,
and then die, death is not attributed to the injury; but in Scotland,
although no definite time is fixed, yet no case would I believe
be entertained at any lengthened period after the commission of a
homicidal act. The longest interval, according to Taylor, at which
conviction has taken place from indirectly fatal consequences was _nine
months_.
In the United States, as a rule, the crime of murder admits of two
degrees: in the _first_, where the act is intentional or is the result
of an attempt at burglary, rape, arson, or by poison; otherwise the
crime falls under the _second_ degree.
WOUNDS
=Legal Definition.=--According to the statute (24 and 25 Vict. c. 100,
sec. 18), the word “wound” includes incised, punctured, lacerated,
contused, and gunshot wounds. But to constitute a wound within the
meaning of the statute, the _whole skin_, not the mere _cuticle_, or
upper skin, must be divided (R. _v._ M‘Laughlin, 8 C. & P. 635). But
a division of the _internal_ skin, _e.g._ within the cheek or lip, is
sufficient to constitute a wound within the statute (R. _v._ Warman,
1 Den. C.C. 183). If the skin be broken, the nature of the instrument
with which the injury is inflicted is immaterial, for the present
statute extends to wounding, &c., “_by any means whatsoever_.” A wound
from a kick with a boot is within the statute (R. _v._ Briggs, 1 Mood
C.C. 318). Injuries, burns, and scalds--which, in accordance with the
above definition of a wound, are not wounds--are provided for under
the clause, “or cause any grievous bodily harm to any person.”
Casper defines “an injury” to be “every alteration of the structure
or function of any part of the body produced by any external cause.”
Taylor proposed the following as the best definition which can be given
to the word “wound,” whether in a medical or legal sense, viz. that
it is “a breach of continuity in the structures of the body, whether
external or internal, suddenly occasioned by mechanical violence.”
This would include dislocations, fractures, either simple or compound,
injury to the skin or mucous membrane, and to internal organs. Burns
and injuries due to the action of corrosives are excluded from the
category of wounds.
=Concerning Wounds in general.=--Great care must be taken to ascertain
the exact site and course of the injury on the body, as this precaution
will greatly assist in answering the questions: _Is the wound dangerous
to life?_ _Does it cause grievous bodily harm?_ _Is it suicidal, that
is, inflicted by the person on himself; or homicidal, inflicted by
another?_ The solution of the question of the dangerous character of
the wound is left to the professional knowledge of the witness, who may
be required to state his reasons for considering the wound dangerous
to life. His mere assertion will not be accepted. “The safest course,”
says Elwell, “for the witness, in regard to all these questions, is to
give a true and plain account of the wound, describing it minutely,
and the probable consequences that may attend it.” In relation to
their danger to life (apart from so-called “simple” wounds which are
not usually extensive, heal easily, and cause little trouble in their
course), wounds may be considered dangerous to life when they are so
extensive, or on account of their position and relation to important
structures when they would prove fatal without the intervention
of surgical skill; and when the danger is _imminent_. A _mortal_
wound is one which is rapidly followed by death. Wounds, however,
which in themselves could not be regarded as dangerous to life, may
become so by intercurrent complications, such as erysipelas or other
infective process. As a general rule, only those wounds in which the
danger to life is _imminent_ should be stated as dangerous to life.
Compound fracture of the bones of the cranium, injury to any large
arterial trunk, or to any of the internal organs, may be considered as
“dangerous to life”; but where the danger is more remote, as in the
probable supervention of tetanus, erysipelas, &c., the medical opinion
must be more guarded. But the medical witness should always bear in
mind that death may follow the slightest injury. A case is recorded of
death in forty-eight hours after extraction of a tooth. The contrary
also holds good, for the most fearful injuries have been followed with
recovery.
The following suggestions may help the practitioner in the formation of
his opinion as to the probable danger of a wound:
1. The extent of the injury. 2. The character of the
instrument used in the infliction of the wound. 3. The
violence suffered by the parts. 4. The size and importance
of the blood-vessels and nerves injured. 5. Is the wound
healing or likely to heal well, and is the constitutional
disturbance severe or slight? 6. Age of the sufferer. 7.
Is there any constitutional taint likely to render even a
slight wound more severe, or even dangerous to life? 8. Has
the previous medical treatment been skilful or otherwise?
Should the injured party be found dead, a careful _post-mortem_
examination will alone determine the probable part the injury bore in
the production of the fatal result.
Points of Importance to be Noticed in Examination of a Dead Body found
Wounded.
1. Note situation, extent, depth, breadth, length, and direction of
wound. Take careful measurements, in order to determine the character
of the weapon, and the organs of the body injured.
2. Is there any appearance of ecchymosis, or is the effused blood
liquid or coagulated?
3. Examine wound as to presence of pus, adhesive inflammation,
gangrene, or foreign bodies.
_Why?_ Presence of pus, &c., will show that death must
have taken place some time after the wound was inflicted.
4. In all examinations of wounds, be careful to disturb as little as
possible their outward appearance, in order to compare the wound with
the suspected weapon.
5. All notes should be taken during such examination, or _immediately_
after.
6. Make a careful examination of all the important organs of the body.
_Why?_ In order to disprove the suggestion that death
was due to other causes--poison, disease, &c. This is
important, as in the case of a girl who, dreading a
whipping, swallowed some arsenic, from which she died,
yet her father was tried for causing her death by the
severity of his punishment.
7. Only facts should be stated in the Report; _no inferences_ should be
drawn or suggested.
8. In describing the appearance of wounds use _simple untechnical
language_, and avoid superlatives and high-flown words to describe and
explain simple facts.
9. In gunshot wounds, note position of body, state and contents of the
hands, and the direction of the wound in relation to external objects.
Note also in all kinds of wounds the relationship of the wound to cuts
or rents in the clothes of the deceased.
INJURIES OF SPECIAL REGIONS
Injuries of the Head and Spine
These may be either _external_, affecting the integuments; or
_internal_, affecting the brain substance, &c. In the latter, as a
rule, there are signs of external violence. An ecchymosed tumour of
the scalp may impart a _sensation of crepitation_ to the finger, and
may thus be mistaken for a fracture of the skull. The tumour may also
pulsate if any large vessel be near it, giving one the idea that
the pulsations are due to the movements of the brain. A large wound
without fracture points to a more or less oblique blow, a small wound
to direct violence. A blow with a heavy blunt weapon may make a clean
incised wound, and often in these cases the seat of the bruise does not
correspond with the centre of the cut. Dr. Ogston mentions the case
of a young lady on whom a cricket ball inflicted a wound across the
forehead, immediately above, and of the length of, one of the eyebrows,
which he could not distinguish from a wound by a cutting instrument.
All injuries to the head are more or less severe and dangerous, and
great care is required in forming a prognosis with regard to the
ultimate effect of an injury to the head. Inflammation of the brain
does not, as a rule, supervene for about a week after the accident, and
patients should not be considered safe from danger till two or three
weeks after. Be it remembered also that in some cases the inflammatory
action may proceed insidiously for some months without giving any
distinct evidence of its presence till close upon a fatal termination.
Scalp wounds are dangerous, from erysipelas, &c. They should be
examined as to their extent, form, depth, and position.
_Concussion_ of the brain may arise from falls on the nates, or from
blows on the head. The face becomes pale, the pupils contracted, the
pulse weak and small, the extremities cold, the respiration scarcely
perceptible, and the sphincters relaxed. The tendency to death is from
syncope. Reaction may then occur: the pulse quickens; the skin is hot
and dry; there is great confusion of thought, from which the patient
ultimately recovers; vomiting is present in most cases. Concussion
often passes into compression, due to hæmorrhage from the lacerated
cerebral vessels. Concussion and compression differ in this: in the
former, the effects are instantaneous; in the latter, a short time
elapses before the symptoms make their appearance; and these become
more and more marked, whereas in concussion they gradually pass
off. It is often a difficult matter to distinguish the effects of
compression from those common to drunkenness or narcotic poisoning.
The odour of the breath and the history of the case will assist in
forming an opinion. Concussion of the brain may prove fatal without
either fracture of the skull, effusion of blood within the cranium, or
any other change being observed on dissection, death being caused by
the shock given to the whole nervous organ, which, being unrelieved,
speedily lapses into annihilation of function.
_The symptoms of compression_--a full, strong, and often irregular or
slow pulse; normal heat of surface; muscular relaxation; dilatation,
contraction, or inequality of the pupils; stertorous breathing, and
paralysis--are not unfrequently retarded, and this consideration should
render the opinion very guarded. Bryant records a case (_Surgery_,
vol. i. p. 216) in which a man was thrown out of a gig on to his head.
After a short period of insensibility he walked for half an hour,
and then gradually again became insensible, and ultimately died. A
large clot was found over the left cerebral hemisphere, the blood
evidently having flowed from the middle meningeal artery. The short
period of insensibility probably arrested the flow of blood from the
artery, which recurred on the sufferer walking. The structural form
of the cranium may have much to do with the danger to be expected
from blows--some skulls being thinner than others--and in a few rare
instances the fontanelles may not have become ossified during life.
The possibility of an unhealthy condition--atheroma--of the arteries of
the brain, or of disease of the heart, must be taken into consideration
before venturing an opinion as to the tendency or ultimate cause of
death.
It may be stated that the patient died of apoplexy. Apoplexy is a
disease of old age, and seldom occurs in the young, although it is
just possible it _might_ occur. The arteries should, in every case,
be examined for the presence or absence of disease. When violence is
used, the effusion of blood is, as a general rule, on _the surface_ of
the brain; but two cases are given by Dr. Abercrombie of spontaneous
bursting of a blood-vessel within the head, followed by effusion of
blood _upon the surface_ of the brain. “An external injury, coexisting
with an extravasation of blood into the cerebral substance, does not
necessarily imply cause and effect. The previous condition of the
brain, or the outpouring of blood from diseased vessels, may, in fact,
have been the cause of the accident” (Hewett). When, however, blood is
found effused on the surface of the brain, especially between the dura
mater and the skull, either beneath or opposite to an external wound,
we may reasonably infer that the hæmorrhage is due to a direct blow.
Hæmorrhage so severe as to produce dangerous pressure on the brain, as
a rule, comes from a rupture of the middle meningeal artery.
Husband relates a case in the Edinburgh Infirmary in which there was
a large clot over the left frontal lobes, accompanied with aphasia
and right hemiplegia, with no rupture of the middle meningeal artery,
or any signs of external injury. The man had just left the cells on a
charge of drunkenness. The source of the hæmorrhage was not clearly
made out, but it seemed to be due to the rupture of an artery in
a pachy-meningitic patch. Blood may be found in the cavity of the
arachnoid in the great majority of severe injuries to the head, and
even in trifling cases where least expected. Rupture of the venous
sinuses may take place without fracture of the skull. I have met with
this in a fatality during a boxing match; a large effusion over the
brain, and especially in the temperosphenoidal fossa, taking place from
rupture of the left lateral sinus at the junction with the superior
petrosal; there was also a vertical hæmorrhage into the pons. The
effused blood may, after a time, become changed, and form a false
membrane on the _parietal_ arachnoid, seldom on the _visceral_ surface.
Blood cysts may even be formed, in the course of time, having all the
appearances of a serous membrane. The blood may spread to parts remote
from the seat of injury, and the extravasation does not always occur
at the exact spot of the application of the blow, but often at a spot
directly opposite. Two extravasations may be the result of one blow.
Fits of passion have been advanced as a cause of apoplexy, but
this cause is rare. _Fracture of the cranial_ bones may be due to
counter-stroke--_contre-coup_--or to falls on the nates, &c. Fractures
of the skull are divided into two groups (Körber): (1) those produced
by _bilateral_ compression of the skull; and (2) those resulting from
violence applied to _one side_ only. _In both groups the line of
fracture runs parallel with the axis of compression._ Fissures of the
base from bilateral compression of the skull are always transverse.
Punctured wounds of the cranium are always dangerous, but the patient
may survive many days. Dr. Bigelow, Professor of Surgery in Harvard
University, U.S.A., relates a case in which an iron bar, weighing
thirteen and a quarter pounds, three feet seven inches in length, and
one inch thick, was driven through the head, followed by recovery, the
patient only losing the use of the injured eye.
Contusion and laceration of the brain may occur from injuries to the
head, either at the seat of injury or by contre-coup at some other
part. The contused area may exhibit local extravasation of blood,
or in the diffuse form, extravasations may be multiple and also on
the surface. The symptoms are those of cerebral irritation, coma,
or restlessness, paralysis, tonic or clonic spasms. In slight cases
recovery may follow, in others some degree of loss of mentality and
paralysis may remain.
There is great danger of inflammatory complications. I have met with a
case of severe comminuted fracture of the skull with laceration of the
brain, the latter substance appearing on the surface of the scalp, with
loss of brain substance, in a boy who made a complete recovery without
any loss of intelligence or power following the injury.
For the detection of brain substance on weapons the microscope is alone
reliable, and then only the cellular portion of the brain is of any use.
_Injuries to the spinal cord_ may cause immediate death; cases,
however, occur of life being prolonged for some days, or even longer,
after injury to the cord. The symptoms are progressive paraplegia and
paralysis of the bladder and rectum, ending in death. Bedsores and
septic infection of the bladder and kidneys are complications which
add to the gravity of the condition. Spicula of bone in the cord,
dislocation of the vertebræ, or extravasation of blood in the membranes
of the cord, may be found after death. The presence of blood upon the
spinal cord is not necessarily the result of violence, as hæmorrhage
may take place spontaneously. The spine should be examined in all fatal
cases of supposed injury. Concussion of the spinal cord is a fertile
source of differences of opinion in railway cases. In no case should a
hasty decision be given as to the probable future result to the patient
from the injury.
Wounds of the _face_ are not generally dangerous, unless they penetrate
the brain. There is always the possibility of injury to the eye causing
detachment of the retina, or inflammation leading to blindness.
Punctured wounds in the neighbourhood of the orbit may become septic
and lead to secondary meningitis.
Wounds of the Throat and Chest
Wounds of the _throat_ are more or less dangerous, due to the
possibility of severe hæmorrhage, emphysema, and bronchitis.
Wounds of the _chest_ are dangerous, on account of the amount of the
hæmorrhage which may take place, and the importance of the organs
which may be injured. Death may result more from the mechanical action
of the blood effused than from the depressing effect of the quantity
evacuated. Penetrating wounds of the thorax injuring the lungs cause
emphysema, pneumo-, pyo-, or hæmothorax, any of which may prove fatal;
pleurisy and pneumonia may occur. A fracture of the ribs may give rise
to injury of the lung substance or to inflammation of its coverings.
Laceration of the lungs may take place without fracture of the ribs.
The ventricles of the heart may be pierced, and yet life may be
prolonged for one or two months, permitting of considerable locomotion
during that period (Briand et Chaudé, _Med. Leg._, vol. i. p. 511).
Wounds of the heart, however, are, as a rule, rapidly fatal. Rupture
of valves may follow blows on the chest, and rupture of the heart may
occur from crushes or violent blows. Rupture of the heart has taken
place during violent exertion, and this is more likely to occur when
the muscle is diseased. It is often difficult to make out the direction
of the wound, as the lungs change their position during respiration.
Injuries of the Abdomen
Wounds of the _abdomen_, penetrating the intestines, although not
necessarily fatal, may cause death from peritonitis, due to the escape
of the intestinal fluids. Rupture of the intestine may follow blows or
crushing; it is generally fatal from peritonitis unless early surgical
treatment is carried out. Hernia may also follow wounds of the abdomen.
Rupture of the liver is not of infrequent occurrence, and may occur
without any external signs of the injury. The rupture is, as a rule,
longitudinal, transverse lacerations being rare. It is often followed
by pneumonia if not rapidly fatal. The cœliac plexus may be much
damaged by a blow or kick on the stomach, especially if this organ be
distended with food, and death may result without leaving any trace of
the injury externally or internally. The bladder may be ruptured and
death result from extravasated urine. Rupture of the bladder may occur
from fracture of the pelvis without sign of external injury. Rupture of
the _kidney_ may be recovered from if slight, but when severe is fatal.
Rupture of the spleen is usually fatal, and is more likely to occur
when enlarged from any cause. Coagulable lymph, the effect of a wound
of a serous membrane, may be thrown out in twelve hours or less.
Injuries to the abdomen may cause death by--
1. Shock; without lesion of the internal organs,
inflammation, or external signs of injury.
2. Hæmorrhage.
3. Lesion of the internal organs, but without inflammation.
Death in these cases seems to be due to depression of the
nervous system due to the intense pain following these
injuries.
4. By inflammation without lesion of internal organs.
5. Inflammation from lesion of internal organs.
6. Destruction of the natural functions of the organs, and,
as a result, malnutrition of the body.
Except in the first case, when death is instantaneous,
wounds of the abdomen are not as a rule immediately fatal.
Wounds of the _genital organs_ of the female may cause fatal
hæmorrhage, which takes place from the plexus of veins which, in these
parts, are devoid of valves. A kick from behind whilst the woman is
stooping or kneeling may rupture the labial vessels and death supervene.
Blows and kicks upon the abdomen do not often injure the non-gravid
uterus, but during gestation may produce abortion and hæmorrhage. If
the pregnancy be advanced the uterus may be ruptured or the placenta
separated. Penetrating wounds either through the abdominal wall, or
per vaginam in the attempt to procure abortion, cause hæmorrhage and
peritonitis with septic infection.
FRACTURES OF BONES
Unless they implicate some special structure, such as the brain and
medulla, simple fractures are not considered dangerous to life. When
compound, they may be complicated with hæmorrhage and infective
processes.
Certain pathological conditions favour the spontaneous fracture of
bones, or this occurrence with such slight violence as would not cause
fracture in the normal may take place.
In old people bones are more liable to fracture from their brittle
condition. Liability to easy fracture occurs in the insane, in nervous
lesions as locomotor ataxia and general paralysis of the insane,
when the bones are the seat of new growths, in fragillitas ossium,
osteopsathyrosis; in the latter disease I have seen the femur fracture
by the weight of the leg while resting the foot on a cushion. The
liability to fracture depends upon the proportion of organic and
inorganic constituents. In disease, the latter may be reduced and
predispose to fracture; in the young, the bones are more liable to
greenstick or incomplete fracture; and in the old, from excess of
inorganic constituents causing brittleness.
A medical man may be required to express an opinion as to whether or
not fractures are the result of direct violence, and especially when
allegations have been made against attendants on the senile or insane.
The previous predisposing pathological conditions must always be taken
into account, and also the amount, if any, of repair that has followed
in relation to the time the alleged violence took place.
As the condition of a fracture of the bone of a limb may become a
question of considerable importance in medico-legal investigations,
the following brief account of the process of repair in fractures is
given:
_From the First to the Third Day._--The period of
inflammation and exudation. Ordinary signs of inflammation
and laceration of the parts. Blood will be found
extravasated round the fracture, also in the medullary canal
mixed up with the fat.
_From the Third to the Fourteenth Day._--Gradual
subsidence of inflammatory action and growth of the soft
provisional callus from the periosteum and surrounding
structures, and internally in the medulla, forming a
fusiform mass holding the broken ends of the bones together
with some degree of firmness. This becomes firmer and almost
cartilaginous in density. When the bones are kept immovable,
or are impacted, the provisional callus may not be formed.
In the case of the ribs the provisional callus is always
formed, and Dupuytren‘s “ring of provisional callus” is
constant. This may also occur in fractures of the clavicle.
_From the Fourteenth Day to the Fifth
Week._--Ossification of the provisional callus. The bone
is first soft and spongy till the conversion of the soft
callus is complete.
_From the Fifth Week to some Months after the
Injury._--Complete bony union of the fracture and
absorption of the provisional callus.
Although the blood clot completely disappears from the immediate
neighbourhood of the fracture at an early period, yet layers of dark
coagulum may often be found beneath the superficial fascia for four
weeks or more after the accident (Erichsen).
It may be of importance to remember this in medico-legal inquiries.
The presence or absence of the signs of vital reaction will help to
distinguish fractures caused before or after death.
A fracture taking place immediately after death cannot be distinguished
from one immediately before death, but if a few hours after death, the
differences are easily recognised, blood is not effused round the ends
of the bones unless a large vessel be torn.
In the examination of bones for fracture in the living it is the duty
of the examiner to have an X-ray plate taken of the injured bone,
especially if the seat of injury is in close vicinity to a joint.
Previous fractures are easily recognisable after death even when the
bone does not show manifestations externally; on longitudinal section
the seat of fracture is rendered evident.
Is the Wound Suicidal, Homicidal, or Accidental?
An attempt is made to answer this question by a consideration of the
wounds in reference to their _position_, _nature_, _extent_, and
_direction_.
In reference to their _position_ it has to be borne in mind that one
person may wound any part of the body of another, but that to the
suicide certain parts only are accessible, and they have a predilection
for wounding themselves in favoured regions; the front of the body
and vital parts are chosen by the suicide, while wounds on the back
point to homicide. Suicidal wounds on the head are generally in front
or lateral, and on the neck in front or to one side, in cutting the
throat. Accidental head injuries are more often on the vertex, and
when there may be no history of a fall on the occiput, wounds in this
situation indicate homicide.
Suicides may choose unusual regions, such as cutting of a large vessel
as the femoral artery in Scarpa‘s triangle, or by a limited incision,
the carotid in the neck, the injury may be about the genitals, and the
penis and scrotum have been amputated.
Accidental injuries may occur on any part of the body, but most
commonly on exposed parts.
The _nature_ and _extent_ of the wounds does not afford much
assistance; with the exception of contused wounds which are usually
homicidal or accidental, any other form of wound, particularly incised
or punctured wounds, may be suicidal or homicidal, and with regard to
gunshot wounds, much depends upon their position and extent. As a rule,
the suicide does not make several wounds, and the homicide may not only
inflict several but of a greater severity than are necessary to carry
out his purpose.
Suicides, especially when insane, may wound themselves severely
and cause great injuries by leaping from buildings or similar high
positions. In some cases suicides have inflicted several and varied
wounds on their bodies.
The _direction_ of suicidal wounds, when the person is right-handed,
is generally from above downwards and inwards on the chest, and on the
left side. An upward direction points rather to homicide.
=Cut throat wounds=, when suicidal and inflicted by the right hand, are
generally oblique from left to right, beginning higher up than they
end. They generally cross the thyroid cartilage, and the larger vessels
may escape; if made below the thyroid cartilage they are generally
smaller and horizontal. The skin is the last structure divided, and
there may be several so-called “tentative cuts.” It has been held
that when the large vessels are cut the suicide stops, but this is
incorrect, as in some cases the wound has reached the spine and the
vessels been quite severed. Suicides may try to decapitate themselves
from behind, and failing this stab themselves. A homicidal cut throat
wound, when made from the front with the right hand, commences on the
right side and is carried to the left; they are often deep incisions to
the vertebræ and the tissues “undercut” at the ends. A homicidal cut
throat wound when made from behind the victim resembles a suicidal one.
When wounds are present on the forearms, hands, and fingers, and if
there are injuries on other parts of the body also, the inference would
be that the hand wounds were received in guarding the throat or other
efforts at defence from a homicidal attack.
=Wounds produced by Firearms.=--To distinguish between suicidal,
homicidal, and accidental wounds is far from easy. If the weapon be
held hard up or close to the body, as in suicide, the skin and hair
would be scorched and blackened, as would probably the hand that held
the weapon, but this has not occurred in every case. The grasping
of the firearm by the hand in cadaveric spasm is certain evidence
of suicide, as this cannot be simulated by an assailant placing the
weapon in the hand after death. Full investigation should be made by
noting the bullet track and surrounding objects which may have been
grazed in its course, in order to form a probable estimate of the
direction from whence it came. Bullet wounds in the back are usually
homicidal.
Duties of a Medical Man When Called to Examine a Wounded Person
The surgeon should at once visit the wounded party, and proceed to
examine the injury, for if this be done before swelling occurs, he will
be better able to form an opinion of its nature, extent, and severity.
If the wound has been dressed, he should, if possible, obtain the
attendance of the person who applied the dressings, and who would be
able to describe their nature, and the dangers to be avoided in their
removal, should that be deemed necessary. In no case should a surgeon
remove the dressings applied by a professional brother without his
presence and assistance. The condition of the injured party should be
carefully noted, and a minute description of the wound written down at
the time. The statements of the bystanders are also useful and should
be noted. The procedure in the examination of the dead body has been
previously described (p. 60).
An important question here arises. Have the wounds found on the
body been produced during life or after death? The answer is beset
with difficulties, and considerable caution will be necessary, but
tables will be given under the different kinds of wounds to assist
the diagnosis. Signs of vital reaction are important, as showing
the _ante-mortem_ infliction of the wound; but these may, to some
extent, be removed by the action of water, as in cases where the body
is found in a pond. Under these circumstances the evident signs of
drowning--water in the stomach, &c.--will assist the diagnosis. The
presence of putrefaction also greatly obscures the diagnosis. The
presence of coagulated blood between the edges of the wound is not a
trustworthy indication of the _ante-mortem_ infliction of the wound, as
experiment has shown that as long as the body remains warm coagulation
may take place. Coagulation even in contused wounds, effected before
death, may be retarded from various unknown causes--disease, _e.g._
scurvy; mode of death, _e.g._ asphyxia. The amount of hæmorrhage on
or around the body is, other things being equal, a safe criterion as
to the time when the wound was inflicted; if in considerable amount,
arterial blood points to _ante-mortem_ injury; the presence of venous
points blood to _post-mortem_ injury.
Care should be taken to record and photograph the body in position
where found, and its relation to surrounding objects. Careful note
should be made of the surroundings and the character and presence
of any blood-stains, footprints, &c. The question may have to be
considered as to whether the body is in the place it was when the
wounds were inflicted. Blood in any quantity in one place, and the
body found in another so seriously injured that locomotion would be
impossible, point to the body having been removed.
Signs of a struggle, if any, should be recorded. If a weapon be found
near to the body, its position should be noted, and if in the hand,
the firmness of the grasp--cadaveric spasm--should be recorded. All
clothing should be carefully examined, and the relation of cuts and
body wounds noted. All blood-stains on the clothing should be examined
and described.
Multiple bullet wounds denote homicide, but suicides have been known
to inflict more than one wound. It is strong evidence of suicide if
the gun or pistol has burst by the explosion, as suicides have a
predilection for overloading the weapon employed.
PRETENDED ASSAULT
How may wounds, alleged to have been the result of an assault, be shown
to have been self-inflicted? This has to be done by considering:
(1) The character of the wounds: in these cases they are generally
slight, and may consist in a series of small, superficial wounds.
(2) The parts of the body where they are, and those from which they are
absent. They are never found on vital parts, but always where there
is little danger of doing harm. They are present on parts accessible
to the individual. The hands are seldom wounded, and if they be, not
severely.
(3) The clothing may not be cut, and if it be, the cuts may not go
right through, and if they do, they may not coincide with the position
of the wounds. The person should be clothed in order to determine
this. Blood-stains on the cuts in the clothing may be erratic in
distribution, some being on the inner layer only, some on the outer,
and rarely soaking through all, pointing to the probability of its
having been artificially applied.
Such self-inflicted wounds are usually produced for the purpose of
bringing a fictitious charge of assault, feigning self-defence or
provocation on the part of the assailant when accused; and in order
to divert suspicion, as in the case of a person who alleges he has
received the injuries by an assailant who was committing robbery while
he himself is guilty of it.
THE CAUSES OF DEATH FROM WOUNDS
Wounds may prove fatal from results which are (1) =directly=
due to injury--_hæmorrhage_, _shock_, or _mechanical injury
to some vital organ_, _e.g._ the heart or lung; or (2) =indirectly=
from _complications_ which may supervene such as infective
processes--erysipelas, tetanus, septic infections,
gangrene,--exhaustion, or the effects of surgical operations; or (3)
_malum regimen_ (_a_) on the part of the patient, (_b_) on the part of
the medical attendant.
1. Direct
Hæmorrhage.--Hæmorrhage may be profuse and cause rapid death if a
large blood-vessel, more especially an artery, has been injured.
The hæmorrhage may take place internally, in which case it need not
necessarily be profuse; it will depend upon the position; a small
hæmorrhage into the pericardium or in the brain may prove rapidly fatal.
Shock.--Death from shock is generally associated with severe injury,
either a single one, or from several smaller injuries, any of which
alone would not be expected to prove fatal. Death may occur from shock
when the visible injury may be slight, as in blows over the heart
and abdomen, the latter causing fatal syncope from dilatation of the
splanchnic vessels. Repeated lesser injuries as in flogging may cause
death through shock; and fatal psychical shock may be caused by mental
excitement, as, for instance, in an encounter when no physical injuries
have been received.
Mechanical Injury to Viscera.--This causes rapid death, more especially
when the viscus injured, as the heart or medulla, is necessary for
the immediate functions of life; injuries to other organs may not be
followed by immediate death unless very severe and with great shock. A
wound of the lung may not be followed by death for some time.
In a healthy person the violence necessary to prove fatal ought to
be greater than in one diseased, and pathological conditions may be
found _post-mortem_, which were pre-existent to the injury, _e.g._
degeneration of blood-vessels, aneurysm, valvular disease of the heart,
phthisical cavities which may have bled, gastric ulcer which may have
ruptured. Such conditions might influence the findings of a jury, as,
for example, it is not always possible to form the opinion that death
has been directly due to violence when signs of injury are slight; a
man may receive a blow on the head while in the act of falling in a
fight, and _post-mortem_ a cerebral hæmorrhage be found with diseased
vessels, when it would be difficult to say with certainty that the
hæmorrhage was directly caused by the blow or preceded it.
2. Indirect
Fatal Complications.--In English law if death follow injury inflicted
by a person within a year and a day, the assailant may be tried and
punished; beyond that time the person is not held responsible for the
death. The infective processes mentioned above may supervene at any
time during the course of wounds with fatal result. Further, as a
result of altered conditions left by injuries which in themselves have
not proved fatal, and from the immediate effects of which the person
has recovered, fatal complications may follow, _e.g._ a person may have
received an abdominal wound which after healing may become the seat of
hernia which may strangulate; or an injury to the spinal cord, which
may cause death at a late date from bedsores and exhaustion.
Septic Processes.--These may cause death at an early date according to
their nature and virulence and the power of resistance of the person.
In such cases the original injury need not have been dangerous to life.
In other cases the infection may persist after the wound has healed, as
infective endocarditis might conceivably do.
Surgical Operations.--Should a surgical operation be considered
necessary for the treatment of the injury or in order to save life, and
the person dies after it, the prisoner will be held responsible for the
death. This holds good if the operation has been done in good faith and
performed with reasonable skill and care. If, however, it can be shown
that the operation was unnecessary, or performed unskilfully and death
resulted, the prisoner would not be held responsible unless it can
be proved that the injury apart from the operation could have caused
death, when the jury might convict.
Where from improper treatment of an injury an operation is called for
because of the improper treatment and the person dies, the prisoner
would not be held responsible. The main points to be considered in
reference to surgical operations for criminal injuries are:
(1) The operation must be absolutely necessary.
(2) The operator must have acted with reasonable skill and care.
(3) That the wound was dangerous to life, and without operation
would most probably have proved fatal.
3. Malum regimen
(_a_) On the part of the Person Injured.--If the wound is not in itself
sufficient to cause death, but by negligence in the care of it by
the injured person, complications arise which cause death, then the
punishment would probably be mitigated; but in law a person accused
of criminally injuring another is held responsible for the immediate
and remote results. “No man is authorised to place another in such a
predicament as to make the preservation of his life depend merely on
his own prudence.” If, however, it can be proved that death was largely
due to the imprudence or recklessness of the deceased, it is probable
that this would lessen the punishment.
(_b_) On the part of the Doctor.--A person accused of criminally
injuring another being held responsible for the results immediate and
remote, may plead that the latter, _i.e._ complications, or the death
itself are not due to the injury directly, and endeavour to throw the
responsibility on someone else, either the injured person through
negligence, or on the doctor for unskilful treatment. In reference to
the complications, the medical witness may be asked for his opinion as
to the cause and effect of the complication, and how it might have been
avoided. Having considered all the facts laid before him and made his
deductions, he must give his opinion fairly, and leave it to the Court
to decide in what way his opinion may influence its judgment and the
amount of punishment for the offence.
When there is an allegation that the treatment has been unskilful or
negligent, and contributory to complications and death, and a defence
raised accordingly, the prisoner has to prove this to the satisfaction
of the Court in order to mitigate the offence and punishment. The
medical man is expected to have exercised reasonable skill. If the
person treating the injury is a registered medical practitioner, and
has applied his treatment in good faith and for cure, even if the
treatment were improper, the assailant would be held responsible.
The care which the medical man ought to exercise is that which everyone
ought to exercise who has received the statutory education and passed
the statutory examinations.
THE SEVERAL KINDS OF WOUNDS
(1) Incised; (2) Punctured; (3) Lacerated and Contused; and (4) Gunshot.
1. Incised Wounds
Made by sharp instruments.
_General Characters._--Incised wounds are somewhat spindle-shaped,
their superficial extent being greater than their depth; the edges are
smooth and slightly everted, and the wounds are always larger than the
weapon which inflicted them--due to retraction of the divided tissues.
If a wound be in a line with the fibres of a muscle, there will be
less “gaping” than when the wound is directly or obliquely across the
muscle. From muscular contraction, or the elasticity of the skin, an
incised wound may assume a crescentic form. The cellular tissue is
infiltrated with blood, and coagula are found at the bottom and between
the edges of the cut. It must be borne in mind that a wound with smooth
edges may be made by a _blunt_ weapon over bones near the surface,
as on the scalp and over the tibia or shin, but a certain amount of
contusion may, in most cases, be detected by careful inspection a short
time after the receipt of the injury.
It is often of importance to distinguish where the weapon entered, and
where it was drawn out. The end where the weapon entered is usually
more abrupt than the other, which is naturally more drawn out. But in
some cases I have seen, when the weapon was simply drawn across the
part, both ends of the wound alike.
2. Punctured Wounds
The orifice is generally a little smaller than the weapon.
A stab may sometimes present the appearance of an incised wound; the
depth will, however, help to distinguish the one from the other. The
wound may not at all correspond with the shape of the weapon, and the
same pointed instrument may produce very different-shaped wounds in
different parts of the body. Much depends upon the movement of the
instrument in the action of puncturing; in the case of a double-edged
instrument the wound will most probably be fusiform or diamond-shaped.
When made with a knife the wound may be wedge-shaped if the knife have
a thick back. A circular weapon splits the skin and leaves a slit;
broken glass and pottery act in a similar way, but the wounds may
have jagged edges and show signs of contusion in them. On dissection,
two or more punctures may be found in the soft parts, with only one
external orifice; these are due to the weapon being only partially
withdrawn at each stab. Punctured wounds are always more dangerous
than incised. They cause little, if any, hæmorrhage externally, unless
a large vessel, such as the femoral artery, be injured, but they may
cause internal hæmorrhage or penetrate a viscus, _e.g._ the lung or
heart. These wounds generally heal by suppuration, and not infrequently
an abscess is formed in and around the track of the wound. Perforating
wounds generally have a large entrance wound with inverted edges, and a
small exit with everted edges; if the weapon be rough, the reverse may
be the case.
3. Lacerated and Contused Wounds
The edges of these wounds are never smooth, and generally do not
correspond at all with the weapon. A considerable amount of contusion
or bruising surrounds the solution of continuity of the part.
Hæmorrhage from these wounds is usually slight. A point of considerable
interest may arise in connection with this class of wounds; the defence
may declare that the injury was the result of a fall, and not due to
a blow. The history of the case, and the presence of a bruise where
no theory of a fall can explain its existence, will often afford the
only solution of the difficulty. Lacerated wounds heal by suppuration,
generally with more or less sloughing, and leave a permanent scar.
Scratches with the finger-nails may be considered as lacerated wounds,
but the skin is merely abraded, not divided. They are never important
as wounds, but often as a proof of a struggle in cases of rape, &e.
Bites are also lacerated wounds. The diagnosis of lacerated and
punctured wounds, whether inflicted before or after death, will depend
on much the same grounds as those of incised wounds, hæmorrhage, vital
reaction, &c.
Table of Differentiation Between Ante-mortem and Post-mortem Wounds:
---------------------------------------------------------------------
Incised Wounds.
-----------------------------------+---------------------------------
IN THE LIVING. | IN THE DEAD.
|
1. Edges sharply cut and everted, | 1. Edges close, and not everted.
the skin and muscles being |
retracted. |
|
2. Bleeding copious, and generally | 2. Bleeding absent or scanty.
arterial. |
|
3. There are clots. | 3. There are no clots in most
| cases; sometimes a few strial
| clots.
|
4. There is a good deal of staining| 4. There is little or no staining
or diffusion of blood in the | or diffusion of blood in the
muscular and connective tissues.| tissues of the wound.
|
5. After some hours or days | 5. There will be no attempt at
there will be signs of repair or| repair, and no signs of
inflammation. | inflammation. There may be
| signs of putrefaction.
-----------------------------------+----------------------------------
Lacerated Wounds.
-----------------------------------+----------------------------------
|
1. There will be more hæmorrhage | 1. There is hardly any hæmorrhage
and staining from the blood at | or staining unless large veins
first | are torn across.
|
2. After a few hours, or days, | 2. No evidence of repair, or
there will be suppuration or | inflammation, or gangrene can
other sign of repair; | be detected.
inflammation or gangrene may |
also supervene as in incised |
wounds. |
-----------------------------------+---------------------------------
Contused Wounds.
-----------------------------------+---------------------------------
|
1. There is swelling, and, after | 1. There is little swelling or
a few hours or a few days, if | change of colour.
deep-seated, the skin changes |
colour, particularly at the |
edges. |
|
2. There is effusion of liquid | 2. Very little blood is effused.
blood and lymph in the deeper | There are hardly any clots.
parts, and coagula form. |
|
|
3. The swelling subsides and the | 3. There are no rainbow-like or
colours fade after some days, | prismatic changes of colour.
or, in some cases, weeks. |
|
|
4. Abscesses may form, or | 4. No abscesses form, and no
ulceration, sloughing, | erysipelas or dangerous
or erysipelas set in. | changes are met with.
-----------------------------------+---------------------------------
4. Gunshot Wounds
The appearance which gunshot wounds present will to a great extent
depend upon the form of the projectile, and the distance at which the
firearm was discharged. Round halls make a larger opening than conical.
Small-shot, fired within a short distance of the body, make one large
ragged opening. The scattering of the shot depends on the calibre of
the gun, on the charge of powder, and essentially on the distance.
A charge of ordinary (No. 5) shot, to make a single hole, must have
been fired at less than _one foot_; but experiments should always be
made with the alleged weapon. A patent cartridge would make a single
hole at a considerable distance--five or six yards. Round bullets may
split, but the conical ones seldom do. The edges of wounds produced
by the discharge of firearms are always more or less ecchymosed; this
condition appears in about an hour after the infliction of the injury.
If the ball strikes obliquely, the edges of the wound may be much
lacerated, or the opening may be valvular and of small size, if the
skin over the part be in any way tightened, or if a conical ball has
been used. The injury to bones is greater from conical than from round
balls. The old round balls were easily deflected; the conical are not
so easily turned aside. The track of the ball _widens as it deepens._
This is the reverse of an ordinary punctured wound. The ball may either
lodge in a part, or perforate it. Should it have lodged, it must be
preserved and compared with the alleged firearm. Bits of clothing or
wadding may be carried into the wound. The latter should be carefully
kept, as they may prove important as a means of identification.
The aperture of entrance and exit must, if possible, be determined. On
this point there is much difference of opinion. The wound of _exit_
is always _smaller_ than the wound of _entrance_ (Casper). In this
opinion Casper agrees with M. Malle, Olliver d‘Angers, and M. Huguier,
but is opposed by Taylor, M. Matthysens, and others. “The characters
of a gunshot wound,” says Assistant-Surgeon Neill, “are those of a
contusion and laceration of all the tissues. Sometimes they are so
simple as to bear resemblance to a punctured wound, particularly if a
rifle-ball (conoidal), revolving on its long axis, has passed through
the soft parts at a great speed, but within a few hours it resembles
a contusion. The wound of entrance, as it has been termed, bears no
comparison in size or shape to that of the exit when a rifle-ball has
caused the injury. In the former you see the edges of the wound curving
inwards, and the circumference small, with little or no hæmorrhage.
In the latter, the wound is large, with torn and irregular edges
projecting outwards, and perhaps only slight oozing of blood. In a
short time, averaging an hour, round the entrance wound slight redness
begins, gradually extending to about two inches round its orifice.
Again, this colour changes to a blue- or greenish-black, and you see
all the appearances of a severe bruise, with a small wound of the skin,
its edges still curved inwards. In the exit wound the discoloration of
the skin is not apparent.” The probable reason for the discrepancies in
the statements of observers, as to the characters of entrance and exit
wounds, may be found in the fact that experiments have been conducted
with different-sized balls, different kinds of weapons, with varying
quantities and qualities of the powder used, the character of the wads,
and with varying velocities and distances. As pointed out by M. Roux,
the two openings may be equal if the ball preserves the same velocity
through the tissues as it possessed before entrance; the _entrance_
hole is smaller than the _exit_, when the ball has lost much of its
trajectile force, and enters the softer parts of the body first; the
_entrance_ is larger than the _exit_, when the ball first enters
through the denser tissues of the body, and leaves through the softer.
The opening of entrance made by the ball has generally, but by no means
always, inverted edges. The edges of the exit opening are everted,
bloody, and raw; but both the entrance and exit wounds may be everted
in fat persons, due to the protrusion of the fat; and this eversion
may also result from the expansive power of the gases generated during
putrefaction, should this condition be present. Wounds made by _double
shots_, as from double-barrelled guns, or pistols, or from slugs fired
from one barrel, diverge after their entrance into the body.
Observations during the war in South Africa threw fresh light upon the
results of gunshot wounds produced by modern projectiles. Of wounds
produced by the Mauser bullet, one correspondent (_The Physician and
Surgeon_, 1900, p. 49) states that “the aperture of entrance seldom
shows any bruising of surrounding tissue; frequently it has been
difficult to locate it, for where the skin is dense and elastic, there
is seldom any bleeding. There is never any inversion of the edges,
which are sometimes circular in form, and sometimes triangular like
a leech-bite. The aperture of exit, where the bullet has not been
distorted, is seldom any larger than that of entrance; there is no
bruising of surrounding tissue, and no eversion of the edges; bleeding
varies, of course, in accordance with the proximity of large, medium,
or small blood-vessels in the track, but in the vast majority of cases
it is slight.”
The late Sir William MacCormac, quoted by Sir William Stokes (_B. M.
J._, vol. i., 1900, p. 1453), says: “I saw a large number of injuries
inflicted by the Mauser bullet, which is remarkable for the small
wound it produces. In three-fourths, if not a larger proportion, it
was impossible to tell the exit from the entrance wound, they were so
similar in appearance.”
In the examination of gunshot wounds we have to consider--
1. _Direction in which the Gun was fired._--The track and position of
the ball in the body, coupled with the relative position of the body
to a window or door through which the gun may have been discharged,
and the place where the ball is found, should it have passed through
the body, may assist us in forming an opinion. It is often impossible
to trace the course of the ball through the cavities of the body,
but through the muscles and denser structures this is more easily
accomplished. The effects of the ball on surrounding objects may assist
very much in finding the direction of its course. Sir Astley Cooper,
by a careful consideration of the above suggestions, once correctly
determined that a left-handed man had fired the fatal shot.
2. _Distance at which the Charge was fired._--In the case of wounds
inflicted by a small shot, the scattering of the shot must be our
guide. Dupuytren has related a case in which a fowling-piece charged
with powder alone and fired at a distance of two or three feet from
the abdomen made a round hole in it and killed the man. If the weapon
be fired a short distance, _e.g._ a few inches from the body, the skin
will be scorched, smoke-blackened, and tatooed with powder, the flame
may singe the hair or clothing. If discharged quite hard up to the
body, the edges of the wound are freely lacerated, ecchymosed, and
burnt. Smokeless powder will not cause blackening of the skin. The
absence of scorching, or marks made round the wound by the half-burnt
powder, allows of the assumption that the shot must have come from
some distance--rather more than four feet. The absence of any of the
above, however, is not an absolute proof that the shot has come from a
distance.
There is no means of deciding, from an examination of a pistol or
gun, when the weapon was last used. In all cases, medical men, unless
sportsmen and familiar with firearms, should hand over the weapon to a
gamekeeper or gunsmith, and not attempt to give an opinion on matters
about which they know nothing. The following may be of use to students
for examination purposes, but for nothing else: Among the products
formed when gunpowder is exploded is the sulphide of potassium, but if
exposed to the air some portion of this substance is converted into
the sulphate of potash. If, then, the gun-barrel be washed out with
distilled water, and the washings filtered, and, on the addition of a
solution of acetate of lead, a black precipitate of sulphide of lead be
formed, this is supposed to point to recent use; if, on the other hand,
a white precipitate of sulphate of lead forms, to the use of the weapon
at some more distant date than the period alleged.