Ruptures of internal organs are not rare in such cases. According to Vibert,[656] the order of frequency of rupture of the various organs is as follows: liver, spleen, kidneys, lungs, heart, stomach, intestines, bladder, brain. Rupture of the liver occurs especially on the anterior and inferior surfaces and the bleeding is rather abundant. The healthy spleen does not rupture readily, except from a severe traumatism, but if it is hypertrophied it may rupture spontaneously from muscular violence. The lung may be ruptured internally without showing the rupture on the surface and with the ribs intact. Two such cases are mentioned by Vibert,[657] and he refers to others mentioned by Nelaton and Holmes. Rupture of the brain without fracture of the skull is very rare, though cases have been observed and reported, among others by Casper-Liman. In falls from a height the rupture of the aorta, mesentery, diaphragm, and larynx have been noted. It should be remembered in this connection that rupture of the liver, intestine, bladder, etc., may be caused by contusions without sign of violence externally, and such cases cannot, therefore, be attributed to falls unless there are other signs of the latter.

In crushes caused by a heavy vehicle, the lesions resemble in many respects those due to a fall from a height. Thus we find fractures and internal ruptures, but we more often and regularly find subcutaneous ecchymoses and ecchymoses between the muscles. The skin is often stripped up extensively and the injuries are generally limited to the region injured. It is rare to find that the cause of the injury leaves no trace on the skin, for it usually gives the form to the erosions or ecchymoses. Sometimes, for instance, the marks of a horseshoe are clearly visible. Ruptures of internal organs may occur here too when there are slight external marks of violence or even none at all. Thus Vibert[658] relates the case of a man with the head crushed, but with no signs of injury to the trunk save a few erosions at the level of the sternum, who had not only rupture of the kidneys, the liver, and the spleen, but also of the lungs and of the heart. In the heart the apex was completely detached and floating in the pericardium, which was intact. There was no fracture of the ribs nor subcutaneous or sub-muscular ecchymoses. The age of the subject was thirty-two, so that the costal cartilages were not probably ossified, which may have accounted for the absence of fracture of the ribs.

Crushes by the fall of heavy weights resemble the latter class of crushes, and differ from falls from a height in the fact that the wounds are usually limited to one region. The lesions themselves are more or less similar. Similar internal lesions may be caused by the compression of the chest and body by the knee of a murderer, which may occasion rupture of the internal organs, fractures of ribs, etc. Thus, too, from the pressure of a crowd the ribs may be fractured and the lungs injured. It is particularly in these cases of injury from crushes or falls from a height that we may have most difficulty, as far as the medical evidence goes, of distinguishing between accident, suicide, and murder. But the various points and considerations mentioned above will sometimes enable the medical witness to clear up the case. In some cases the non-medical evidence, circumstantial and otherwise, may be sufficient of itself, or at least in conjunction with the medical evidence.

In falls from a less high place the difficulty is somewhat different, for here there may arise the question between a fall and a contusion or contused wound, and the question generally lies between accident and murder, or, very rarely, between accident and suicide. We have referred to both of these questions above, and from the facts mentioned the case can often be solved.

Of more than One Injury which was the First Inflicted?

We can sometimes tell the order in which wounds were received, but the question is rarely answerable with certainty. If one wound is mortal and one or more are not, whether the wounds are suicidal or homicidal, it has sometimes been considered that the former must have been inflicted last. But we cannot admit that as a general rule the most grave wound was the last inflicted. For the murderer or suicide, especially the former, may go on wounding after the infliction of a mortal wound, especially as it is the exception, and not the rule, to die instantly after a mortal wound. Several assailants may have inflicted wounds at the same time, which would still further increase the difficulty. The question might then arise, Which assailant had inflicted the mortal wound or which had first inflicted a mortal wound? Under such circumstances, it would not be easy to give a specific answer. There are several signs which may indicate which wound was first inflicted in certain cases. An instrument may become duller or even bent or twisted after and on account of the first wound, and the subsequent wounds would vary accordingly. The wound of the clothes corresponding to the first stab-wound may be and often is only bloody internally, while the second and following wounds are bloody on both sides. The following case quoted by Taylor[659] from the Annales d’Hygiene, 1847, p. 461, illustrates this point. A man received three stabs from an assailant, one in the back at the level of the eighth rib, traversing the lung and heart and causing rapid death, and two on the left elbow, cutting the coat and shirt but only grazing the skin. The first one was evidently the first inflicted, for both the wounds in the clothing on the arm were bloody externally at the edges, although there was no blood effused here. The correctness of this opinion was confirmed at the trial.

The point of a knife arrested and broken off in a bone may show that this was the last wound. The amount of bleeding may show which was the first wound. Thus if several severe wounds have been inflicted, all or several of which would naturally cause profuse hemorrhage, and one showed signs of such hemorrhage while another did not, the former would be likely to be the first wound inflicted. Or if one showed slight hemorrhage where much would be expected, this fact would indicate that it was one of the last inflicted. The absence of the signs of spurting blood may tell which of two or more fatal wounds were first inflicted, for this would indicate that this wound was inflicted when the heart action was weakened by loss of blood or even after death, and the other wound or wounds which did not present this sign would have been the first received. In fact, if any of the signs are present about a wound which we have seen to indicate that a wound was inflicted at any time after death, this would show that this wound was not the first received, and that the other or others were inflicted earlier.

Questions as to the CONSEQUENCES of WOUNDS NOT FATAL may often be brought up in civil actions for damages. In certain countries the question of the consequences as to incapacity may determine whether an injury shall be the ground of a criminal as well as of a civil action. Thus in France an injury which involves an incapacity of twenty days or more subjects the assailant to a criminal action. The term “incapacity” in this instance refers to general incapacity and not to incapacity for fine and professional work. The latter, however, comes in under the civil action which may be instituted against the assailant or those directly or indirectly responsible for the injury. The amount of the incapacity, its causes, whether due wholly or partly or not at all to the given injury, the probable duration of the incapacity, the treatment which it has and will necessitate, and many other such questions form part of the medical testimony required in such cases. Sometimes with slight wounds the results, accompaniments, and complications may prolong the incapacity very greatly, as also the state of health and the habits of the wounded person, the neglect of treatment, improper treatment, etc.

Any bodily or mental infirmity or ill-health which may result from an injury and its necessary treatment in the past and future, all these questions and many more unnecessary to mention may be required of the medical witness. No general rules can be laid down for all such cases. In giving his testimony the medical man must depend in any particular case upon his knowledge, judgment, and experience.

We can seldom give a precise solution of the question of survival to determine the succession or inheritance if several of a family die together in an accident. In case of death from inanition, cold or heat, or in drowning especially, if some have wounds more or less grave in themselves, we can sometimes form an opinion. With wounds we cannot often do so, although in case of murder, the nature of the wounds, the position of the bodies, the examination of the spot of the accident or tragedy, may sometimes help us to form an opinion.

INCISED AND PUNCTURED WOUNDS AND WOUNDS OF BLUNT INSTRUMENTS REGIONALLY CONSIDERED.

The several varieties of wounds which we have been considering vary considerably in their nature, their effects, their danger, and in many other ways according to the region of the body in which they are situated. Some of these varieties are common in one situation and almost never occur in others. Although the nature of wounds found in the several regions of the body is not as important for a medical jurist as their danger and their influence in causing death, we will now consider the differences they exhibit on account of the region in which they occur.

WOUNDS OF THE HEAD.

These are often characterized by their apparent harmlessness and their real gravity sooner or later. We might almost make the opposite statement and say that those apparently grave are often virtually harmless, though this would be true only in a limited sense and in certain cases.

As to their nature, we find punctured wounds extremely rarely, incised and lacerated wounds often, while contusions and contused wounds are still more common. Incised and lacerated wounds of the head involve the scalp almost exclusively. These wounds heal remarkably well, even when the attachment is merely by a narrow pedicle, owing to the abundant blood-supply. Hemorrhage from the incised wounds is often free, for the vessels cannot retract, but it is seldom dangerous unless the wounds are very extensive. The only way in which they differ materially from similar wounds elsewhere is in the greater frequency of complicating erysipelas here than elsewhere. This is probably owing to the presence of septic conditions, as the head is generally dirtier than other parts of the body, and slight wounds especially are neglected. If the scalp is shaved over a wide margin and cleaned like other parts of the body, erysipelas is found little or no oftener than with similar wounds elsewhere. The density of the scalp is so great that the redness and swelling accompanying inflammations is comparatively slight. If erysipelas follows slight wounds of the head, there is some reason to suspect constitutional predisposition or careless treatment. From infection of such wounds of the scalp abscess or diffuse cellulitis of the scalp may develop as well as erysipelas. The constitutional symptoms in such a case may be marked or even severe, but the prognosis is favorable. In very rare cases necrosis of the skull may result or the inflammation may even extend to the brain. These incised and lacerated wounds of the scalp are usually accidental or inflicted by another; they are rarely self-inflicted. Contusions and contused wounds are the most common forms of injury to the head. These two kinds of injuries are almost invariably inflicted by another or are accidental. We have already seen that contused wounds of the scalp or over the eyebrow may closely resemble incised wounds in these localities. This fact should be borne in mind, as careful examination can usually distinguish them if they are fresh and until they begin to granulate. These wounds are liable to the same complications as incised wounds, in fact more liable, as the contusion makes the wound more susceptible to inflammation and the edges are more apt to be infected at the time of the injury.

One of the results of contusions of the head is the extravasation of blood, most often between the aponeurosis of the occipito-frontalis muscle and the pericranium. These extravasations are usually in the form of a hematoma. Such hematomata often present a hard circular or oval rim with a softer centre, and may readily be mistaken for fracture of the skull with depression. The diagnosis between hematoma and depressed fracture is not usually difficult, however, for with hematoma the ridge is elevated above the level of the skull and is movable on the surface of the skull; also the wounded edges often pit on pressure. With depressed fracture, on the other hand, the edge is at or about the level of the rest of the skull; it is sharper, more irregular, and less evenly circular. Contusions and the resulting hematoma may occasionally end by suppurating, but this event is rare. Contusions and contused wounds may occasionally show the marks of a weapon, indicating that they were inflicted by another. Also the position of the injury will indicate its origin, whether it is accidental or inflicted by another, for the former would not naturally occur on the vertex unless the fall was from a considerable height.

Another result of injuries to the head, especially of contusions and contused wounds, is FRACTURE OF THE SKULL. This may be simple or compound, depressed or not, etc. Fractures are serious inasmuch as they imply a degree of violence which may do damage to the brain. The fracture itself, especially if properly treated, affords a good prognosis, irrespective of any brain lesion. One variety of fracture of the skull offers an exception to this favorable prognosis, and that is fractures of the base of the skull. These may be fatal directly from injury of the vital centres at the base of the brain or soon fatal from hemorrhage in these parts. Or the fatal result may be secondary to an inflammation or meningitis which good treatment is often unable to prevent. It should not be considered that these fractures are uniformly fatal, for quite a considerable proportion recover. Fracture of the base usually occurs as the result of a fall. The injured person may land on the feet or buttocks, and yet receive a fracture of the base of the skull, the force of the fall being transmitted through the spine to the base of the skull. Fracture of the base of the skull usually occurs from an injury to the vault, not by contre coup, but by extension of a fissure found higher up in the skull. This extension takes place in the same meridian line of the skull with that of the force which produced the fracture, and in this way the base of the skull is fractured in different parts according to the point and direction of the application of the force. Thus in case the force compresses the skull antero-posteriorly the fracture will pass antero-posteriorly toward the base from the front or the back, whichever received the blow (see Fig. 13). Fractures of the vault of the skull occasionally occur opposite to the point struck; this may occur by contre coup, but not always so, as not infrequently in such rare cases a close examination may reveal an extension of a fissure from the point injured to the opposite pole of the skull. The shape and rarely the size of a fracture of the skull, especially if punctured in character, may show the shape and more rarely the size of the instrument or object which produced it. Apart from fracture of the base, the prognosis in fracture of the skull is serious, mainly on account of the danger of inflammation, which is greater in compound fractures, and also on account of the more remote danger of irritation from depressed fragments causing epilepsy, insanity, etc., at a later period.

A circumstance that Taylor[660] says is connected with fracture of the skull with depression—namely, that the person, sensible as long as the object producing the fracture remained wedged in, became insensible and began to manifest other fatal symptoms as soon as it was removed—must be extremely exceptional. It may be explained, if it occurs, by the occurrence of hemorrhage after the object which occluded an open vessel by its presence or its pressure was removed. For it should be remembered that the symptoms of compression in a depressed fracture of the skull are very rarely due to the compressing effect of the depressed bone, but rather to an injury of the brain, intracranial hemorrhage, or a local and temporary interference with the circulation.

We may truly say that wounds of the head are dangerous in proportion as they affect the brain. The existence of affection of the brain may be hard to tell from the appearances, for an injured person may recover from the first effects of a comparatively slight wound and yet die suddenly later.

Concussion is the name applied to one of the effects on the brain of a more or less violent blow directly on the head or transmitted indirectly to the head. Though the term “concussion” implies a functional rather than an organic lesion, yet in the majority of cases it is equivalent to laceration of the brain. With laceration of the brain there is usually more or less effusion of blood which may be limited to a very thin layer. Concussion may exist without laceration of the brain. Even death has been known to occur from concussion of the brain without any visible signs of injury to the brain, so that the concussion must have been functional and the fatal result due to shock of the nervous system. Fatal concussion does not, therefore, necessitate the existence of compression or visible injury of the brain. Concussion may sometimes be due to a violent fall upon the feet, in which case the shock is transmitted through the spinal column to the head with or without fracture of the base of the skull. It was in this way that the Duke of Orleans, the son of Louis Philippe, died.

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The symptoms of concussion show all degrees of severity. Thus the injured person may become confused and giddy with or without falling, he may become pallid and nauseated and may vomit, but after a short period he recovers gradually.

With a more severe injury, with which there is generally some laceration of the brain, the injured person falls and lies quiet and relaxed, apparently unconscious, though often he can be partly roused. Paralysis and anæsthesia are absent. The heart is feeble and fluttering, the skin cold and clammy. The pupils, as a rule, react to light, but otherwise vary considerably. Urine and fæces may be passed involuntarily. As he begins to regain consciousness, vomiting usually occurs. Consciousness usually returns within twenty-four or forty-eight hours, when headache and indisposition to exertion are complained of, and this may last for a long time. Occasionally the symptoms instead of abating increase, and coma supervenes, often indicating meningitis, encephalitis, or intracranial hemorrhage. In other cases the person may die almost immediately on the spot where he fell, while in still others apparent recovery takes place and death occurs later either suddenly or after a reappearance of symptoms. In such cases, abscess of the brain may occur and be the cause of the fatal result. These abscesses are the result of the injury, which may be almost anything from a compound fracture to a slight contusion not leaving any scar. The abscess may occur within a week[661] or not until after months or years. This interval of apparent recovery may lead to the false supposition that death was not due to the injury, but to some intervening cause. It is well to bear in mind that about half of the cases of abscess of the brain are not traumatic. A large majority of these are due to suppuration in the middle ear, a few to septic diseases or tuberculosis. The situation of the abscess often distinguishes between the traumatic and non-traumatic varieties. The traumatic variety is usually found beneath the injury or sometimes directly opposite, where the brain is injured by a kind of focussing of the radiated effects of the blow. The cases of abscess of the brain due to ear disease are usually found in the temporal lobe of the brain lying over the position of the ear or in the cerebellum behind it. The uncertainty of the nature and the extent of the cerebral injury in so-called contusion of the brain renders it necessary to be very careful in giving a prognosis. Any injury should be considered serious which has produced unconsciousness, for such an injury may produce enough laceration of the brain to render serious danger possible or even probable. We have seen that as a rule the symptoms of concussion come on immediately, but it is possible that symptoms at first so slight as to escape notice may become serious in a few hours or days. A gradual hemorrhage may sometimes account for this. The knowledge of certain acts performed or a conversation held at the last moment before the injury may be retained after recovery from concussion of the brain. This is not necessarily the case, for instead of remembering up to the moment of the injury, the injured person may remember only up to a certain time shortly before, or a part and not everything may be remembered.

The diagnosis of concussion of the brain from alcoholism is sometimes a matter of medico-legal interest or importance. Concussion may be so slight as to simulate intoxication. The history often clears the case up. The history of a blow or a fall or the presence of marks of violence on the head indicates concussion, though the blow or fall may not have caused the symptoms, which may be due to alcoholism. The odor of the breath may indicate alcoholism, but here too we may have both present and the concussion may be responsible for the symptoms. Or again the alcohol may have been given as a heart stimulant after the accident. This combination often occurs. If there is no odor in the breath, the presumption is in favor of concussion. As mistakes are still not infrequently made in diagnosis, those cases in which there is any ground for doubt should be carefully watched for developments. In general, the existence of concussion is more often overlooked than the coexisting alcoholism, so that if there is any doubt in a given case it should be treated as one of cerebral injury. The injury which causes the concussion in such cases is often due to the alcoholism. We may be able to verify this supposition if the injury is such as would be likely to be caused by a fall. There may be nothing found in the brain after death to distinguish between concussion and alcoholism. A bruise on the head only indicates a probability of concussion, for the bruise and alcoholism may both be present, the former perhaps due to the latter. The presence of alcohol in the stomach would indicate the existence of alcoholism.

Another effect of an injury which has caused concussion of the brain is an extravasation or effusion of blood. Extravasation of blood in or on the brain is one of the commonest causes of death from injury to the head. It may occur with or without marks of external injury. A person suffering from such an extravasation of blood may recover from the first effects of the injury, and at a varying time afterward the symptoms may return and increase so as to result fatally. In such a case the opening of the bleeding vessel may have become plugged until some exertion, emotion, or excitement on the part of the injured person has loosened the plug. A hemorrhage may have ceased from partial syncope and return with a stronger heart action due perhaps to the administration of alcohol. This effusion may occur on the surface of the brain in connection with a superficial laceration of the brain or just beneath or outside the dura mater and not involving the brain directly. The latter cases are almost always due to the effects of violence, though there is at least one case of apparently spontaneous rupture of the middle meningeal artery. The violence which causes a rupture of the branches of this artery may be so slight as to leave no bruise or so severe as to cause fracture of the skull. The most important symptom of such extradural hemorrhage is a period of consciousness after recovery from the first effects of the injury, then stupor may appear and deepen into coma. A subdural hemorrhage may cause almost the same symptoms, though the injury is usually such as has produced a depressed fracture. This hemorrhage is most often due to the rupture of a number of small vessels under the fracture, though if one larger vessel is ruptured it is most often the middle cerebral. A thin layer of hemorrhage in connection with a superficial laceration of the brain is of frequent occurrence with or without the other two forms of intracranial hemorrhage. If the brain is lacerated we may have convulsions in addition to other symptoms. Death occurring during or soon after a prize-fight may occur from some of the above classes of intracranial extravasations. It may be questioned whether the blows or a fall caused the hemorrhage. It is generally due to a fall in such cases, but may be due to blows, but the guilt is the same unless the fall was accidental. As the result of severe traumatism the vessels of the interior of the cerebrum may be ruptured or hemorrhage may occur into the ventricles of the brain. In such cases the symptoms will resemble those of ordinary apoplexy, only the cause is different from the latter and the injury is usually so severe as to leave no doubt as to the existence of a traumatism. The following question may arise in cases of intracranial hemorrhage and especially in the latter class of such cases, i.e., in cerebral hemorrhage:

Was the Extravasation of Blood due to Disease or Violence?—It may be alleged in defence that the hemorrhage was the natural result of disease. Where the hemorrhage is extradural or subdural or in connection with a superficial laceration of the brain, the cause is almost always traumatic. We have referred to one case of extradural hemorrhage from spontaneous rupture of the middle meningeal artery.[662] Subdural hemorrhage may occur from Pachymeningitis hæmorrhagica interna, but this condition is readily diagnosed on post-mortem examination and often with considerable certainty during life. A history of alcoholism, headache, impaired intellect, unsteady gait, occasional losses of consciousness, stupor increasing to coma, etc., indicates such a condition.

It is in cases of cerebral hemorrhage that there is the most difficulty in discriminating between that due to disease and that due to injury. It may be alleged that the hemorrhage was from diseased vessels, or that the effects of a blow, which cannot be denied, were aggravated by disease of the cerebral vessels or by excitement due to intoxication or passion. Cerebral hemorrhage from disease is rare before 40 years of age, except in alcoholics. When the hemorrhage is due to disease the blood-vessels are diseased. The most frequent site of such hemorrhages is the course of the lenticulo-striate artery in the ganglia of the base or the white substance of the centrum ovale.

When injury is the cause of the hemorrhage it is usually found beneath the point injured or directly opposite to this. External signs of the blow are generally visible if it be severe enough to cause a cerebral hemorrhage. The vessels may be perfectly healthy and the victim quite young if the hemorrhage is due to an injury, also the ruptured vessels may be plainly torn. The most difficult cases are those where there is the history of an injury and at the same time such a condition of disease of the cerebral vessels, etc., as would account for spontaneous hemorrhage. Where the injury was slight in the case of alcoholics or aged people the medical witness should be especially careful in stating that a cerebral hemorrhage was due to the injury. Then, too, in the act of falling from the occurrence of a cerebral hemorrhage due to disease the head may be injured and show marks of violence. It should be borne in mind that an injury to the head may be inflicted when disease of the brain, vessels, or membranes already exists. In such a case a slight blow might cause extensive hemorrhage, but as that which accelerates causes, death, even though it might sooner or later have occurred in the same manner without injury, is due to the injury inflicted.

From the above considerations we see that spontaneous cerebral hemorrhage and that due to disease are not always easily distinguished from that due to violence. In severe injuries the structure of the brain is plainly bruised, etc., but the greatest difficulty exists in cases of slight violence where arteritis of the cerebral blood-vessels coexists. The spontaneous extravasation of blood in or upon the brain from excitement does not usually occur except with diseased vessels, old age, or alcoholism. It is rare, therefore, in the young and healthy. If there is any doubt as to the origin of the hemorrhage, the medical witness should state the cause most probable in his judgment. Taylor[663] supposes the case of a man excited by passion, alcohol, or both, who becomes insensible and dies after being struck a blow so slight that it would not have affected a healthy person. If examination reveals a quantity of blood effused into the substance of the brain, there can be little doubt in the mind of the medical man that the excitement was the principal cause of the effusion. On the other hand, if a severe blow or a violent fall on the head had been received in a personal conflict with another and it is found that death was due to an effusion of blood upon the surface, there can be little doubt in the mind of the medical examiner that death was due to the blow, which would satisfactorily account for the conditions found without reference to coexisting excitement, etc. In fact, in all cases where a question is raised as to the cause of the hemorrhage, it is most important to consider whether the violence was not sufficient to account for the hemorrhage without the coexistence of disease or excitement. It is also most important to bear in mind that after severe injuries, as after a fall, causing extensive fracture of the skull, followed or not with extravasation of blood, the injured person may walk about and die some distance from the place of the accident and where no chance for a similar accident exists. In this way the suspicion of murder may be occasioned, as illustrated in the following case cited by Taylor:[664] A man was accused of the murder of his companion, who was found dead in a stable with fracture of the temporal bone which had caused rupture of the middle meningeal artery. The accused stated that the deceased had been injured by falling from his horse the day before. After the fall, however, the deceased had gone into a public-house, where he remained some time drinking before returning to the stable. The extravasation had here taken place gradually, as is characteristic of hemorrhage from the middle meningeal artery, and perhaps the excitement due to the drinking had influenced it.

The date of an effusion of blood may sometimes be a matter of importance in determining whether a given extravasation of blood in or on the brain was caused by a recent blow or had existed previously. The color and consistence of these effusions indicate whether they are old or recent; the precise date we cannot state, but the information we can give is often all that is required. The color of recent effusions is red, which changes after some days to a chocolate or brown, which generally turns to an ochre color (see Plate I.). This latter color may be met with from twelve to twenty-five days after the injury. The consistence of the coagula also becomes firmer with age, and as the coagula become firmer they are more or less laminated and the expressed lymph may lie between the laminæ or around the coagula.

MEDICAL JURISPRUDENCE—PLATE I.

RECENT AND OLD CEREBRAL EFFUSIONS.

On account of the many layers of the brain coverings, a rough diagram of the coverings as given by Taylor[1] may be of much use to the medical expert in illustrating his evidence so as to make it clear to the court (see Fig. 19).

Wounds of the brain vary very widely in their immediate results according to the part of the brain injured. Thus sometimes a slight wound of the brain may be instantly fatal and often a severe wound in another part is not so. Extensive wounds may occur especially in the frontal lobes with remarkably slight disturbance. If a person with a wound of the brain survives the first effects of the injury the danger of inflammation remains. This danger may not be removed for a long time, for the inflammation may develop very slowly, not showing itself for from three to ten weeks or even later. Thus Taylor[665] cites the case of a child who was accidentally shot through the brain. The symptoms of inflammation did not appear until the twenty-sixth day and death occurred on the twenty-ninth day.

Wounds of the face heal remarkably well on account of its great vascularity. If severe they may leave great deformity or disfigurement, which may be the ground of a civil suit and thus require the testimony of a medical expert. If the wound involves the orbit or its contents it may be more serious, either from a fracture of the thin upper or inner wall of the orbit, separating it from the brain, or from extension of a secondary inflammation of the contents of the orbit to the brain. Wounds of the eyebrow may cause supra-orbital neuralgia or amaurosis from paralysis of the upper lid. Some fractures of the nose, especially those due to severe injury near the root of the nose, may be more serious than they appear. For in such cases, of which the writer has seen several, the fracture is not confined to the nose, but involves also the ethmoid bone and its cribriform plate forming part of the base of the skull. In such a case a fatal meningitis is a common result.

Wounds of the neck are very rarely accidental, more often homicidal, but most often suicidal. In nature they are most often incised wounds. As we have already seen, the kind and condition of the weapon used is often indicated by the character of the wound. We have also seen that in many cases a suicidal wound of the neck can be distinguished from a homicidal one with more or less probability or even certainty. Wounds of the neck are often dangerous, and they may be rapidly fatal if they divide the main vessels, especially the carotid arteries. Wounds of the larynx, trachea, and œsophagus are grave and often fatal from entrance of blood into the air-passages or from subsequent œdema or inflammation occluding the air-passages. Wounds of the sympathetic and pneumogastric nerves may be fatal, and those of the recurrent laryngeal nerves cause aphonia. The situation of the average suicidal or homicidal cut-throat wound is in front, generally across the thyro-hyoid membrane, sometimes dividing the cricoid-thyroid membrane, and not at the side of the neck where the great vessels lie and would be more easily divided. The force is expended, as a rule, before the great vessels are reached. The epiglottis may be cut or detached and the incision may even reach the posterior wall of the pharynx, but the majority of the suicidal cases recover with proper treatment. The homicidal cases are more often fatal from division of the great vessels, though, as already stated, in either class of cases a fatal result may occur if the air-passages are opened from the entrance of blood into them and the consequent asphyxia.

Contusions of the neck may be so severe as to cause unconsciousness or even death. The latter may be due to a reflex inhibitory action, as in cases of death from a blow upon the pit of the stomach. As a result of such contusions we may have a fracture of the larynx usually confined to the thyroid and cricoid cartilages (see Fig. 20). This may be followed by hemorrhage from the larynx, some of which may pass down into the trachea and threaten death from asphyxia. Later emphysema often develops throughout the tissues of the neck, and there is great danger of œdema of the larynx. The prognosis is serious unless tracheotomy is performed early or the case is closely watched. It is most serious where the cricoid cartilage had been fractured, as this requires a greater degree of violence. Whereas incised wounds of the throat are most often suicidal, contusions are most often accidental or inflicted by another. Among the latter class of injuries may be included the so-called garroting, by which a person is seized violently around the throat, usually from behind, and generally with a view to strangle and rob. In such cases the larynx or trachea may be injured in the same way as by a contusing blow.

WOUNDS AND INJURIES OF THE SPINE AND SPINAL CORD.

Injuries of the spine resemble more or less closely those of the head. Fractures of the spine generally occur in combination with dislocation, as fracture-dislocation. Thus displacement is generally present and causes a fatal compression or crushing of the cord. When the cord has once been crushed at the site of the displacement of the fracture-dislocation there is no hope of its ever healing. Therefore the lower end of the cord is never again in functional connection with the brain. These injuries are more rapidly fatal the higher up they are. If the injury is above the fourth cervical vertebra death is nearly immediate, for then even diaphragmatic breathing is impossible, and the injured person dies of asphyxia. Fracture of the odontoid process of the axis, which regularly occurs in hanging, may occur from falls on the head, etc., and is not always immediately fatal. Thus in one case[666] the person lived fifteen months and in another case sixteen months. In the latter case the fracture was due to the patient turning in bed while his head was pressed on the pillow. In some cases it may be questioned how far this injury may result from disease of the bones or ligaments. Therefore a careful examination of these parts should be made after death, which will usually enable us to answer this question, which may be brought up by the defence. It is hardly necessary for our purpose to enumerate the symptoms of fracture-dislocation of the spine. Of course the patients are almost always unable to walk and so are bed-ridden. A marked feature of fracture-dislocation of the spine is the length of time intervening between the injury and the fatal termination, and yet the injury is wholly responsible for the death of the injured person. This delay may last for months or even for years with careful treatment. But sooner or later the case generally ends fatally, though not necessarily so. Where the cord has been entirely crushed the result is almost always fatal; where the cord is not so injured recovery may and often does occur. According to Lutaud, fractures of the spine are sometimes followed by secondary paralysis coming on after healing of the fracture. At the outset we can seldom give a definite prognosis, which can only be given after watching the developments of the case. The prognosis is more favorable in fracture of the arches alone or when the injury is in the lower part of the spine and not very severe. The commonest cause of fracture-dislocation of the spine is forced flexion of the spinal column. Injuries to the spine are generally the result of falls or blows on the spine, especially in its lower part. Lutaud[667] states that after forced flexion of the spine without fracture paraplegia may sometimes occur, which is attributed to forced elongation of the cord. This paraplegia, which may seem to be grave, is completely recovered from as a rule.

Incised or punctured wounds of the spinal cord are rare, as it is so well protected except in the very highest part behind. Here between the occiput and the atlas and between the latter and the axis, and to a less extent between the axis and the third cervical vertebra, the cord is more exposed, owing to the narrowness of the laminæ. It is here that pithing is done, which is almost instantly fatal, as the medulla oblongata and upper part of the spinal cord are the parts injured, and they contain the respiratory and other vital centres. Pithing may be done with such a small needle-like instrument as to leave scarcely any trace. Only a slightly bloody streak may persist, which may appear superficial if the instrument is introduced obliquely. Such a mark in this location with no other apparent cause of death should always lead to an examination of the upper part of the cord, which will always reveal the cause of death in such cases. Pithing is practised especially in infanticide.

As with the brain, so with the spinal cord, we may have CONCUSSION due to the shock of a contusing blow. Concussion of the spinal cord, as of the brain, may be fatal without showing scarcely a mark of violence externally or internally. As the cord is so well protected from injury, it must be extremely rare to have concussion of the cord without some actual lesion of its substance. As concussion of the cord is not often the result of the injuries of which we are treating, but rather of railroad injuries and the like, it will not be considered at length in this connection. As a result of a blow or fall on the spine or communicated to it, hemorrhage may occur in the substance of the cord or around it between or outside its membranes. In very rare cases such a hemorrhage may occur spontaneously as the result of disease, of which the writer has seen one case. It may be associated with concussion or laceration of the cord. It may destroy life directly by extension or indirectly by leading to a spreading inflammation. Hemorrhage in or about the cord causes a gradual compression of the cord, and in cases of fracture of the spine often adds to the compression due to the displacement of the bones. In hemorrhage into the substance of the cord paralysis comes on early or immediately and may be complete while symptoms of irritation fail. The latter symptoms are most marked in meningeal hemorrhage in which paralysis is delayed in appearance and generally incomplete. The products of an inflammation due to an injury may compress the spinal cord in the same way that hemorrhage does.

Wounds and injuries of the varieties we are considering, affecting the spine and spinal cord, are generally accidental, less often homicidal, and almost never suicidal.

WOUNDS OF THE THORAX AND THORACIC ORGANS.

Wounds of the thorax caused by incising, puncturing, or blunt instruments. These wounds are most often punctured wounds; contused wounds are common and incised wounds are not rare. They are perhaps most often homicidal in origin or at least inflicted by another, and the accidental origin of these wounds is probably the least common.

Incised or punctured non-penetrating wounds of the thoracic wall are rarely grave. Bleeding, as a rule, is not serious, though it may be quite free. Such wounds may be accompanied by emphysema, though not penetrating, owing to the movements of the chest and a valve-like action of the edges of the wound. Contused wounds of the thorax are more dangerous, especially if the violence was great, owing to the complicating fracture of the ribs, rupture of the thoracic viscera, etc.

Fracture of the ribs is a common result of contusions of the chest. It is more dangerous when due to a direct blow or injury, as then the splintering occurs internally and may wound the lungs, heart, or large vessels, while with fracture from indirect violence, from compression of the chest, the splintering of the ribs occurs externally. Fracture of the upper ribs requires more force than that required to fracture the lower ones, and consequently the former is the more dangerous. The diagnosis of fracture of the ribs is generally quite easy by means of crepitus felt or heard, false motion, local tenderness, etc. Fracture of the sternum may be serious if depressed on account of the wounding of the viscera behind it. Devergie[668] cites such a case where the depressed portion of the sternum produced a transverse non-penetrating wound of the heart about an inch in length, which had caused death in thirteen days. Simple fracture of the sternum without displacement of the fragments is rarely serious unless injury of the thoracic viscera is produced by the same violence. Wounds or injuries of the thorax are grave or not according as they penetrate or injure the thoracic viscera or do not do so. A wound may just penetrate the thoracic wall without wounding the thoracic viscera, and is then serious as a rule only when followed by inflammation. In fact, many of the penetrating wounds of the thorax wounding the viscera are only grave on account of consecutive inflammation. We have already seen that various characteristics of wounds of the thorax, especially of stab-wounds, enable us to determine the kind of weapon used, its size, sharpness, etc., and sometimes to identify the weapon itself. In much the same way we can often determine whether the wound was suicidally or homicidally inflicted. The cause of death in wounds of the thorax may be directly due to the wounding of one or more of the thoracic viscera, or it may be due to the inflammation occasioned by it. Wounds of the lower part of the thorax may involve at the same time the thoracic cavity proper and its contained viscera, the diaphragm and the abdomen and its viscera. This is the order in which the different parts would be met with in a wound from behind forward; the order might be the reverse of this in a wound from before backward. Penetrating wounds of the thorax may involve the lungs, heart, or great blood-vessels. Of these, the lungs are most often injured, which is easily accounted for by the greater size of the lungs. In wounds of the lungs the immediate danger is from hemorrhage. The hemorrhage appears externally through the wound and from the mouth, being coughed up. Where the lungs are injured by a blow, fall, or crush without external injury, blood appears in the mouth only. The blood coughed up from the lungs is bright red and frothy, and it may also be frothy at the external wound. Hemorrhage from the external wound may be slight, especially if the wound is oblique and acts as a valve. In wounds of the lungs most of the blood may collect in the pleura or in the lungs, and thus, by compression from without or by displacement by the blood within it, prevents air from entering the lungs and produces asphyxia, which may be fatal. More or less dyspnœa usually occurs at first. Emphysema is generally present in the cellular tissues, but this latter symptom may also occur at times with non-penetrating wounds of the chest. If death does not occur speedily from hemorrhage by compression of the lungs or heart, there are good hopes of saving the patient, but the prognosis should be reserved. For even when the first effects of the wound of the lung are survived, the patient may die from the effects of inflammation, recurring hemorrhage, or a too sudden relaxation of regimen. Thus, for instance, if too much food, talking, or exertion are indulged in the case may on this account terminate fatally, and such aggravating causes of death may mitigate the sentence.

Wounds of the heart are among the most fatal. Although it was once considered, and is usually thought now by laymen, that wounds of the heart must be necessarily and instantly fatal, the facts are otherwise. If the wound is small and oblique life may be prolonged, and cases are recorded[669] in which wounds of the heart were not directly fatal, and in some of which recovery would have probably resulted if not for other diseases. Cases in which the heart wall was wounded but not penetrated, and in which healing took place, are not very rare.[670] Thus Callender removed a needle from the substance of the heart. But there is perhaps only one case[671] on record in which a wound penetrating the cavities of the heart was recovered from. It is the rule rather than the exception that wounds of the heart, penetrating or not, are not immediately fatal. Thus in a series of twenty-nine cases of penetrating wounds mentioned by Devergie,[672] as collected by Ollivier and Sanson, only two ended fatally within forty-eight hours, the rest in periods ranging from four to twenty-eight days. This delay in the fatal result has been attributed to the arrangement of the muscle fibres crossing one another and tending to close the wound, or at least to make it smaller. As to the various parts of the heart wounded, the right side, especially the ventricle, is most often wounded. Thus out of fifty-four cases of wounds of the heart, Taylor[673] states that the right ventricle was wounded in twenty-nine cases, both ventricles in nine, the right auricle in three, and the left auricle in one case. This greater frequency of wounds of the right side of the heart is easily accounted for by its more exposed position anteriorly, just beneath the chest wall in a part of its extent. The rapidity of death depends largely upon the site and extent of the wound. Lutaud[674] states that out of twenty-four cases of wounds of the right ventricle only two were fatal within forty-eight hours, and out of twelve cases of wounds of the left ventricle three were not immediately fatal. Wounds of the auricles are generally fatal immediately, especially if the cavity is extensively laid open. It is the general opinion that wounds of the auricles are most rapidly fatal, next those of the right ventricle, and lastly those of the left ventricle. This difference is probably due to the comparative thickness of the walls of these parts. Thus the wall of the left ventricle is so thick as to tend to close a wound unless it be extensive. In wounds of the heart death rarely occurs from external hemorrhage, which may be quite slight or even altogether wanting where the wound is due to a crush or fracture of the ribs. Death is usually due to the compression of the heart by the blood in the pericardium. This usually causes syncope, or a slighter pressure may be fatal by causing cerebral or pulmonary anæmia or shock. Death may occur suddenly in this manner or not until after some time. Thus in penetrating stab-wounds little or no blood probably escapes at first, in most cases, but it may ooze or, later on, suddenly burst out into the pericardium. Therefore after a wound of the heart the patient does not, as a rule, die immediately, as formerly and often at the present time erroneously supposed. This fact is of little importance as a rule in surgery, for the patients generally die sooner or later, but it is of importance in medical jurisprudence, for upon it may hang the solution of questions of murder, suicide, or justifiable homicide. It also accounts for the fact that the injured person can exercise voluntary power after the injury. Thus Watson[675] met with a case where a man ran eighteen yards and died six hours after a stab-wound of the right ventricle. The coronary artery was divided and the pericardium was filled with blood. Also Boileau met with an accidental penetrating stab-wound through both ventricles in a soldier who ran two hundred yards, then fell and died in five minutes. A boy admitted to Guy’s Hospital in 1879 lived forty-two hours with a bayonet-wound transfixing the right auricle, the septum, the left ventricle, the mitral valve, and entering the left auricle.

Minute wounds of the chest are sometimes made by needles, etc., in the region of the heart with the intention of killing infants or children. Taylor[676] also mentions the case of a fatal wound of the heart from a needle, the result of accident. We have already cited the case of a needle lodged in the heart wall and removed by Callender by operation. That the puncture of the heart by a small instrument is not necessarily serious is proved by the experiments of Senn,[677] by which he found that “the heart can be punctured with a perfectly aseptic, medium-sized aspirator needle without any great immediate or remote danger.”

In cases of RUPTURE OF THE HEART the question may come up as to whether it was the result of disease or violence. We have already seen that rupture of the heart may occur from falls or crushes without marks of violence to the chest. In general, we may say that in rupture of the heart from violence the right side and base are most often involved, while in rupture from disease the left ventricle is generally ruptured, especially near the apex. The exciting causes of rupture of a diseased heart are often violent emotions or exertion, which may both be present in a quarrel with another and cause rupture without direct violence. The cause need be but slight if the heart is diseased, whether the cause is a natural one or outward violence. Rupture from disease may therefore excite suspicions of murder, but those cases can usually be satisfactorily solved by examination of the organ post mortem. A slight degree of violence may cause rupture of a diseased heart about ready for rupture from natural causes. When a diseased heart ruptures during a quarrel, the symptoms of rupture of the heart may be observed to come on suddenly before and without the infliction of any violence.

Wounds of Arteries and Veins, especially within the thorax.—Wounds of large trunks are generally speedily mortal. In the chest we may occasionally meet with wounds of the intercostal or internal mammary vessels or the vena azygos veins. These wounds are often serious and may be fatal. We have already seen that blood in the large cavities of the body, like the chest, is commonly not coagulated, or at least the greater part of it. We have already seen, too, that after wounds of the carotid artery the victim may preserve the power of locomotion for a short time, but not the power of struggling. This fact may be important to help distinguish between murder and suicide. In such wounds of the carotid the voice may be lost, as the trachea is often divided. Death from wounds of large vessels may be due to loss of blood, and if this danger is passed the case may still terminate fatally, as in a case where the brachial was tied for injury and death occurred in three days from gangrene. The wounds of comparatively small vessels may prove fatal from hemorrhage, etc.

In wounds of blood-vessels death may occur from the entrance of air into them. In some cases where this is supposed to have occurred it is quite probable that death was really due to hemorrhage. A considerable quantity of air may enter the circulation, especially the arterial circulation, without a fatal result. When death does occur it is owing (1) to “mechanical over-distention of the right ventricle of the heart and paralysis in the diastole,” or (2) to “asphyxia from obstruction to the pulmonary circulation consequent upon embolism of the pulmonary artery.”[678] Senn found that fatal air embolism could hardly occur spontaneously in a healthy jugular vein, as the walls collapse readily from atmospheric pressure.

Wounds and Ruptures of the Diaphragm.—These may be due to weapons, fracture of the ribs, falls or crushes, and disease. They also occur as the result of congenital malformation, though these cases seldom survive long. These injuries are generally homicidal or accidental in origin. As a rule, the viscera are wounded at the same time, or, if not wounded, at least herniated, and may thus become strangulated. It is therefore hard to estimate the danger in such cases, but the prognosis is at all times serious. The most serious cases of such injury to the diaphragm are due to violent contusions or falls when the stomach and intestines are full. The hemorrhage is usually slight, but hernia of one or more of the abdominal viscera usually occurs in such cases, and is said to be more readily produced during inspiration when the fibres are on the stretch. According to Devergie, rupture of the diaphragm with hernia is more common on the left side in the central tendon in front of the crura and at the junction of the left muscular leaflet. Also on either side of the ensiform cartilage and especially on the left side there occurs an area of the diaphragm which may be congenitally weak or even absent, and here too rupture and hernia are likely to occur. Phrenic or diaphragmatic hernia occurs especially after lacerated wounds, even after the wounds have apparently healed. If hernia occurs long after the injury was inflicted, it may be asked whether the wound was the cause of the hernia, and so of death. This can only be determined by examination. Almost any or all of the movable abdominal viscera may be found in a diaphragmatic hernia. It was once supposed that this accident would be immediately fatal, but this is far from the truth. Devergie relates the case where a person lived nine months with the stomach and colon in the chest and died from another cause. Thus a person may have a phrenic hernia and die from another cause, or having had a rupture or wound of the diaphragm he may suddenly acquire a diaphragmatic hernia by reason of a blow or sudden exertion, or the latter may strangulate an existing hernia. A person with a diaphragmatic hernia may have the power of moving or walking, but is more or less incapacitated owing to the compression of the lungs which exists and the consequent dyspnœa, etc.

WOUNDS AND CONTUSED INJURIES OF THE ABDOMINAL WALL AND VISCERA.

Such wounds and injuries of the abdominal wall may be incised, punctured, or due to blunt instruments, etc. They are usually homicidal or accidental, seldom suicidal except in delirious patients or lunatics. The cause of death in such cases may be due to hemorrhage, shock, etc., or to secondary inflammation, which is especially likely to occur in penetrating wounds. The kind of weapon used may often be judged from the nature of the wound. Incised and non-penetrating punctured wounds are usually simple and not grave, but may be otherwise from hemorrhage from the deep epigastric artery, or from inflammation in or between the muscles, or in the subperitoneal connective tissue. In the latter case peritonitis may occur, but is rare. A ventral hernia may, however, result later on, as also from a cicatrix, especially if it is transverse. In such cases the question arises whether the natural results of the wound were aggravated by unskilful or improper treatment or even wilful neglect on the part of the patient or practitioner.

Contusions of the abdomen are more serious often than those of the chest, for there is less power of resistance. We have already seen that death may occur from a contusion of the abdomen too slight to show a mark of ecchymosis or a serious injury internally. This has been attributed by some to an effect on the solar plexus or reflexly on the cardiac plexus causing a fatal inhibition. Lutaud and others have expressed the doubt whether the cases reported by Travers, Allison, Watson, Cooper, Vibert, and others were carefully examined, and have inferred that some visible organic change must have been present. Some such cases, however, have been examined with especial reference to this point, and no physical injuries and no other cause of death elsewhere has been found. There is no ground, therefore, for a jury to doubt that a contusion of the abdomen was the cause of death because there are no visible marks of injury.

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.