GENERAL CONSIDERATIONS. THE DIFFERENT KINDS OF WOUNDS.
The surgical and medico-legal ideas of wounds are quite different, the latter including the former as well as other varieties of injuries.
Definitions.—Surgically a wound means a solution of continuity and refers to every such lesion produced by external violence or developing spontaneously. The medico-legal acceptation of the term is much broader and includes any injury or lesion caused by mechanical or chemical means. Vibert[601] quotes Foderé as defining a wound medico-legally as, “Every lesion of the human body by a violent cause of which the results are, singly or combined, concussion, contusion, puncture, incision, tear, burn, twist, fracture, luxation, etc.; whether the cause is directed against the body or the body against the cause.” The same author quotes another definition of a wound as, “Every lesion however slight, resulting in concerning or affecting the body or health of an individual.” Taylor[602] defines a wound in a medico-legal sense as “a breach of continuity in the structures of the body whether external or internal, suddenly occasioned by mechanical violence.” Thus, the term wound in its medico-legal acceptation includes not only surgical wounds but contusions, fractures, burns, concussion, etc. In France at least the voluntary inoculation of syphilis has been considered as coming under the category of wounds.[603]
Medico-legally, the severity of a wound is much more important than the kind of wound. Thus we may consider wounds according to their comparative gravity, as mortal, severe, or slight.
A mortal wound is one which is directly fatal to life in a comparatively short time, usually from hemorrhage, shock, or the injury of a vital part. A wound may result fatally without being a mortal wound, as when a slight wound causes death on account of some wound infection.
Severe wounds, or “wounds causing grievous bodily harm,” as they have long been called, do not put life in imminent danger, though they may be inconvenient or detrimental to health. Pollock, C. B., says that a wound causing grievous bodily harm is “any wound requiring treatment.”
A medical opinion or certificate may be required as to the danger of a given wound, and on this opinion may depend the question of bail for the prisoner. By the danger of a wound in such a case is usually meant imminent danger, as any wound may be remotely dangerous to life.
Slight wounds, as already stated, may result fatally under certain conditions. Under the French practice a slight wound is one which does not incapacitate one from work for more than twenty days. Looked at in another way, slight or severe wounds may be classified according as they are completely curable, leaving no infirmity or disturbance of function, or not completely curable. The latter are such as are necessarily followed by permanent or temporary infirmity.
The question as to the severity of any given wound may sometimes be left to the jury to decide from the description of the wound, or a medical opinion may be required.
Although the intent of the assailant is often of equal or greater importance than the severity or kind of wound, yet this can only occasionally be inferred from the surgical aspects of the wound.
The classes of wounds to be treated in the following pages are incised and punctured wounds and wounds with blunt instruments, some of the characteristics of which we will now consider.
Incised wounds are such as are produced by a cutting instrument, and they are distinguished by the following characteristics: They measure more in length than in the other dimensions. They are usually straight in direction, though not infrequently curved, and they may even be zig-zag, especially where the skin lies in folds. The edges of an incised wound are linear, and show no signs of contusion. They are either inverted or everted and the edges and sides of the wound are retracted. The eversion of the skin is due to its elasticity, but in some regions of the body, e.g., in the scrotum, etc., the skin is inverted owing to the contraction of the muscle fibres immediately beneath. The gaping of the wound is due to the retraction of the divided muscles and fibrous structures. It varies according as the muscles are cut directly across or more lengthwise, and in proportion to the distance of the wound from the points of attachment of the muscles.
The fibrous tissues, fasciæ, and aponeuroses retract less, and so give a somewhat irregular surface to a large wound.
Ogston[604] divides incised wounds into three parts, the commencement, centre, and end, of which the end often has two or more serrations differing from the commencement, which has but a single point. There are often one or more slight, superficial, tentative incisions situated almost always, though not invariably, near the commencement.[605] The deepest part of the wound is more often near the commencement. If there are angular flaps on the edges their free angles point to the commencement of the wound.
Coagula and clots of blood are to be found in the wound, more or less filling it up if it has not been interfered with. On examination the ends of the divided vessels are found plugged with clots which may protrude somewhat from their openings.
If the wound is seen very shortly after its infliction, hemorrhage is in progress, and the divided arteries show their position by their individual, intermittent jets of blood. The severity of incised wounds depends upon the amount of hemorrhage, which is greater the deeper and larger the wound, and the more vascular the tissues in which it occurs, especially if large and important vessels are concerned. In the latter case an incised wound may be very rapidly fatal.
Incised wounds present the least favorable conditions for the spontaneous arrest of hemorrhage of any form of wounds. The edges of an incised wound may be quite rough and even dentated or lacerated if the edge of the weapon be rough and irregular.
The kind and condition of a weapon which has produced a given incised wound may often be learned by an examination of the characteristics of the wound.
Weapons cutting by their weight as well as by the sharpness of their edges, such as axes, etc., may cause a certain amount of contusion about a wound; they crush the soft parts to a certain extent, and the bones may be indented or even fractured.
Wounds caused by fragments of bottles, pieces of china, earthenware, or glass, though strictly speaking incised wounds, are often curved, angular, and irregular, and their edges jagged and contused.
Wounds caused by scissors may sometimes be of the nature of incised wounds. When they present a double wound of triangular shape, with the apex of the triangle blunt, they are more of the nature of punctured wounds. In general a “tail” or long angle in the skin at one end of an incised wound indicates the end of the wound last inflicted, and some light may thus be thrown upon the inflicter of the wound.
Incised wounds present very favorable conditions for healing by primary union, but often fail in this and heal by secondary union. When an incised wound fails to unite by primary union, bleeding continues for several hours or even as long as a day, the blood being mixed more or less with a serous discharge. The latter continues until the third day or so. By the fourth or fifth day the surface has begun to granulate, and there may be a more or less profuse purulent discharge from the surface. The granulating surfaces do not necessarily discharge pus, however. For some days, therefore, after the infliction of an incised wound, or until the surface is covered with granulations, the characteristics of the wound permit of a diagnosis as to the nature of the wound.
The diagnosis of an incised wound is generally without difficulty. Some wounds by blunt instruments, however, in certain regions of the body, resemble incised wounds very closely. Such instances are found where a firm, thin layer of skin and subjacent tissue lies directly over a bony surface or a sharp ridge of bone. These are seen most often in the scalp or in wounds of the eyebrow where the sharp supra-orbital ridge cuts through the skin from beneath. The diagnosis of an incised wound can often be made with great probability from the cicatrix. This is especially the case if the wound has healed by primary union and the cicatrix is linear.
The prognosis in incised wounds is good as to life unless a large vessel has been divided or unless an important viscus has been penetrated. The prognosis as to function varies with the position and extent of the wound, and the circumstance of the healing of the wound.
Punctured Wounds, Stabs, etc.—These are characterized by narrowness as compared to depth, though the depth is not necessarily great. They are more varied in character than incised wounds owing to the great variety of form of the weapons by which they may be made. From the form, etc., of a particular wound we may often infer the variety of weapon by which it was produced. According to the weapon used, punctured wounds have been divided into several classes, of which M. Tourdes distinguishes four: 1st. Punctured wounds by cylindrical or conical instruments like a needle. If the instrument be very fine like a fine needle, it penetrates by separating the anatomical elements of the skin, etc., without leaving a bloody tract. Such wounds are generally inoffensive, even when penetrating, if the needle is aseptic, and they are difficult to appreciate. On the cadaver it is almost impossible to find the tract of such a wound. If the instrument be a little larger it leaves a bloody tract, but it is difficult to follow this in soft tissues, more easy in more resistant structures, such as tendon, aponeurosis, cartilage, or serous membrane.
If the instrument be of any size this variety of punctured wounds presents a form quite different from that of the weapon. Instead of a round wound it is generally a longitudinal wound with two very acute angles and two elongated borders of equal length, showing but little retraction. This is the shape of the wound even when the instrument producing it is so large that the resulting wound resembles that made by a knife (see Fig. 2). The direction of the long axis of these wounds varies in different parts of the body and is uniform in the same part. Their shape and direction are explained by the tension of the skin or still more clearly by the direction of the fibres of the skin, just as with the same round instrument in a piece of wood a longitudinal opening or split would be made parallel to the grain (see Fig. 1). In some regions, as near the vertebræ, the fibres may run in different directions, and the resulting wound is stellate or triangular in shape as if a many-sided instrument had caused it. As the direction of the fibres of the various tissue layers, such as aponeuroses, serous and mucous membranes, etc., may be different, a deep wound involving several such layers would have a different direction for each layer. In illustration of this, examine the figure of a wound through the wall of the stomach (see Fig. 3).
Fig. 1.—Direction of the Long Axis of Wounds of the Back caused by Conical Instruments.
(After Langer.)
The wounds above described when large are smaller than the weapon, as the splitting of the skin has certain limits and also owing to the elasticity of the skin, which is put on the stretch by the weapon and relaxed on its withdrawal. When such wounds are small they are larger as a rule than the instrument causing them.
Fig. 2.—Slit-like Wound caused by a Pointed Conical Instrument 2.5 cm. in Diameter. Natural size.
Fig 3.—Wounds of Stomach Wall by a Conical Instrument, showing the Different Direction of the Long Axis of the Wounds in Different Layers.
Fig. 4.—Stab-Wound of the Skin with a Knife a Few Minutes before Death.
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2d. Punctured wounds by instruments both sharp pointed and cutting, like a knife or dagger. If these wounds are perpendicular to the surface, they have more or less the form of the weapon used. The angles may show whether the knife, etc., had one or two cutting edges, but even though the back of the knife is broad the wound may resemble one caused by a double-edged weapon. Thus stab-wounds from a common pocket-knife show only exceptionally a wedge-shape, but regularly a slit, the edges of which are slightly curved to one another and end in two acute angles. The reason of this lies in the fact that the wound is only caused by the cutting edge of the knife, so that we cannot tell as a rule which angle was occupied by the back of such a knife (Figs. 4 and 5). The depth of these wounds may equal the length of the weapon or be almost any degree less, but the depth may even be greater than the length of the weapon by reason of a depression of the parts at the time of the blow. The wound is often shorter and broader than the weapon causing it, though more often it is larger than the weapon from the obliquity of the wound and the movement of the weapon on being withdrawn. The wound is smaller than the instrument where the parts are on the stretch at the time the wound is inflicted.
Fig. 5.—Nine Suicidal Stab-Wounds in the Region of the Heart made by a Knife used for Cutting Rubber.
This variety of punctured wounds may resemble the former class in the direction of its long axis, if the cutting edge of the instrument is blunt. The regularity and smoothness of the edges distinguish them from certain contused wounds.
3d. Wounds made by instruments with ridges or edges, files, foils, etc. If the edges are cutting the wound presents more or less the shape of the weapon (Fig. 6). But this is not always so, probably from the instrument puncturing obliquely or from the tissues being unequally stretched (Fig.7). If the edges are not cutting the wound resembles those of the first class, though the edge often presents little tears, and the wound may thus be more or less elliptical with two unequal angles. The wound of entrance and exit may be different.
Fig. 6.—Stab-Wounds caused by a Three-Sided Sharp-Edged Pointed Instrument.
4th. Irregular perforating instruments, the wounds from which resemble contused wounds.
Contusions and Contused Wounds.—A contusion is a wound of living tissues by a blow of a hard body, not sharp-edged or pointed, or by a fall, crushing, or compression, and without solution of continuity of the skin. A contusion usually involves a moderately large surface in comparison to the two other classes of wounds. Contusions are of all degrees of severity. If the blow or injury is slight, there is only slight redness and swelling of the skin with pain, disappearing in a few hours, and leaving no traces. If the blow be harder it produces more or less crushing of the tissues, accompanied by ecchymosis with or without a wound or excoriations of the skin, etc. The contusion may have the shape of the contusing body, such as a whip, the fingers, etc.
Fig. 7.—Stab-Wounds caused by an Eight-Sided Sharp-Edged Instrument. Some show a transition stage to wounds made by a conical instrument.
Ecchymosis.—This is characteristic, as a rule, of contused wounds. It consists in the infiltration of blood into the tissues, especially the cellular tissues. The source of the blood is from the rupture of blood-vessels, and the size of the ecchymosis varies partly with the number and size of the blood-vessels, or with the vascularity of the part. The size of the ecchymosis also varies with the looseness of the tissues into which it is infiltrated. This looseness of the tissues may be natural as in the scrotum and eyelids, or it may be due to the attrition of the tissues caused by the blow. An ecchymosis is larger when the contused parts cover a bony or resisting surface, and there may be no ecchymosis whatever, even from a severe blow, where the underlying parts are soft and yielding, as is the case with the abdominal parietes. Here we may have rupture of the viscera without any signs of ecchymosis superficially. An ecchymosis may be infiltrative or it may mostly occupy a cavity usually formed by a traumatic separation of the tissues; this is especially the case in the scalp and extremities when the injury is severe. These tumors, which are called hematomata, may be rapidly absorbed or they may remain a long time and occasionally suppurate. Sometimes the anatomical conditions, especially of the connective-tissue spaces, allow the extension or migration of the ecchymosis under the action of gravity, even to a considerable distance. When it meets an obstacle it accumulates above it, as in the inguinal region for abdominal ecchymosis and at the knee for those of the thigh. The course along which the ecchymosis travels is indicated externally by a yellowish stain, soon disappearing, so that soon no sign persists at the site of injury, but only below where the blood is arrested.
An ecchymosis becomes visible at varying times after the injury according to the depth of the ecchymosis and the thinness of the skin, for the ecchymosis is mostly beneath, not in the skin. If the ecchymosis is superficial it shows in one or two hours or even in less time where the skin is very thin, as in the eyelids and scrotum. In such cases it increases for thirty or forty hours and disappears in a week, but may last longer, i.e., as long as fifteen to twenty-five days.
An ecchymosis may not show at the point struck, at least not until several days have elapsed, or it may only show on the under surface of the subcutaneous fat until it has imbibed its way, as it were, to the surface. This may explain the discrepancy in the description of an injury examined by two medical experts at different times.
If an ecchymosis is extensive and deep, especially if it occupies a cavity, there may be nothing to see in the skin for four or five days, and then often only a yellowish discoloration instead of a dark blue color. In such cases, too, the appearance in the skin may be more or less remote from the injury, having followed the course of the least anatomical resistance. Between these two extremes, an ecchymosis may become visible at almost any time. Rarely an ecchymosis occurs only deeply between muscles (pectorals, etc.) and not superficially at all.
The extravasation of blood which forms an ecchymosis has sometimes been given different names, according to its extent or position, for instance, parenchymatous or interstitial hemorrhages or apoplexies, suffusions, ecchymoses, petechiæ or vibices. All such may, however, be called ecchymoses or hematomata. When blood is effused into the serous cavities of the body, special names are sometimes applied according to the position, such as hemothorax, hematocele, etc.
The color of an ecchymosis is at first a blue-black, brown, or livid red. This color changes first on the edges, later in the darker centre, and becomes in time violet, greenish, yellow, and then fades entirely. This change in color is owing to a gradual decomposition of the hæmoglobin of the blood. We can tell the age of an ecchymosis from its coloration only within rather wide limits, for the rapidity of change of color varies widely according to a large number of circumstances, especially according to whether the ecchymosis is superficial or deep. We can only say that the first change, i.e., that to violet, in a superficial ecchymosis, occurs in two or three days.
As an exception to the above color change, we may mention subconjunctival ecchymosis, which always remains a bright red, as the conjunctiva is so thin and superficial that the coloring matter of the blood is constantly oxidized.
The form of an ecchymosis often reproduces well enough that of the instrument, except if the latter be large it cannot all be equally applied to the surface, and its form is not distinctly shown by that of the ecchymosis. After its first appearance an ecchymosis spreads radially, the edges becoming less clear. This change occurs more rapidly the looser the surrounding tissues, and at the end of a few days the first form of an ecchymosis may be changed, so that an examination to determine the nature of the weapon should be made as early as possible.
Ecchymoses are more easily produced in the young, the aged, and in females, also in the case of such general diseases as scurvy, purpura, hemophilia, etc. In fact, in the last three classes they may occur spontaneously. This fact should never be lost sight of, as the attempt may be made to explain a traumatic ecchymosis in this way. The diagnosis between the traumatic variety and such cases of spontaneous ecchymoses is, in general, easy, for in the latter case their number, form, size, and occurrence on parts little exposed to injury and on the mucous membranes, as well as the general symptoms of the disease, leave little or no room for doubt.
From an oblique or glancing blow a considerable area of skin may be stripped up from its deep attachments forming a cavity which may be filled by a clear serous fluid alone, or with some admixture of blood. These cases have been studied especially by Morel Lavallée and Leser, and the fluid has been thought to be lymphatic in origin, hence the name “lymphorrhagia.” Carriage accidents, especially where the wheels do not pass directly but obliquely across or merely graze the body, are especially liable to show this form of extravasation, which is thought to be more common than is generally supposed, being often obscured by a small quantity of blood.
Fig. 8.—Linear Wound with Nearly Clean-Cut Edges, with Strands of Tissue bridging across at the Bottom and caused by a Fall on the Head on a Smooth Surface.
Contused Wounds.—If with the contusion we have a solution of continuity of the skin, then we have a contused wound. This may sometimes resemble an incised wound if the weapon has marked angles or edges, as a hammer, or, as we have already seen, in wounds of the scalp or eyebrow (Fig. 8). Careful examination, however, by a small lens if necessary, is sufficient to distinguish them if they are fresh. If they are four or five days old and have begun to granulate, it may be impossible to distinguish them. Contused wounds present on examination small tears on the edges which are widely separated and more or less extensively ecchymosed. Contused wounds are often irregular, and have thickened or swollen and ragged borders. They may, like simple contusions, show by their shape the form of the instrument which caused them. In contused wounds, unless they be perfectly aseptic, we usually find sloughing of the contused, necrotic tissues. This leaves a cavity to be filled up by granulation like wounds with loss of substance. They therefore often present large cicatrices which may be mistaken for those of ulcers. In contused wounds the bone may sometimes show the impression of the instrument causing the wound.
A variety of contused wounds is that where the wound of the skin consists merely of an erosion or excoriation with an ecchymosis beneath. The wound may reproduce the shape of the weapon, i.e., finger-nails, etc. After death the skin becomes brownish-yellow, hard, and dry, and then they are called by the French “plaques parcheminées.” They are distinguished, as a rule, from those produced after death, by the ecchymosis beneath.
Lacerated wounds resemble contused wounds very closely, but are not ecchymosed to any considerable extent. The solution of continuity is sometimes very extensive and irregular, and may present several flaps. The bone or bones are often fractured at the same time. They seldom bleed much. The course of repair resembles that of contused wounds as a rule. The prognosis is variable, for there may be slow and extensive cicatrization and impairment of function, etc. These wounds usually result from machinery accidents and accidental tears, etc. They are therefore seldom the occasion of criminal proceedings but more often of a civil suit, and thus require medical examination.
The injury which causes a contusion or contused wound may not infrequently produce effects far more serious and more or less remote from the contusion. Some of these effects it may be well to particularize. Blows on the abdomen are sometimes quickly followed by death without visible lesion to account for it. That authentic examples of this exist has been denied by Lutaud, except for cases of rapid death following contusions of the abdomen which had caused extensive rupture of the viscera and abundant hemorrhage. But Vibert gives two cases from his own experience, which are as follows:
A young man, twenty years old, received a kick in the stomach at a public ball. Numerous witnesses of the scene testified that he only received this one blow. The man collapsed immediately and died in a few minutes. On autopsy nothing was found but two small ecchymotic spots in the peritoneum covering the intestine, the largest not the size of a bean.
In the second case, the injury was also a kick in the stomach and the man died almost immediately. Absolutely no lesion was found on autopsy. Both were in full digestion.
König[606] says: “A number of severe contusions of the belly run a rapidly fatal course without the autopsy showing any definite anatomical lesion of the viscera.” He also adds that the less severe cases at first often show very profound shock, which is out of proportion to the force of the injury. The cause of death has been explained, like that of sudden death from a blow on the larynx, by the theory of inhibition. These cases are often illustrated experimentally on frogs, where the same result is obtained under similar conditions. Such cases are the more remarkable from the fact that the fatal blow may cause no ecchymosis or other mark of injury to appear on the abdominal walls.
Blows on the head may produce a variety of results besides that of the contusion itself. In fact, death itself may result though the marks of contusion are very slight or even imperceptible. Intracranial hemorrhage, laceration with ecchymosis of the brain, on the same or opposite side to the injury, and concussion of the brain may result. Of these only concussion will be considered now.
Concussion has been defined as a shock communicated to an organ by a blow or fall on another part of the body, which may or may not be remote, and without producing a material or appreciable lesion. According to Lutaud,[607] English pathologists understand by it a temporary or permanent nervous exhaustion resulting from a sudden or excessive expense of nervous energy. Its effect is observed in the function of an organ and especially in the brain. Concussion of the brain causes stupidity, loss of consciousness, amnesia, coma. The intracranial lesion most often associated with concussion is ecchymosis and laceration on the surface of the brain, but there may be no lesion visible even if the case is a fatal one. Fatal concussion has been observed where the marks of external violence were very slight or even failed entirely, as illustrated by the two following cases cited by Vibert:[608]
Vibert made an autopsy on a man who had been struck by a pitchfork, one of the teeth of which struck behind the ear, the other two in the face, only producing slight skin wounds. The man immediately lost consciousness and died in two days in coma. No lesion whatever was found within the skull, and only three slight ones externally.
He observed another case where the man fell three or four metres into an excavation, landing on his feet, and died in a short time. On autopsy only slight erosions and no intracranial or extracranial lesions were found.
This case belongs to a rare class where the blow is transmitted through the spinal column without sign of injury externally or internally to the head.
The following case cited by Vibert is even more remarkable in the production of the severe though not fatal concussion: An officer was riding at full speed on horseback, when his horse suddenly stopped short. By great exertion the officer clung to the horse, but immediately lost consciousness. His fall from the horse was broken by those about him, and the concussion he received was not due to the fall, but to the shock of stopping suddenly when his momentum was great.
As a rule, however, the diagnosis of concussion, especially if it is severe enough to be fatal, is easily made by the marks of external violence with or without intracranial lesions. The effects of concussion may be transient and leave no trace, but, on the other hand, they may be prolonged and severe, i.e., paralysis, aphasia, loss of memory, imbecility, etc. The medical examiner should be on his guard against simulation in respect to these prolonged effects of concussions. One of the most frequent consequences of concussion is temporary amnesia, which ordinarily succeeds immediately after the injury, but sometimes develops more slowly. The following curious case is quoted from Lutaud as cited by Brouardel:
A woman in getting out of a train at Versailles, where she had gone to attend the funeral of a relative, was struck by the door of the compartment. She fell, but did not lose consciousness, and picked herself up, but forgot what she had come for.
Another result of an injury which has caused a contusion or contused wound may be a fracture or dislocation. Fractures and dislocations of special parts will be referred to later, in considering injuries of the several regions of the body, but it seems appropriate here to refer to some of those general considerations relating to these injuries which may especially demand the attention of the medical expert.
Fractures may be produced by blows or falls, or from muscular action. The medical witness may be questioned as to the cause of the fracture or, if it was produced by a blow, whether a weapon was used or not, as the defence is likely to assert that it was caused by an accidental fall. The nature of the associated wounds and contusions, if any exist, may, as we have seen, indicate the weapon used. If anything exists to indicate that a fall which caused the fracture was not accidental, this should be noted, as the assailant is responsible for the effects of the fall.
A number of conditions influence the ease with which a fracture is produced and account for a fracture being due to a slight injury, and so are mitigatory circumstances in the case.
Fractures are more easily produced in the old and young, especially the former, than in the adult from the same force. This is due to brittleness of the bones in the old and their small size in the young. Certain diseases like syphilis, arthritis, scurvy, carcinoma, and rickets make the bones more frangible, and there is a peculiar brittle condition of the bones known as fragilitas ossium, more or less hereditary, in which the bones become fractured from very slight violence. Mercer is quoted by Taylor as stating, but on how good authority it does not appear, that in general paralysis of the insane the bones are particularly liable to fracture. Certain it is that not uncommonly insane patients are found dead with single or multiple fractures, but the attendants are generally convicted.
In some parts, like the orbital plate of the frontal bone, the bone is very thin and brittle, but brittleness from any cause only mitigates, it does not excuse.
Taylor[609] reports a case in point where it was proved that the bones of the skull were thin and brittle, and the fractured skull proved fatal from inflammation of the brain. The punishment was mitigated owing to the circumstance of the brittleness of the bones.
Spontaneous fractures may occur from only a moderate degree of muscular action, and even where there is no disease of the bones, but the above-mentioned condition of fragilitas ossium, rendering the bones more brittle, aids in the production of such fractures. The olecranon, patella, and os calcis are particularly liable to such fractures, but the long bones of the ribs and extremities are sometimes so fractured, as instanced in the following cases cited by Taylor:[610]
The humerus of a healthy man has been broken by muscular exertion simply by throwing a cricket ball.[611] In 1858 a gentleman forty years old, during the act of bowling at cricket, heard a distinct crack like the breaking of a piece of wood. He fell immediately to the ground, and it was found that his femur was fractured.
Again, in 1846, a healthy man, æt. 33, was brought to Gray’s Hospital with the following history: He was in the act of crossing one leg over the other to look at the sole of his foot, when something was heard to give way; his right leg hung down and he was found to have received a transverse fracture of the femur at the junction of the middle and lower thirds.
The writer had a case in Bellevue Hospital during the past winter (1892-93) of a man who stated that he had been well and active until some weeks previously, when, from muscular force alone, he sustained a fracture of the neck of the femur. Something abnormal in the bone may be present in such cases.
In cases of spontaneous fractures there are no marks of external violence which, if present, would remove the idea of spontaneity.
Fractures of the extremities are not dangerous per se, unless they are compound or occur in old, debilitated, or diseased persons, and they are more severe the nearer they are to a joint. The healing of fractures is more rapid in the young than in the old and in the upper than in the lower extremity. It is not proven that adiposity of itself impedes union.
The question may be asked, how long before examination a given bone was fractured. As a rule, we can only say as to whether the injured person has lived a long or short period since the injury, as the process of repair varies according to age and constitution. No changes occur until eighteen to twenty-four hours, when lymph is exuded. According to Villermé the callus is cartilaginous anywhere between the sixteenth and twenty-fifth days, it becomes ossified between three weeks and three months, and it takes six to eight months to become like normal bone.
The question may also be asked: Has a bone ever been fractured? The existence and situation of a fracture can often be recognized long after the accident, by the callus or slight unevenness due to projection of the edges or ends of the fragments. Where the bone lies deeply covered by soft parts, it is difficult and often impossible to tell, long after union has taken place, whether or where a fracture has occurred.
The answering of this question may sometimes be of importance in identifying the dead, especially in the case of skeletons. In the latter instance by sawing the bone longitudinally we can tell by the thickness, irregularity, or structure of the bone tissue whether a fracture existed, and if it were recent or old at the time of death.
Dislocations call for a medico-legal investigation less often than fractures. They are less common in the old and where the bones are brittle, when fracture occurs more readily. They are seldom fatal per se, unless between the vertebræ or when compound. They may occur from disease in the affected joint or even spontaneously. The diagnosis of a dislocation is easy until it has been reduced, and then it may leave no trace except pain in and limitation of the motion of a joint besides swelling and ecchymosis. These effects are transient, and after they have disappeared it may be impossible to say whether a dislocation has existed on a living body, unless, as sometimes occurs, especially in the shoulder joint, there may be a temporary or permanent paralysis of a nerve and muscular atrophy. After death, the existence of an old dislocation may often be recognized on dissection by scar tissue in and about the capsule.