Medical Jurisprudence, Forensic medicine and Toxicology. Vol. 1

by R. A. Witthaus; Tracy C. Becker

THE CAUSE OF DEATH FROM WOUNDS.

The cause of death should be certain and definite. In reality, there is only one real cause, though one or many circumstances may be accessory causes. In most cases of death from the class of wounds which we have been considering, there is no difficulty in determining the cause of death so as to be able to state it definitely. But if the deceased had recovered from the first effects of the wound and then died, or if death seems as much due to disease as to injury, then the real cause of death may be obscure. If the medical witness is in doubt as to which of two causes was the primary cause of death the doubt should be stated at once, as it may weaken the testimony if brought out later.

Wounds may be directly or indirectly fatal. They are directly fatal if the victim dies at once or very soon after the wound, with no other cause internally in his body or externally from his environment. Wounds are indirectly or secondarily fatal if the injured person dies from a wound disease or complication, the direct consequence of the wound, or from a surgical operation necessary in the treatment of the case. Wounds may also be necessarily fatal either directly or secondarily, or not necessarily fatal. In the latter case death may be due as much, if not more, to other causes than the wound, and sometimes not at all to the wound itself. Thus death may be due to natural causes, latent disease, an unhealthy state of the body, imprudence or neglect of treatment, or improper treatment, etc. These various degrees of responsibility of a wound as the cause of death we will now consider more at length.

I. Was the Wound the Cause of Death Directly?

If so, it must have caused death in one of the following ways:

1. Hemorrhage.—This may act by producing syncope. But the amount of the hemorrhage may not be sufficient for this result, and still cause death by disturbing the function of the organ into which it is effused, as in the brain or in the pleural or pericardial cavities. The blood here acts mechanically. Blood in the trachea may also kill mechanically by causing asphyxia.

The amount of hemorrhage required to produce syncope varies under a variety of circumstances. Less is required in the very young, the aged, and the diseased, also less in women than in men. Young infants may die from hemorrhage from very slight wounds, even from the application of a leech or the lancing of the gums. A sudden loss of blood is much more serious than an equal amount lost slowly. This is the reason that the wound of an artery is more serious and more rapidly fatal than a similar loss of blood from other sources. It is hard to specify the absolute quantity which must be lost in order to cause death by syncope. The total blood in the body is about one-thirteenth of the weight of the body, making the total amount of blood weigh about twelve pounds. Of this, about one-fourth is in the heart, lungs, and large blood-vessels. According to Watson, the loss of an amount varying from five to eight pounds is enough to be fatal to an adult. But less is enough to prove fatal in many cases, as the rapidity of the loss of blood and the age, sex, and bodily condition of the wounded person affect the amount necessary. Though death from a small artery is slower than that from a large one, yet it may occur in time, as shown in the instance quoted by Taylor,[626] where a man bled to death in thirty-eight hours from the wound of an intercostal artery. Thus, too, a wound of the branches of the external carotid artery is often enough to cause death, and a wound in a vascular part may cause death from hemorrhage, though no vessel of any size be divided.

Internal hemorrhage may be fatal from mechanical interference with the function of an organ, as well as from syncope. Thus we may have death from syncope due to hemorrhage into the peritoneal cavity or, after contusions, into the intercellular spaces and the cavity due to the blow, into which several pounds of blood may be extravasated. Internal hemorrhage is most fatal when due to the rupture of a viscus such as the heart, lungs, liver, kidney. Taylor[627] cites a case of a man run over and brought to Guy’s Hospital in November, 1864. He had pain in the back, but there were no symptoms or marks of severe injury. He left the hospital and walked home, where he was found dead in bed a few hours later. His abdomen contained a large amount of blood from the rupture of a kidney. After severe flagellation blood may be effused in large quantity beneath the skin and between the muscles, which is just as fatal as if it had flowed externally from a wound. In fact, if the injuries are numerous the loss of much less blood is enough to prove fatal, the element of shock here assisting that of hemorrhage.

How are we to ascertain whether a person has died from hemorrhage? This may be more difficult in the case of an open wound, for the body may have been moved from the spot where it lay after the wound was received, and the blood on the body, clothes, and surrounding objects may have been removed. Then the case may be presumptive only, but we may arrive at a definite conclusion by attention to the following points: If the wound was in a very vascular part and of some size, or if a large vessel or many moderately large vessels were divided and the vessels, especially the veins in the neighborhood, are empty, then we may be quite sure of death from hemorrhage. If there is no disease found which could be rapidly fatal the case is still stronger. The body should be pallid after fatal hemorrhage, but the same may be the case from death from other causes. In case the body and surrounding objects have not been disturbed, then the amount of clotted blood in the wound, on the body and clothes, and about the body, taken in connection with the foregoing points, can leave no doubt. We should remember, however, that not all the blood about the body was necessarily effused during life, but a little hemorrhage may have occurred after death while the body was still warm and the blood fluid, i.e., during the first four, eight, or ten hours. But the amount thus lost is small. In cases of death from internal hemorrhage we do not have so much difficulty in pronouncing an opinion, as by post-mortem examination we can determine the amount of the hemorrhage. We can judge, too, from its position, whether it has acted mechanically to interfere with a vital function, and has thus caused death, or whether the latter was due to syncope from the quantity lost.

2. Severe mechanical injury of a vital organ, such as crushing of the heart, lungs, brain, etc. This crushing may be accompanied by hemorrhage, but death may be more immediate than the hemorrhage would account for. The mechanical injury done to the vital centres in the medulla by the act of pithing is the direct cause of the sudden death which follows it. Exceptionally slight violence to a vital organ is fatal, but this may be better explained by attributing it to shock.

3. Shock.—An injury is often apparently not enough to account for the fatal result so speedily. The marks of external injury may fail entirely or be very trifling. Thus more than once persons have died in railway collisions with no external marks of violence. So, too, a blow on the upper abdomen, on the “pit of the stomach,” has been rapidly fatal without any visible injury to the viscera. Death is attributed to the effect on the cardiac plexus, and there may be no marks externally or only very superficial ones. In Reg. v. Slane and Others (Durham Wint. Ass., 1872), quoted by Taylor,[628] the deceased was proved to have sustained severe injuries to the abdomen by kicks, etc., but there were no marks of bruises. All organs were found healthy on post-mortem examination, but the injured man died in twenty minutes. Death was attributed to shock and the prisoners were convicted of murder.

Death from concussion of the brain is another example of death from shock. This may occur with only a bruise on the scalp and with no intracranial hemorrhage or laceration of the brain. The medical witness should be cautious in the above classes of cases in giving evidence, as the defence may rely upon the absence of any visible signs of mortal injury to prove that no injury was done, a principle fundamentally wrong.

Also a number of injuries, no one of which alone could be the direct cause of death, may cause death on the spot or very soon afterward. Death in such cases, where there is no large effusion under the skin, is referred to exhaustion, which, however, is merely another term for shock. Such cases are exemplified by prize-fighters who, during or after the fight, become collapsed and die of exhaustion. Having sustained numerous blows on the body during the many rounds, the body presents the marks of various bruises, but there may be nothing else to explain the sudden death. No one injury or bruise is mortal, and yet, when the deceased was previously sound and in good health, death must be referred directly to the multiple injuries received in the fight. We have already stated above that if the injuries are numerous, the loss of a smaller amount of blood may be fatal. We see, therefore, that there is not always a specific and visible “mortal” injury to account for death. This is a well-known medical fact, but it does not accord with the erroneous popular prejudice that no one can die from violence without some one visible wound which is mortal. In other words, the non-professional mind leaves out of account the idea of shock, only regarding material injury and not functional disturbance. If the circumstances accompanying death are unknown, it is well to be cautious. But if the deceased was in ordinary health and vigor and there was no morbid cause to account for the sudden death, we need not hesitate to refer death to the multiple injuries.

II. Was the Wound the Cause of Death Necessarily?

This brings up a number of interesting questions to be considered. In medical jurisprudence there is probably no condition so common as that the injury is admitted, but death is attributed to some other cause. Thus if there are several wounds it may be hard to decide on the relative degree of mortality of any particular one, so as to be able to say that death was directly or necessarily due to this or that one. The defence may plead that death was not necessarily due to the particular wound attributed to the prisoner. This brings up the question—

Which of two or more Wounds was the Cause of Death? No general rule can be laid down for all cases, but each case must be judged by itself. Another way of putting the question is: “Which of two or more wounds was mortal?” The questions are not quite synonymous, for two or more of the wounds might be “mortal” but not equally the cause of death. In fact, as we have already seen, no one of the wounds if they are multiple may be of itself mortal, but taken together they are so. Consequently we will suppose that there are but two wounds, and not multiple ones, and the question remains which of these wounds was the cause of death. A wound may be said to be of itself mortal when it is the cause of death directly or indirectly in spite of the best medical assistance. In some continental states mortal wounds are divided into two classes, those absolutely and those conditionally mortal, the former including those in which the best medical assistance is at hand, sent for or timely rendered without everting the result. The mortal result in the second class is conditional on want of treatment, improper treatment, or accidental circumstances. As Taylor says, it is better to look at the effect of the wound and the intent of the assailant, as is done in English law, rather than at accidental relations of the wound.

To return to the question, we can readily imagine that a man may receive two wounds at different times or from different persons, and die after the second wound. Taylor[629] mentions the following case in which the question arose as to which of two injuries caused death: In Reg. v. Foreman (C.C.C. February, 1873) the prisoner had struck the deceased some severe blows on the head. A fortnight later, having partially recovered, another man gave him some severe blows on the head. A fortnight later still he had left hemiplegia, and died a few days later of a large abscess in the brain. The question arose which set of blows had been the cause of the abscess. The prisoner, the first assailant, was acquitted, as the deceased had had no serious symptoms until the second assault, and there was no satisfactory medical evidence as to the relation of the two assaults to the abscess formation. The same author also supposes the following case: A man having received a gunshot wound of the shoulder is doing well, when in another quarrel he receives a penetrating stab-wound of the thorax and abdomen. He dies after lingering for a time, under the effects of these wounds. If the wound of the shoulder could be proven to be the cause of death, the second assailant could not be convicted of manslaughter, and so too with the first assailant if it could be shown that the victim died of the stab-wound. It might be possible for a surgeon to decide the question definitely at once if death occurred soon after the stab, which was found to have penetrated the heart, a large blood-vessel, or one of the viscera; or, on the other hand, if the stab-wound was found to be superficial and not penetrating, and the wound in the shoulder had suppurated and caused septicæmia.

In either or any case, everything would depend upon the evidence furnished by the medical witness. His knowledge and judgment are required to distinguish the guilty from the innocent.

Again, sometimes death may appear to be equally the result of either or both wounds, in which case, as far as the medical evidence goes, both assailants would be liable to the charge of manslaughter. Or the second wound may be accidental or suicidal, and again the question would arise as to the cause of death. A case illustrating this is told by Taylor[630] substantially as follows: A grocer’s assistant pursued a thief, who had stolen from a cart, into a coal-shed, where he was stabbed twice in the abdomen. The larger wound suppurated, the smaller wound healed up, and the man died of peritonitis. On post-mortem examination the suppurating wound was found not to involve a vital part, while the small healed wound had wounded the liver and gall bladder and had set up the fatal peritonitis. The large suppurating wound had apparently been inflicted purposely; the fatal wound, directed upward and backward, might have been accidental by the deceased rushing upon the knife held more or less in self-defence. The case never came to trial, as the assailant was never found, but it can be readily imagined what complications might have arisen.

Furthermore, the wounded person may have taken poison or been subsequently ill-treated, and he may have died from these causes rather than the injury. But the question arises as to whether the wound was necessarily the cause of death. Here, in order to exculpate the assailant, the supervening disease or maltreatment must be such as to account for sudden or rapid death under the symptoms which actually preceded death.

Was Death Due to Natural Causes? Again, the injury may be admitted, but it may be claimed that death is due to natural causes. It is not unusual for wounded persons to die from natural causes, though the case may appear otherwise to laymen. This is often seen with suicidal wounds, especially those inflicted during the delirium of a disease, or the disease may supervene later and cause death without relation to the wound. Where the wound was inflicted by another, accurate discrimination is especially important in order to save the accused from imprisonment under false accusation and consequent loss of character. A careful examination is the only way to determine such cases, which depend therefore on the medical testimony.

Again, the question may arise as between DEATH FROM WOUNDS OR LATENT DISEASE, the wound perhaps being admitted, but death being attributed to latent disease. Here a close attention to symptoms and a careful post-mortem examination can alone decide. A man may die from the rupture of an aneurism, from an apoplexy or some other morbid condition after receiving a severe wound. Or a man with a hernia may receive a blow upon it causing a rupture of the contained intestine followed by peritonitis and death, or the recipient of a blow may have a calculus in the kidney which may perforate a blood-vessel or the kidney tissue and set up a fatal hemorrhage as the result of a blow.

Thus, medically speaking, the result of the injury is unusual and unexpected, and due to an abnormal or unhealthy state of body of the wounded person.

If it can be clearly shown by the medical testimony that death was due to the above or any other latent diseases, the responsibility of the assailant may be lessened or removed. The law looks to this point and is lenient in its punishment in the absence of malice on the part of the assailant. The crime is still manslaughter and may even be murder if the assailant was actuated by malice and the abnormal or unhealthy state of the body of the victim was taken advantage of. Generally there is no intention of murder, but the nature of the wound and the means of infliction will help to show this, which is for the jury rather than the medical witness to decide. There is less ground for mitigation of the punishment if the assailant was aware of the peculiar condition of the wounded person, especially in the case of those notoriously ill or of pregnant women.

Closely allied with this subject are those rare cases where ABNORMAL ANATOMICAL CONDITIONS, such as a thin skull or brittle bones, cause a slight injury to be followed by unexpected and untoward results, not to be looked for in the average individual. In such cases the evidence of the abnormal condition furnished by the medical witness may diminish the responsibility and mitigate the punishment.

Furthermore, the responsibility of the assailant may not be altogether removed, for the question naturally arises, Was death accelerated by the wound? This depends upon the circumstances in each case upon which the medical witness must base his opinion. Maliciously accelerating the death of another is regarded as criminal on the principle that that which accelerates causes. The following cases are quoted from Taylor[631] to illustrate the above distinctions. In Reg. v. Timms (Oxford Lent Ass., 1870) the deceased had been struck on the head by the accused with a hatchet, from which injury he had partly recovered under treatment in twelve days. But six weeks later he was seized with inflammation of the brain, with convulsions, and died. At the autopsy disease of the kidneys was found, and death was referred to this and the inflammation of the brain due to the blows. The prisoner was convicted after the judge had charged the jury that it was manslaughter if they believed that the blows conduced in part to the death of the deceased.

In the following cases there was no connection between the violence and the cause of death. A man struck his father on the head with a hammer and was sentenced to two months’ imprisonment, as the injury did not appear serious. The father thought the punishment too little, became much excited, and was hemiplegic six days after the wound was inflicted and died three days later. No injury of the brain was found under a fracture of the inner table at the site of the blow, but a large clot was found in the lateral ventricle which, in the opinion of the medical witnesses, was not dependent on the blow, and the prisoner was acquitted (see Reg. v. Saxon, Lancashire Sum. Ass., 1884). Also in Reg. v. Hodgson (Leeds Sum. Ass., 1876) the prisoner had struck his wife with a belt, a short time after which she fell back and died suddenly. The cause of death was found to be heart disease, and the blow not being causative in producing the fatal result, the prisoner was acquitted. Or again in Reg. v. Thompson (Liverpool Sum. Ass., 1876): The prisoner had stabbed his wife in the cheek. The wound was severe but not mortal. Two days later she was delivered of a child in the infirmary to which she was taken. She died nine days later of puerperal fever. The prisoner was acquitted on the charge of murder, as there was no necessary connection between the wound and the puerperal fever. Acquittals have taken place in cases of death occasioned by terror or dread of impending danger produced by acts of violence, as in the case of Reg. v. Heany (Gloucester Lent Ass., 1875). Here the prisoner in an altercation with his wife, who was suffering from cancer, held up a knife in a threatening manner, but did not touch her. This gave her a shock; she died two days later from fright. As there was no distinct proof that death was accelerated by this act, the prisoner was acquitted of the charge of murder. Taylor[632] found among a large number of cases occurring in England during twenty years that the latent causes of death, as registered in wounded persons, were chiefly inflammation of the thoracic or abdominal viscera, apoplexy, diseases of the heart and large blood-vessels, phthisis, ruptures of the stomach and bowels from disease, internal strangulation, and the rupture of deep-seated abscesses. Sometimes the person was in good health up to the time of injury, while in other cases there was merely a slight indisposition. It was only by carefulness on the part of the medical experts that the true cause of death was ascertained.

Again, it may be claimed that DEATH was not necessarily the result of the wound and was AVOIDABLE BY GOOD MEDICAL TREATMENT. There are many cases of wounds not mortal with proper and skilled treatment which might become so by improper treatment. They may thus become directly mortal by interfering with a source of hemorrhage which had been arrested, or secondarily mortal by infection of the wound by meddlesome treatment. It would depend on the medical witnesses to determine whether and how far the treatment had been responsible for the fatal result. If the wound is not of itself mortal and it has only become so from improper treatment, this should be a mitigating circumstance in favor of the accused. Medically speaking, we can seldom make the sharp distinction which Lord Hale did legally between a wound becoming mortal from improper treatment and one in which improper treatment causes death irrespective of the wound. In case of a slight wound this distinction might be possible, but not so in case of severe wounds. Also there would probably be no conviction, as far as the medical evidence is concerned, if the wound was only mortal in consequence of improper treatment and not mortal as its usual and probable result. This may naturally introduce the question of the COMPARATIVE SKILL IN TREATMENT. If death is entirely or partly due to a wound the responsibility of an assailant is not altered by unskilful treatment. The entire question of the relation of the wound to the fatal result and the effect on this result of the treatment employed is left to be determined by the medical experts, and in its solution great care and judgment must be used. Although a given fatal wound might not have caused death under the best possible treatment and surroundings, yet, according to the above rule, the assailant is held responsible as long as the fatal result is due partly, at least, to the wound. Therefore we see the responsibility of the surgeon not only for the life of his patient, but also for that of the prisoner. He should, therefore, not deviate from the ordinary and most accepted practice in such cases, as any such deviation is taken hold of by the counsel for the defence. In fact, every point of the treatment is subjected to criticism.

In a lacerated wound of the foot, if death occurs from tetanus, it may be claimed that death would not have occurred if the foot had been amputated, or, if the foot were amputated and death followed, it may be claimed that amputation was unnecessary and was the cause of death. The surgeon should, therefore, be able to give the best reasons for every step of treatment.

Again, it may be claimed that DEATH was not a necessary result of the wound and WAS AVOIDABLE BUT FOR IMPRUDENCE OR NEGLECT on the part of the wounded person. A man after being wounded may refuse to receive medical assistance, or, after receiving it, may disobey instructions or refuse to submit to an operation proposed. Thus with a compound depressed fracture of the skull the patient may either refuse to see a surgeon, or he may refuse to submit to an operation proposed, or he may with or without operation disobey the instructions as to diet and quiet, and eat or drink heavily and refuse to go to bed. Such a case we can readily imagine might die of meningitis, etc.

If the symptoms of a wound are unfavorable from the start, or if the wound of itself is likely to prove mortal, the responsibility of the assailant is unmitigated by imprudence or neglect of medical assistance by the wounded person. This is not allowed as mitigatory, as a sane man is a free agent and is not obliged to call in or submit to medical treatment. Moreover, a medical witness in many cases could not swear that an operation or other plan of treatment would certainly save life. Thus an amputation of the leg for wound of the foot causing tetanus is by no means a certain means of cure. But we can readily imagine a case where the refusal to submit to the treatment proposed might be an important element in causing death. Thus in a compound depressed fracture of the skull with compression, the medical witnesses would agree that the operation would in all probability save life. This fact would probably be only mitigatory in diminishing the penalty, and, as stated above, would not secure acquittal. But it is none the less important for the medical witness to bear these facts in mind and bring out the facts and conclusions clearly in his testimony.

Death Following Slight Personal Injuries.—Here again the claim might apparently be justified that death was not necessarily due to the trifling injury. And in reality there is commonly some unhealthy state of the body to explain such an unexpected result. When the disease accounting for this unhealthy state of the body is in some other part than the injury, an examination with ordinary care will explain the case. But if the disease and injury are located in the same part, especially in the head, the case is more perplexing, but may be cleared up by careful and thorough examination. Also the usual results of such an injury should be considered, and whether the disease would be a usual result of the injury, or whether the sum total of the pathological conditions found would be accounted for by the violence. It should be remembered that the presence of chronic disease is no excuse. Thus Taylor[633] cites the case of Reg. v. Hapley (Lewes Aut. Ass., 1860), where a boy with chronic disease of the brain suffered from no unusual symptom until he received a severe flogging, which was followed by death in less than three hours. The same author mentions also the following case to show that fatal results may follow very slight and trivial blows. Annan[634] tells of a healthy four-year-old girl who received a slight blow from the shaft of a wheelbarrow on the skin about three inches below the knee. There was even no external mark of violence, and the injury was thought to be so slight as not to require treatment. There was pain, however, which increased on the following day, marked constitutional symptoms appeared, and the child died on the fourth day. Even to the punishment inflicted by schoolmasters death has been imputed.

When DEATH occurs FROM WOUNDS AFTER LONG PERIODS the injury may be admitted, but it may be claimed that death was not necessarily due to the wound. Medically speaking, death is just as much the result of the injury as if it occurred on the spot. Of course, death must be clearly traceable to the usual and probable results of the injury, and not be dependent on any other cause. An examination of the wounded part and of the whole body will enable the medical witness to determine the cause of death and whether it is clearly traceable to the injury. A doubt on this point may lead to acquittal. Certain forms of wounds or wounds in certain localities are especially liable to end fatally after a long delay, but as the direct result of the wound. These are wounds of the head and of the spine. As to the first class, the injured person may apparently recover and be doing well, when he may suddenly die from a cerebral abscess, for instance. This is the result of the injury, but remains a longer or shorter time latent. In wounds of the spine the patient is generally paralyzed below the point of fracture, but is apparently in good health. In a longer or shorter time he may die of a pneumonia, cystitis, or bedsores, which are the known and regular consequences of the injury or injured condition. Astley Cooper cites the case of a man who was injured on the head and died two years later from the effects of the injury, as was clearly made out by the continuance of brain symptoms during the entire period. An interval of eleven years occurred in another head injury between the injury and the fatal result. The first result of the injury was concussion of the brain, and the case is mentioned by Hoffbauer.[635] This long interval is unusual. There is a rule in English law by which the assailant cannot be indicted for murder if the victim of the assault lives a year and a day. Practically this makes little difference, as nearly all cases would die within that time; but the principle is wrong as looked at from the medical standpoint. The protracted cases concern, as above stated, mostly injuries of the head, spine, and chest, among which there are some cases, like the examples cited, where, according to English law, justice would fail to be done.

III. Was a Wound the Cause of Death Secondarily?

A wound is secondarily the cause of death when the victim, having recovered from the first ill effects, dies from some wound disease or accident or from a surgical operation rendered necessary in the proper treatment of the wound. There may be much difficulty in establishing the proof of death from a wound by means of secondary causes, for, 1st, the secondary cause must be in the natural course of things; and, 2d, there must be no other accidental circumstances to occasion the secondary cause.

The secondary cause may be partly due to the constitution of the deceased from habits of dissipation, which fact would serve as an expiatory circumstance in the case. Among the secondary causes of death may be mentioned septicæmia, pyæmia, erysipelas, tetanus, gangrene, that is, wound diseases, also the wound accident—as we may call delirium tremens, and surgical operations rendered necessary to the treatment of the case. We may add, besides the regular wound diseases, inflammation in and about the wound, septic in character, perhaps not justifying the title of septicæmia, but which, with its accompanying fever, may be the “last straw” in a case which might otherwise recover. Some of these secondary causes will now be considered more at length.

Septicæmia is a general febrile disease due to the absorption into the system from a wound of the products of bacteria or due to the introduction into the blood and tissues of the bacteria themselves. Depending on the two sources of origin, we have two forms of septicæmia: 1. Septic intoxication or sapremia, due to the absorption of a chemical poison, ptomaïnes, and often readily influenced and cured by the removal of the source of these ptomaïnes in decomposing blood-clots, secretions, etc. 2. Septic infection comes on less rapidly but is more serious than the former is, if properly and quickly treated, because the source of the trouble cannot be removed, but is in the blood and the tissues. The latter form is the more common one in wounds, though the former may occur in abdominal wounds, especially when a blood-clot is present. The first form begins acutely, the second form more gradually. The infection in septicæmia takes place through a wound and may be due to the weapon which caused the wound, the unclean condition of the parts wounded, or to the subsequent treatment or want of treatment. It may even take place through the intestinal mucous membrane as in cases of tyrotoxicon poisoning. It is most likely to occur during the first four or five days before the surfaces of the wound granulate, and it consists in the introduction of bacteria, especially staphylococci and streptococci. The disease is characterized by severe constitutional symptoms, acute continuous fever, inflammation of certain viscera and of the wound, and nervous disorders. A pronounced chill ushering in the fever is generally absent. Prostration is especially marked, the patient finally passing into a typhoid condition indifferent to surroundings. Anorexia and headache are usually present; diarrhœa is common, vomiting is not. The skin is pale and dusky, but not commonly icteric; at first it is hot and dry, later moist and finally cold and clammy. The spleen is often enlarged. The pulse becomes weak and rapid and delirium is followed by coma. The prognosis is grave. Antiseptic treatment generally prevents and often cures the disease, as is the case with many other of the wound diseases; hence the failure to employ it may be alleged by the defence in mitigation of the responsibility of the assailant for the fatal result.

Pyæmia is closely allied to septicæmia. It is due to the setting free of bacterial emboli or septic emboli from a broken-down, septic thrombus in the neighborhood of the wound, and the circulation of these emboli in the blood until they are arrested and form the characteristic metastatic abscesses, especially in the lungs, joints, abdominal viscera, and parotid gland. Almost always the source of infection is an infected wound. Granulation does not prevent the occurrence of pyæmia, which, as a rule, commences at a later stage than septicæmia. It is most important, however, for our purpose to remember that there is such a thing as spontaneous pyæmia. An injury not causing a wound may here be the exciting cause, but the resulting pyæmia is an unexpected consequence. A bruise of a bone, for instance, by allowing bacteria, which in certain conditions may be circulating in the blood, to find an exit from the vessels into the bruised part, may develop an acute osteo-myelitis, which may be a starting-point of a pyæmia. It is but proper to state, however, that spontaneous pyæmia is a rare occurrence. In fact, it is so rare that if pyæmia occurs and we find ever so trifling an infected wound, we can safely attribute the pyæmia to the wound and not to a spontaneous origin.

Pyæmia begins, as a rule, in the second week of the healing process or even later. It usually begins with a chill, which may be frequently repeated. The fever is very irregular and exacerbations occur with each metastatic abscess. The skin is icteric, the icterus being hematogenous. The pulse is rapid and becomes weaker. Infective endocarditis may develop, which increases the danger of metastatic abscesses, which may then occur in the brain. Otherwise the mind is clear and unaffected until the final delirium and coma. The disease may become chronic, but usually lasts a week or ten days. The prognosis is very grave.

Erysipelas is a still more frequent complication of medico-legal wounds, and though not so fatal as the two preceding, it is probably more often the secondary cause of death on account of its far greater frequence. It too is an acute infective inflammation due to the presence of a micro-organism, streptococcus erysipelatis. This occurs mostly in the lymphatics of the skin, and effects an entrance through some wound or abrasion of the skin or mucous membrane, which may be almost microscopic in size. Probably there is no such thing as true spontaneous erysipelas, though the wound may be often overlooked and only visible on the closest examination. If a wound has been inflicted, the size and severity of it cannot be alleged as a reason why it was not the starting-point of an erysipelas. The erysipelas must be clearly traced to the injury. That is, it must occur before recovery from the wound or not later than a week after it has healed, for the incubation is probably not longer than this. It is difficult to connect an erysipelas with a wound if it occurs some time after it has healed or if it occurs at a different place and not about the wound. Wounds of certain regions, as, for instance, scalp wounds, are especially liable to develop erysipelas, but this is probably owing to the imperfect antiseptic treatment or delay in applying it. Certain individuals are more prone to it than others; thus it has been stated that blondes and those suffering from Bright’s disease are more susceptible, though how true this is it is hard to say. It is also probably more prevalent at certain times of the year, particularly in the spring. A wound after it has scabbed over or has begun to granulate, that is, after the first four or five days, is very much less apt to serve as the avenue for infection. Erysipelas usually begins with a chill, or a convulsion in children. Nausea and vomiting are the rule. The fever is remittent and ranges from 102° to 104° F., and the temperature may be subnormal when the inflammation is subsiding. Prostration is marked and the pulse more or less weak. There may be delirium while the fever is high. Locally there is rarely anything characteristic until twenty-four hours or so after the chill. Then we have a reddish blush with some tension, burning and itching of the skin. At first the redness is most marked about the wound, later at the edge of the advancing, serpentine margin. It spreads widely and rapidly, and after three or four days the part first attacked begins to improve. Desquamation follows. The duration may be a week or ten days or as long as a month. The inflammation may be much more severe, involving the subcutaneous connective tissue in phlegmonous erysipelas.

Facial erysipelas is a common variety and was once regarded as idiopathic, but a wound on the skin or mucous membrane is probably always present. The prognosis of erysipelas is usually favorable. Since the use of antiseptics it is far less common than formerly, though still the most common of the infective wound diseases.

If a man wounded in an assault is taken to a hospital where erysipelas prevails, the question of responsibility arises, for, medically speaking, he is subjected to great and avoidable risks.

Tetanus is an infective bacterial disease affecting chiefly the central nervous system and almost always, if not always, originating from a wound. Tetanus, like erysipelas, is probably always traumatic and never strictly idiopathic. The wound may be so slight as to escape notice. When it follows such injuries as simple fracture internal infection probably occurs, though such cases are extremely rare. It is said that the weather influences the development of tetanus, and that it is more common in the tropics. There are also certain sections where tetanus is much more common than elsewhere and where it may be said to be almost endemic. Punctured wounds are most likely to be followed by tetanus, for they offer the best opportunity for the development of the bacteria, which are anaërobic. Wounds in dirty parts of the body, like the hands and feet, are more apt to be followed by tetanus than those elsewhere. Tetanus usually appears about the end of the first week after a wound has been received, but it may not appear for a longer period, even three or four weeks, so that the wound may have been some time healed. To connect tetanus with a particular wound, note (1) if there were any symptoms of it before the wound or injury, (2) whether any other cause intervened after the wound or injury which would be likely to produce it, and (3) whether the deceased ever rallied from the effects of the injury. Tetanus comes on suddenly without warning. The injured person first notices that he cannot fully open the mouth, he has lock-jaw, and the back of the neck is stiff. The muscles of the abdomen and back are next involved so that the back is arched in the position known as opisthotonos, and the abdomen presents a board-like hardness. The muscles of the fauces, pharynx, and diaphragm may next become involved, causing difficulty in swallowing and breathing. The thighs may or may not be involved, but the arms and legs almost never. Owing to the spasm of the abdominal muscles, micturition and defecation are difficult and respiration is hindered. The muscles are in the condition of tonic spasm which permits the patient no rest, the face bears the “risus sardonicus,” and the suffering is extreme. If the patient lives more than two or three days the tonic spasm partly gives way to increased reflex irritability, in which a noise, jar, or draught of air may give rise to clonic and tonic spasms in the muscles affected. The patient may die at such times from tonic spasm of the respiratory muscles, or he may die of prostration from want of food and sleep, worn out by the suffering and muscular spasm. The mind is usually clear to the last. Fever is not characteristic of the disease. Tetanus may be rapidly fatal; in two or three days, or it may be or become more chronic. The prognosis of acute tetanus is almost invariably fatal; that of chronic tetanus is grave, but a certain proportion of cases recover.

Diagnosis.—This is easy. It differs from a true neuritis in the peripheral nerves in that no matter where the wound is situated the first symptom is in the muscles of the jaw and the back of the neck, and not at the site of the injury and distally from this point. Trismus is applied to a milder form of the disease in which only the face and neck muscles are involved and “lock-jaw” is a prominent symptom. Some cases of tetany may be mistaken for so-called spontaneous tetanus. Tetany may follow child-bed, fevers, mental shocks, exposure to cold and wet, extirpation of goitre, intestinal irritation, etc. It consists of painful tonic spasms of the muscles of the arms and feet. The attacks last one-half to two hours or more, and may be preceded by a dragging pain. They may be brought on by pressure on the nerve leading to the muscles affected. Striking the facial nerve often causes contraction of the face muscles. There is no trismus but there may be opisthotonos. The patient seems well between the attacks and most cases recover without treatment.

Delirium tremens may occur as a secondary consequence of injuries, or necessary surgical operations in the case of those who are habitually intemperate. Those who habitually use opium, tobacco, cannabis indica, or even tea or coffee to excess are said to be subject to it. It may, therefore, be justly alleged that death is avoidable in very many cases, but for an abnormal and unhealthy state of the body. The disease is characterized by delirium, a peculiar tremor of the muscles, insomnia, and anorexia. Pneumonia may complicate the case. The patients die in fatal cases from exhaustion due to insomnia, lack of nourishment, and their constant activity of body and mind. The prognosis is usually favorable, taking all cases together, but in delirium tremens secondary to surgical injuries or operations the prognosis is serious.

Death from surgical operations performed for the treatment of wounds. The operation is a part of the treatment, and if it is done with ordinary care and skill the accused is responsible for the result. The necessity and mode of operation must be left to the operator’s judgment. As the defence may turn on the necessity for and the skilful performance of the operation, it is well to wait for the advice and assistance of others if practicable, for death is not unusual from severe operations. The patient may die on the operating-table after losing little blood, from fear, pain, or shock. Or he may die from secondary hemorrhage or any of the secondary causes of death from wounds enumerated above. The evidence of the necessity of the operation must, therefore, be presented by the operator. If an operation is necessary and not performed, the defence might allege that death was due to the neglect of the surgeon. Another question for the medical witnesses to determine is whether the operation was rendered necessary because of improper previous treatment, for if it was the responsibility of the assailant may be influenced. The meaning of the term “necessity” is here a matter of importance. Unless an operation is necessary to the preservation of life, if death occurs there is some doubt whether the assailant is responsible. But, medically speaking, we would not hesitate to urge an operation on a wounded man in order to preserve function, or even to save deformity as well as to save life. In the case of operations done under a mistaken opinion, neither necessary to save life nor, as the result proves, to save function or guard against deformity, if death follows the assailant may be relieved from responsibility. Thus an aneurism following an injury might be mistaken for an abscess and opened with skill but with a fatal result. It is also for the medical experts to determine whether an operation was unnecessary or unskilfully performed, for if it were and death resulted from it, the responsibility of the prisoner is affected unless the original wound would be likely to be fatal without operation. According to Lord Hale, if death results from an unskilful operation and not from the wound, the prisoner is not responsible. But yet death may occur as the result of the most skilful operation necessary to the treatment of a wound, and not be dependent at all on the wound itself. If the operation is skilfully performed, and yet the patient dies from secondary causes, such as those above enumerated or any others, the prisoner is still responsible, and the medical testimony is concerned with the performance of the operation and the secondary causes of death. The relative skill of the operator or surgeon is probably not a question for the jury in criminal cases, on the ground that the man who inflicts the injury must take all the consequences, good or bad. In a civil suit, for instance an action for malpractice, the case is otherwise, and all the medical facts and opinions are submitted to the jury. The law regards three circumstances in death after surgical operations: (1) The necessity of the operation, (2) the competence of the operator, and (3) whether the wound would be fatal without operation.

Death may occur from anæsthetics used in an operation without any recognizable contributing disease of the patient, or carelessness or lack of skill in the administration of the anæsthetic. Of course, the question of absence of contributing disease on the part of the patient and of its proper administration must be satisfactorily answered in cases of death from the anæsthetic in an operation rendered necessary in the treatment of a wound. Death from an anæsthetic may occur before, during, or after an operation itself. Medically speaking, the necessity of the use of an anæsthetic in operations cannot be questioned, and in emergencies where an operation becomes necessary, and not a matter of choice, its use, with special care, is justifiable even with existing organic disease, which usually contraindicates it. As death may be alleged to be due to the use of a particular anæsthetic, it is always best in operating on account of an injury which may require a medico-legal investigation, to use that anæsthetic which is most generally used and indorsed in the particular section of country in question. Of course, it is not lawful to operate against the will of a person who preserves consciousness and will. It may be added in this connection that if a medical man be guilty of misconduct, arising either from gross ignorance or criminal inattention, whereby the patient dies, he is guilty of manslaughter, according to Lord Ellenborough. Omissions or errors in judgment, to which all are liable, are not criminal.

IV. Was the Wound made by the Instrument Described?

It is not often necessary to prove that a weapon was used, though it may affect the punishment. For the use of a weapon implies malice and intention and a greater desire to do injury. The prisoner may swear that no weapon was used when the nature of the wound clearly proves that one was used. The explanation of the prisoner of the origin of the wound may thus be discredited. We cannot often swear that a particular weapon was used, but only that the wound was made by one similar to it in shape and size. Thus Schwörer tells of the case of a man stabbed in the face by another. The medical witness testified that the wound was caused by a knife shown at the trial which had a whole blade, but a year later the point of the knife which had really caused the wound was discharged from an abscess in the cheek at the site of the wound. The surgeon thus made a too definite statement in regard to the knife shown.

It is often very difficult to answer the above question. We base our opinion chiefly on two sources: 1st, and most important, by an examination of the wound, and, 2d, by an examination of the instrument said to have been used. Certain particulars of the wound may furnish indications as to the weight, form, and sharpness of the instrument used. There are certain wounds which must have been made by an instrument, namely, incised and punctured wounds. The above question is determined more or less by what has been said in a former section on wounds, but we will now consider what special features of these and other classes of wounds indicate the nature, shape, size, etc., of the weapon used.

Incised wounds must be made by a cutting instrument. We would here exclude those contused wounds of the scalp and eyebrows which closely resemble incised wounds, but we have already seen that we can diagnose between these wounds and incised wounds by careful inspection. But the locality should put us on our guard, so that in case of wounds of these two regions we should be especially careful in making the examination.

In the case of incised wounds we cannot often tell the shape or size of the weapon, but we are able to tell certain characteristics about it. The sharpness of the instrument may be inferred from the clean and regular edges. The depth of the wound may also indicate the sharpness of the weapon. A long “tail” in the wound indicates that the weapon was sharp as well as that this was the part of the wound last made. If the edges of the wound are rough, we may infer that the edges of the weapon were rough and irregular. Wounds caused by bits of china or glass or fragments of bottles, besides having rough and lacerated edges, are characterized by an irregular or angular course in the skin.

Some cutting weapons, like an axe, act as much by means of their weight as by their cutting edges. Wounds caused by such weapons we can often distinguish by the following signs: The edges are not as smooth as is the case with a cutting instrument, and they may be more or less lacerated and show signs of contusion. The wound is often deep in comparison with its length, and the ends of the wound abrupt instead of slanting up from the bottom to the surface. The section of resisting organs and the impression of the edge of the weapon on the bone are further signs of the use of such a weapon.

The form and direction of a wound may possibly give some indication of the form of the instrument—for instance, whether it be straight or curved like a pruning-knife, as in the case cited by Vibert[636] of a wound of the neck which suddenly became deeper toward its extremity and changed its direction; the whole being explained on the supposition that it was made by a pruning-knife.

But it is in punctured wounds especially that we are enabled most often and most accurately to determine the kind of a weapon used. Here from the form of the wound we may judge of the form and size of the weapon. In speaking of punctured wounds in a former section we divided them into four groups, reference to which may here be made. In the first group, or those caused by cylindrical or conical weapons, when the weapon is very fine it may leave no track at all; if a little larger, we may infer from a linear bloody track that the weapon was needle-like in shape. The length of the instrument or the depth to which it penetrated may be found, as a rule, only by dissection. If the weapon were larger and conical, we have seen that the wounds would be linear with two angles, the length of the wound being parallel to the direction of the fibres in the skin.

Here we may judge of the form of the weapon from the following circumstances: From a comparison of the depth with the size of the opening, we know that it was a punctured wound. The edges and angles are not smooth and even enough for a stab-wound with a knife, for the edges are torn and not cut, and a stab-wound would be the only form of wound with which we would be likely to confuse it. Furthermore, the direction of the long axis of the wound parallel to that of the skin fibres in the region in which it occurs and the very slight retraction of the edges distinguish it from a stab-wound. By these signs we can almost always distinguish such wounds from stab-wounds, and thus tell the form of the weapon used. As to the size of weapon used, these wounds if of any size are generally smaller than the weapon, for the skin is put on the stretch by the weapon and yields to a certain extent. The actual wound, therefore, is smaller in circumference than the weapon. The size of the wound is smaller than that part of the weapon occupying the wound when the weapon was arrested; it may be very much smaller than the weapon at its largest point. Small wounds of this kind are generally larger than the instrument producing them.

The second group of punctured wounds, or stab-wounds, are by far the most common and, therefore, the most important variety of punctured wounds. If the stab-wound is perpendicular to the surface the form of the wound may represent pretty closely that of the weapon at the point where the latter was arrested, whether it has a single or double cutting edge. But even here there are exceptions. Frequently a weapon with a broad back and only one cutting edge may produce a wound resembling that of an instrument with two cutting edges, the second angle tearing as in the former class. Here on close examination we can sometimes distinguish the difference between the two angles, and judge correctly of the shape of the weapon. In fact, wounds made by common pocket-knives are regularly slit-like and not wedge-shaped, as the wound is caused only by the cutting edge of the knife. Again, if the single cutting edge is blunt, in rare cases the wound is produced in the same manner as those of the first group, or conical and cylindrical instruments. We would be led to suppose that the wound was produced by such an instrument, as both angles are torn, unless the direction of the wound might not follow that of the fibres of the skin, in which case we would be left in doubt. Stab-wounds are sometimes angular from the knife being withdrawn in a slightly different direction from that in which it was introduced or from an unequal retraction of the skin (see Fig. 9). If the stab-wound is obliquely directed, we can still judge of the general shape of the weapon, with exception of the cases above mentioned. The dimensions and size of the weapon are here much harder to determine. The dimensions of a stab-wound in the skin may be the same as those of the weapon, or of that part of the weapon which is arrested in the wound, but often they are not so. To measure the size of a wound exactly so as to get at the exact size of the instrument, we should place the region of the wound in the same position, etc., that it was when the wound was inflicted, and this we cannot often do. As the skin was tense or relaxed at the time the wound was inflicted, so the wound in the skin appears smaller or larger, just as with a sheet of rubber under similar conditions. If the instrument is very blunt, the wound in the skin may be smaller than the weapon whether the skin near the wound is tense or not. Thus Hofmann saw the wound from a blunt bayonet one centimetre shorter than the weapon.

The wound of the skin may be shorter and broader than the weapon used on account of retraction of the edges of the wound, and this is especially marked when the wound lies transversely to the direction of the skin fibres. On the other hand, the length of the external wound is more often greater than that of the weapon, because the wound is elongated by making pressure toward the cutting edge on withdrawal of the weapon, and an oblique wound measures longer than the weapon. If the blow is from above downward and the cutting edge of the weapon is uppermost, the length of the wound is not so likely to be increased much beyond the measurement of the weapon as when the cutting edge is directed downward. There is but one condition in which a stab-wound is at all likely to correspond in dimensions with that of the weapon, and that is when the wound is perpendicular to the surface. Even here the wound may be lengthened on withdrawal of the weapon, and we have to allow for retraction of the edges and try to put the parts in the same condition of tension or laxity as at the time of wounding. Even in the most favorable case, therefore, we cannot with certainty tell the exact size of the weapon. If a stab-wound be directed obliquely to the surface, then the length of the wound is greater than that of the weapon, unless this increase be exactly counterbalanced by the lateral retraction of the wound. The size of the weapon in such oblique wounds is further obscured by the changes of size due to withdrawal of the weapon, retraction of the edges, and the condition of the tension of the skin at the time the wound was inflicted.

Fig. 9.—Angular Stab-Wounds of the Anterior Chest Wall caused by a Strong Pocket-Knife.

Dupuytren remarks that stab-wounds are smaller than the weapon owing to the elasticity of the skin, but a lateral motion of the weapon may cause considerable enlargement of the wound. If a stab-wound has traversed a part of the body, the wound of exit is smaller than that of entrance.

The depth of a punctured wound may be any part of the length of the weapon, or it may even be deeper than the length of the weapon owing to a depression of the surface by the force of the blow, or the pressure of the handle of the weapon or the hand holding it. We have already seen that this may occur in a marked degree in penetrating wounds of the abdomen involving one of the movable viscera, also in wounds of the thorax, partly from depression of the surface and partly from an expansion of the thorax when opened at the autopsy, thus increasing the measured depth of the wound. Punctured wounds of the third class made by instruments with ridges or edges, like foils, files, etc., present more or less the shape of the weapon if the edges are cutting, but not always so if the direction of the wound be oblique or the parts unevenly stretched. If the edges are not cutting they cause wounds more or less like the first class of punctured wounds, but we can often distinguish them from the latter by little tears in the edges. The entrance and exit wounds may not be alike.

Wounds made by bits of glass and earthenware have irregular and uneven edges. Taylor[637] relates a case, Reg. v. Ankers (Warwick Lent Ass., 1845), where the wound was attributed to a fall on some broken crockery, but the wound was cleanly incised and the prisoner was convicted. As it may be alleged in defence that a given wound was caused by a fall on broken crockery or other substances capable of producing a punctured wound, it is important to notice whether the edges are lacerated and irregular or smooth and clean. The author quoted above cites another case which occurred to Watson, where the prisoner alleged that a deep, clean-cut wound of the genitals of a woman which had caused her death was due to a fall on some broken glass. The character of the wound disproved this defence. Another feature of such wounds, especially if they be deep in comparison to their length, is that they are very apt to contain small particles of the glass or earthenware which caused them. In fact, in all wounds it is well to search for any small fragments which will throw light upon the weapon used.

Wounds caused by scissors are often of characteristic shape. If the scissors were open we find two symmetrical, punctured diverging wounds, presenting more or less clearly the form of the blades of the scissors. If the blades have been approximated there is a triangular interval between the punctures, the apex of which is truncated if any skin remains between the punctures.

Lacerated wounds may not indicate the weapon used as clearly as punctured wounds, but the agent which produced them is often indicated by the appearance of the wound. They are generally accidental. But where they occur, as they not infrequently do, on the bodies of new-born children, they may give rise to the charge of infanticide. In some cases the weapon which caused the wound fits the wound produced, and thus important evidence may be furnished the prosecution. Taylor[638] cites the case of Montgomery (Omagh Sum. Ass., 1873), where a bill-hook which fitted the injuries on the skull of the deceased was found buried in a spot to which the prisoner was seen to go. These facts connected the prisoner with the weapon and the weapon with the murder. In other cases the wounds may be so lacerated or contused that the indications of the weapon are obscured.

Contusions and Contused Wounds.—The shape of a contusing body is sometimes reproduced by the contusion and the ecchymosis. Thus we are enabled to distinguish the marks of a whip, the fingers, the fist, etc. This is best seen when the ecchymosis is fresh, for soon the edges extend and the outline is less clearly marked. Plaques parcheminées, which we have already described as the marks of contused erosions, may show the form of finger-nails, etc. Contused wounds like simple contusions may show the shape of the weapon.

If the contusing body has a large area, the whole of this area cannot often strike the body at once, so that the outline of the contusion does not represent that of the weapon. But in general, severe contusions present greater difficulties than the preceding classes of wounds. We must generally be content if we can determine whether the wound was caused by a weapon, including the fist, or by a fall, and we are often unable to say even this. A fall is often alleged by the defence as the cause of the injury, but of course if the prisoner was responsible for the fall he is responsible for the results of the fall. If there are contusions or contused wounds on several parts of the head, or if the wounds are on the vertex of the head, it is presumptive of the use of weapons. We cannot often swear that each and every wound on the head was due to the use of a weapon. On the other hand, the presence of grass, sand, gravel, etc., in a wound is presumptive of a fall and of the origin of the wound in this manner. In case of a fall from a height the wound or wounds might be in almost any part of the body, on the vertex or elsewhere. Such a fall may be the result of accident, suicide, or murder. It is not unusual for female complainants to ascribe their wounds to a fall to exculpate the prisoner, especially if this happens to be her husband. We should remember that in the scalp or over the eyebrows a contused wound caused by a blunt instrument may resemble an incised wound. As already stated, however, if the wound is fresh careful examination will lead to a correct opinion, and the use of a sharp instrument may be disproved. If the wound is not recent there is great difficulty in judging of the cause. It is well to caution against accepting the interested statements of others in regard to the use of a weapon, unless the character of the wound bears them out very strongly. There may be a bad motive for imputing the use of a certain weapon to the assailant. It is far better to rely solely upon the evidence furnished by the wound in such cases.

It would be useful if we could lay down some general rules to discriminate between wounds caused by the blow of a weapon and those caused by falls, but this we are unable to do so as to cover all cases. Each case must be judged by itself.

If the question is asked which of two weapons caused certain contusions or contused wounds, we are still less likely to be able to answer it. In such a case we must make an accurate examination of the form of the wound and compare it closely with that of the weapon. In such cases also the second source of information on which we base our opinion as to the relation of a weapon to the wound may be of use, namely, the examination of the weapon. The presence of blood, hair, cotton or woollen fibres on one of two weapons indicates that this was the weapon used. The presence of blood is particularly to be looked for, and in those parts of the weapon from which it could be washed off least easily. We should further note the condition of the point and edge of the weapon, and if the edge is broken or nicked at all, whether this condition is old or recent. The sharpness of the edge should further be noted, and if the edge is sharp note whether it has recently been sharpened. All these points have a certain bearing on the case. Also the location, shape, depth, etc., of the wound should be carefully noted to see if an accidental fall would be likely to account for it. For these features of the wound may be such that no fall could cause it.

We see, therefore, that in incised and punctured wounds the use of a weapon may not be hard to make out, but that in general the question whether a particular instrument caused the wound is often difficult or impossible to answer. Often the best we can do is to say that the wound could have been produced by the weapon.

V. Was a Wound Self-Inflicted or was it Inflicted by Another?

In other words, was it suicidal or homicidal? Speaking of suicide in general, its most common cause is alcoholism. It is not infrequent in youth. Lutaud[639] states that in fifteen years, presumably in France, there were 1,065 cases of suicide between the ages of ten and fifteen years. This seems to be only explicable on the ground of heredity or of cerebral affections. Among 27,737 cases of suicide, observed in France, the same author gives the following commonest causes in the order of greatest frequence: Drowning, strangulation, pistol-wounds, incised and punctured wounds, poison. The age, sex, and social conditions influence the choice of means. Thus among males drowning is preferred by the young, pistol-wounds by the adult, and hanging by the aged, while among females asphyxia is the favorite method, as there is no pain and no disfigurement.

While many pathologists consider suicide an act of mental alienation, and though such may be the case in a large number or even in a majority of cases, yet in a considerable number it is a voluntary and rationally planned act. The question, Is it suicide or homicide? may be put in all cases of death by cutting instruments, and in many from other kinds of wounds. It is often, if not generally, impossible to answer it with absolute certainty. It is hardly suitable for the medical witness to try to reconstruct the scene of the crime from the medical facts, for he should abstain from everything not medical and should distinguish that which is positively proven from that which is merely probable.

Suicides often leave a letter or some such indication to show that the wound was self-inflicted. If such is not the case, the question as to the cause of the wound may or may not be medical. If the question is a medical one, there are certain points to notice as to the wound, such as its nature, situation, direction, and the number and extent of the wounds, from which we are to form an opinion. There are also other circumstances which furnish evidence and thus assist us in answering the question. This evidence is furnished by the weapon, the signs of struggle, the examination of the clothes and body of the deceased and the accused, the position and attitude of the body, and any organic lesions, etc., predisposing to suicide.

The nature of the wound bears upon the question of the homicidal or suicidal origin in the following way: Most suicidal wounds are incised or punctured wounds. Incised wounds of the throat are generally presumptive of suicide, but a homicidal wound may be inflicted here to conceal the source of infliction of the wound. Such a wound if homicidal would imply malice, on account of the attempt at deception and concealment, and would convict the assailant of murder. Unless the deceased was asleep or drunk or was otherwise incapable of resistance, such a homicidal wound can often be distinguished from a similar suicidal wound by the form and direction of the wound, by its irregularity, and by other wounds on the hands or person of the deceased. Taylor[640] mentions a case in which the peculiar form of the wound, like that made by butchers in killing sheep, led to the suspicion that homicide had been committed by a butcher, who was subsequently arrested, tried, and convicted of murder. The regularity of the wound has been taken to indicate suicide rather than homicide. That it does so is not questioned, but it is more or less fallacious if resistance is impossible, in which case a murderer may easily make a regular, clean, incised wound here. Contused wounds are seldom suicidal, for they are not sufficiently speedily or certainly fatal. They are also more painful and disfiguring. Contused wounds usually indicate murder or accident, though there are not wanting cases of suicide by such weapons as a hatchet or a hammer. There is more difficulty in the case of a contused wound from a fall instead of from a weapon; for here we have to decide whether the fall was accidental, suicidal, or homicidal. The nature of the wound is of little assistance in the case of insane or delirious patients, who may commit suicide in the most unusual and curious manner.

Taylor[641] relates the case of a delirious patient in Guy’s Hospital, in 1850, who tore away the whole of the abdominal muscles from the lower part of the anterior abdominal wall. If the case had not occurred in the hospital or where there were witnesses of the deed, the nature of the wound would have indicated homicide except for the delirium. The following case, quoted by the same author, illustrates a wound of very unusual nature and situation, which might have been taken for a homicidal wound with intent to conceal as far as the situation of the wound was concerned. The wound was accidental and occurred in the following way. A girl fifteen years old jumped on to her uncle’s knee while he was holding a stick between his legs which she did not notice. The Stick passed up her anus, but she withdrew it and went on playing, though she complained of pain. On the following night acute symptoms of peritonitis set in, and she died of it in forty-eight hours. On post-mortem examination a rent was found in the anterior part of the rectum penetrating the peritoneal cavity.

The Situation or Position of the Wound.—A suicidal wound must be in such a position that the deceased could have inflicted it himself. Such wounds are, therefore, generally anteriorly or laterally situated. The “site of election” for suicidal wounds is the neck for incised wounds and the chest, especially in the region of the heart, for punctured wounds. The situation of suicidal wounds, of lunatics, etc., shows all kinds of fantasies. The mere situation does not suffice to distinguish suicidal wounds, as a murderer may simulate a suicidal wound for purposes of concealment. Some regard a wound in the back as proof against suicidal origin, but it is not so much the situation of a wound as the situation taken in connection with the direction which furnishes the proof against suicide in such wounds.

As a rule, a suicidal wound, besides being in an accessible part of the body, is also in a part commonly known to be rapidly mortal, as the neck and heart. But suicidal wounds are not always in the situation which is anatomically best for being rapidly fatal. Concealed wounds or wounds in inaccessible parts presumptive of murder may be suicidal and so placed to impute them to another and give rise to the suspicion of murder. The blood-vessels of the arms and legs may be selected as the site of a suicidal wound. This situation is often regarded as uncommon, though the writer has met with it in one or more cases of attempted suicide. It is illustrated in the famous case of Abdul Aziz, the Sultan of Turkey. He was found dead under suspicious circumstances with two oblique, ragged wounds at the bend of each elbow, directed from above downward and from within outward. The joint on the left side was penetrated, while only the skin and veins were involved on the right side. Death was due to bleeding from the ulnar artery and the veins. The clothing was soaked with blood and scissors stained with blood were found on the sofa. These wounds were consistent with suicide, though not what would be expected. Nineteen physicians who examined the body agreed in reporting it as suicidal, though one reason given for this opinion, namely, “that the direction and nature of the wounds, as well as the instrument which might have effected them, lead to the conclusion of suicide,” was hardly a valid one, for the wounds were not typical of suicide in nature, direction, or position. Such wounds are rarely homicidal, though at least one such case is mentioned.

Suicidal incised wounds, as has been said, are usually in the neck, where they may sometimes be arrested by the larynx, especially if it be ossified, though the incision often divides the larynx. The situation of the wounds is often between the larynx and the hyoid bone, and then meeting no bony resistance, they may divide the great vessels and even nick the vertebræ. But it is rare to be so deep, at least on both sides at once. As a rule, it is deepest on the side on which it is begun and ends more superficially. As far as the situation of a wound is concerned, there is no wound which a suicide can inflict but what may also be inflicted by a murderer. The reverse, however, is not true. We cannot always certainly distinguish between suicidal and homicidal wounds from their situation.

The direction of the wound is one of the most important points to notice. It is considered by some to furnish presumptive evidence for the medical jurist, and taken in connection with the nature and situation of the wound may often lead us to a positive opinion as to the question of the suicidal or homicidal nature of a wound. The evidence from the direction of wounds is only furnished by incised and punctured wounds, rarely by contused wounds. Suicidal incised wounds of the throat are almost always directed from above downward and from left to right if the suicide be right-handed, and in the same direction from right to left if the person be left-handed. Transverse wounds in this situation without obliquity are also compatible with suicide, though perhaps more common in homicide, while obliquely transverse wounds from above downward and from right to left in a right-handed individual are indicative of their infliction by another. Homicidal incised wounds of the neck inflicted from behind or the right side, if the victim and assailant are right-handed, or from the left side if they are left-handed, may have the same direction as similar suicidal wounds. Such a wound may be inflicted by a murderer to deceive as to the cause of the wound by raising the suspicion of suicide. If an incised wound of the throat be inflicted by another from in front, then its direction is usually the reverse of a similar self-inflicted wound.

Homicidal incisions, especially in the throat, may extend at one or the other end beyond the skin wound. In similar suicidal wounds at both angles of the wound the skin is the first and the last part injured, and in such wounds the spine is seldom reached. It should be borne in mind in this connection that a given suicide may be ambidextrous and this fact may be unknown to the friends of the deceased. This is especially the case in the use of the razor from practice in shaving, and the razor is the usual weapon used in such incised wounds of the throat. Neglect of this point may lead to an unwarranted suspicion of murder. The two following cases cited by Taylor[642] well illustrate this fact:

In the case of Sellis,[643] the man was generally supposed to be right-handed, though he was found dead in bed with his throat cut and the razor on the left side of the bed. In point of fact, he was ambidextrous in the use of the razor. The second case, which occurred in London in 1865, was still more remarkable.

A publican was found dead in bed with his throat cut in a left-handed manner. He was supposed to be right-handed and there was bloody water in a basin in the room. His wife, who gave the alarm, had marks of bruises on her, and though she said she had found her husband dead in bed after having left it for a short time, suspicion fell upon her, especially as they were in the habit of quarrelling. The suspicions were removed, however, by the explanation that he had been brought up as a wood-carver, which required him to use both hands equally, and that he had frequently threatened to kill himself, and further that the bloody water in the basin was due to a daughter washing her hands after having touched her father. It is even conceivable that an ambidextrous person, to avoid suspicion of suicide or to impute murder to another, might inflict a suicidal wound from right to left. Notwithstanding all this, the above cases are very rare exceptions, and the rules stated above as to incised wounds in the throat hold in almost every case.

In the case of stab-wounds of the chest, especially in the cardiac region, the same rule as to the direction holds good, and in these wounds we can often define the direction more accurately than in the case of incised wounds. If the suicide is right-handed the wound is regularly on the front or side of the body and directed obliquely from above downward and from right to left, while it is from left to right in case of a left-handed suicide. A murderer from behind, or from that side the hand of which the victim would use, may inflict a wound in the same situation and direction as a suicidal one. Here again this may be done with the motive of concealment of the nature of the crime. Homicidal stab-wounds inflicted from in front, as they generally are, are usually directed from left to right, and they may be directed from above downward or in the opposite direction. Oblique wounds from above downward may be either suicidal or homicidal; those directed from below upward are almost always homicidal.

When a wound is caused by an instrument both cutting and puncturing, suicide cannot be admitted unless the direction of the wound is compatible with that which the weapon which inflicted the wound, held in the hand of the deceased, might cause. Taylor recommends to place the weapon in the hand of the deceased to see if the direction of the wound could possibly correspond with that which could be taken by the weapon in the hand of the deceased with any position possible for the arm and hand. Therefore certain wounds by position and direction exclude suicide, but if a wound is possibly suicidal it is also possibly homicidal.

Though suicidal wounds vary, the above points are sometimes of real assistance in distinguishing between suicide and homicide, especially if the body has not been moved.

Evidence Furnished by the Number and Extent of Wounds.—Multiplicity of wounds, as a rule, indicates homicide, and indeed the reverse is true in a majority of cases that a single wound points to suicide. There are many exceptions, however, to both statements. Multiple wounds are possible in suicide, and that, too, with different weapons; even drowning or hanging may be resorted to after self-inflicted wounds have failed. If several wounds are found, each one of which or more than one of which may be considered grave, it is usual to conclude that the wounds were not self-inflicted, but the medical expert should not judge too hastily from this fact alone, for most wounds do not kill instantly. With the presence of several wounds in a case of suicide only one of these, as a rule, is “mortal” in character. This being so, some have asserted that if two mortal wounds are present, especially if one of them is stupefying, such as a wound about the head, such wounds are incompatible with suicide. A definite statement of this kind cannot go unchallenged unless the two wounds are in different parts of the body, and both of such a nature as to be immediately or very rapidly fatal. For all cases of suicide or homicide do not die immediately from wounds commonly called mortal; in fact, this may be said to be the exception rather than the rule. We may safely say, however, that if there are several distinct wounds on the throat, each involving the large vessels, the inference is plainly murder.

Fig. 10.—Suicidal Cut Throat from Left to Right, showing the Tentative Cuts at the Commencement and the Serrations at the Termination of the Wound.

Several wounds by the same or different weapons cannot, therefore, be proof of homicide. The case of a lunatic suicide is reported who inflicted thirty wounds upon his head. In a case of homicide with multiple wounds the situation or direction of some one or more of them may give evidence as to the origin of the wounds. Ogston, Sr.,[644] states that especially in the case of incised wounds of the throat a suicide may make a number of small or superficial tentative cuts besides the principal one, but these incisions are all usually parallel (see Fig. 10). In the case or multiple homicidal incised wounds of the throat, on the other hand, the wounds are not parallel, owing probably to the resistance of the victim in this case and his remaining passive in the former. The extent of the wound refers to the number and importance of the parts injured. In regard to incised wounds of the neck, this point has been thought by some to furnish presumptive evidence of suicide or homicide—of homicide if the wounds are deep, of suicide if they are not. While it is true that suicidal wounds of the neck are, as a rule, not very deep, and that they seldom reach the vertebræ and generally do not divide the vessels on more than one side, yet sometimes such wounds are as deep and extensive as homicidal ones. This may imply a determined purpose not to be foiled in the attempt at suicide. Thus Marc reports a case of suicide by an incised wound of the neck, where the wound was so deep as to reach the vertebræ or their anterior ligaments and to divide the trachea and œsophagus, both carotids and jugular veins. The extent of this wound was greater than in most suicides, but still we can hardly lay down a hard-and-fast rule of much practical value according to which extensive wounds are evidence of murder. Such wounds are, however, presumptive of murder taken in connection with other signs pointing that way.

Fig. 11.—Homicidal Cut Throat from Right to Left, showing a Tentative Cut at the Commencement and the Serrations at the Termination of the Wound.

The question may arise in regard to a wound, whether the victim wounded himself by precipitating himself on the weapon. This may be alleged by the defence, but it is difficult to believe if the wound is deep, for the body would naturally repulse the weapon. If the wound is deep the weapon must at least have been strongly held, which may or may not be consistent with the theory of self-defence. If the direction of the wound is oblique from above downward, or if there is one external wound and two separate tracts internally, from a second use of the weapon on the part of the person holding it, then the above allegation is doubtful, if not impossible.

By comparing the relative positions of the deceased and accused, as indicated by the witnesses and accused, with the position and direction of the wound, we may often judge whether the allegation is possible or probable.

Besides the above points derived from the wound itself, there are several other factors which belong to the category of circumstantial evidence, but which come within the province of the medical expert. These latter points of evidence are sometimes almost as important as the former, while taken in connection with them they help to make the evidence far more conclusive.

Evidence furnished by the weapon as to the origin of wounds.

We have already seen in a former section that we can often tell, by various signs of the wound, with what kind of a weapon it was made. We may thus be able to say that a wound was made by a weapon similar to one exhibited. Also by examination of the weapon itself and from the circumstantial evidence of where and how it was found, we may sometimes say that the wound was inflicted almost certainly with a particular weapon. All this evidence may sometimes be made use of in judging between the suicidal and homicidal origin of a wound.

The POSITION of the weapon or the place where it is found is a matter of considerable importance. If it has not been touched, its position should be carefully examined, or inquired about if it has been moved. The presence of a weapon which might have caused the wounds in the hand of the victim is in general proof of suicide. The weapon must not merely lie in the hand, it must be gripped by the hand. One might suppose that the weapon placed and held in the hand until rigor mortis sets in would still be firmly held. Casper says that this is not so, but that the weapon falls from the grasp as soon as the hand is unbound. Also Hofmann’s[645] experiments proved the same point. By the use of ligatures and several artificial means he tried to confine a weapon in the hand of a recently dead body so that it would be as firmly held as by a contraction of the muscles during life. These experiments were entirely unsuccessful, for though the fingers remained closed, the object was simply held and not grasped, and fell from the hand on the release of pressure.

In suicide the weapon is sometimes held so firmly that force is required to dislodge it. It seems as if the muscular spasm or grip persists after death, as cadaveric spasm, until rigor mortis occurs and sets it, as it were. The murderer, therefore, cannot imitate this grip, and an unsuccessful attempt to do so would indicate murder. It should be borne in mind that the weapon in the hand of the deceased may have been for the purposes of defence; therefore it is necessary to note whether the wounds on the body correspond to those which could be made by the weapon. Indeed, this fact is most important to note in all cases of suspected suicide where the weapon is found. If the weapon is not in the hand of the deceased, note carefully where it lies. If death is due to a suicidal or accidental wound which is immediately or very rapidly fatal, the weapon is generally found near the body. If so, it is well to note on which side it lies, and if it lies near, whether it has apparently fallen or been thrown or placed there. If the relation of the body and the weapon has been disturbed by moving either, the position of the weapon as found by the medical witness is of little value. In cases of suicide the weapon may possibly be found at some distance or even concealed, though this is exceptional. Thus Taylor[646] states that the razor in one instance was found shut at the side of the deceased, who had committed suicide by cutting his throat. In another instance the razor was found in the pocket of the deceased, bloody and closed. As a rule, the weapon is found lying at the side of a suicide if it is not grasped in the hand. If the weapon is far from the body and the wound was quickly fatal, especially if the weapon is hid or cannot be found, it is strongly presumptive of murder. If the weapon is found near the body it is well to note whether the edge is sharp or blunt, straight or bent, or notched, as these points may assist us in forming a judgment as to suicide or murder.

A weapon belonging to the victim may be substituted by the murderer for the one really used, and the former may be placed by the side of the body. Therefore the weapon found should correspond to the wounds as to length, depth, sharpness, etc., to be compatible with suicide.

Generally a suicide foiled in the attempt to take his life uses the same weapon over again if he persists in the attempt. But he may not do so; on the contrary, if the first attempt was made with a knife, the second may be made with a pistol, etc. Several wounds by the same or different weapons cannot therefore be an absolute proof of homicide.

The presence of blood, hair, and other substances on the weapon used, or probably used, is a matter of some importance. Blood is not necessarily found on the weapon used to inflict a mortal wound, especially in the case of blunt instruments. In stab-wounds, too, the vessels may be compressed by the blow or the weapon may be wiped as it were on withdrawal by the elasticity of the skin and by the clothing, except for a thin yellowish film. Thus it is that the first stab-wound shows no blood on the outside of the clothes but only on the inside, but the outside of the second is usually bloody but may be but little so. To make sure whether or not there is blood on a knife or other weapon it is necessary to examine all the depressions on the instrument, as the blade itself may have been washed, and only those traces of blood remain which are less accessible to cleaning by washing. Blood coagulated on a blade indicates, as a rule, blood from a living animal, but it may not do so. Furthermore, it may be hard to distinguish between a thin layer or spots of dried blood not coagulated or coagulated and dried blood in a similar form.

If blood is not found on a weapon, hair and other substances which can be identified may be. This is especially the case with blunt weapons, on which, as we have seen, blood usually fails. A fragment of the weapon may break off in the wound, as in stab-wounds, and may be identified as belonging to one in the murderer’s possession.

The signs of a struggle furnish important evidence, as they are not likely to be found in the case of suicide. If the wounds were inflicted by a cutting instrument, the existence of a struggle may be indicated by incisions on the palm of the hand or fingers or on the dorsum (see Fig 12). Such wounds would not be self-inflicted and would indicate a struggle with the murderer. Or if contusions or ecchymoses indicating the form of the foot, fist, fingers, or finger-nails are found on the face, neck, chest, forearm, or hand of the deceased, this again indicates a struggle with the assailant, and goes far to prove murder. The same is true of the imprint of a bloody or dirty hand on the clothes of the victim when the victim’s hands were not bloody. Also such an imprint in a position where the deceased could not have reached with the particular hand indicated, as is the case if the impression of a right hand be found on the victim’s right arm; this indicates a struggle with a murderer, etc. In one case of murder, on the back of the left hand of the deceased there was found the bloody mark of a left hand evidently not that of the victim himself. The presence of marks of violence about the mouth of the deceased, done to close it to prevent the victim from giving an alarm, especially if surprised during sleep, is presumptive of murder. Sometimes hair or fragments of clothing belonging to the accused are found in the grasp of the deceased, indicating a desperate struggle, and they are very suspicious of murder. Thus Taylor[647] cites the case of a murder trial in Ireland, in 1877, where hairs found firmly grasped in the hands of the deceased were found to correspond to the hair of the accused. The clothes of the deceased, as well as those of the accused, often indicate a struggle unless the accused can satisfactorily account for the condition of his own clothes in some other way.

Fig. 12.—Incised Wounds of Right Hand in the Struggle of Defence. Homicide.

The examination of the clothes and body of the deceased and the accused may furnish important evidence.

If suicide is accomplished by a weapon like a knife, it is rare for the hand not to be bloody. If it is not bloody we may well suspect a case of supposed suicide. The presence of blood on the hand does not prove suicide, though its absence may disprove it, as the hand is generally bloody in case of murder by being carried to the wound.

The examination of the clothing of the deceased is of great importance. As we have noticed before, a suicide generally opens them, a murderer rarely. A suicide is often partly or even wholly undressed when he inflicts the wound, while murder is usually committed on those entirely dressed. The wound of the clothes should correspond to that of the body in case of murder. In suicide the wounds of the body and of the clothes may not correspond, especially if there exists a motive to falsely impute the crime. The clothes of the deceased as well as those of the accused may indicate a struggle, as we have already noticed. Of course, in regard to the clothes examined, it is necessary to clearly prove that they were worn at the time by the deceased or accused, otherwise serious mistakes may be and sometimes are made. In examining the blood-spots on the clothing, note whether the blood occurs in large patches or sprinkled as by a spurting vessel or by continued violence.

The body of the accused may present scratches, marks of nails, contusions, bites, or other wounds indicative of a struggle. It would be well to ask the accused how he received the wounds or scars, to see if his explanations tally with the injuries. It is hard to tell when wounds which have cicatrized were inflicted; we can only distinguish between old and recent ones, and thus control the statements of the accused. An examination of the finger-nails of the prisoner soon after the crime may reveal blood underneath when the rest of the hands and person are free from it. Note also the site and shape of the blood-spots, if they exist, and whether or not they came from an arterial jet. These spots may be on the body or clothes of the accused. The account of the accused as to these spots may or may not correspond to the facts as indicated by them. The above leads us to the more or less important question:

Could the Assailant have Escaped without Stains?

It is possible for the murderer to escape without being spotted with blood, but the probability of this occurrence depends on the nature of the wound and the relative positions of the deceased and the assailant at the time the wounds were inflicted. This latter fact is very largely, if not altogether, a matter of speculation as far as the medical evidence goes. It is a popular, though false, idea that a murderer’s clothes must be bloody, and the police may be misled in expecting to find them so in every instance. Taylor[1] cites several cases in which either no blood was found on the murderer’s clothes, or only small spots wholly out of proportion to the amount of blood which must have spurted or flowed from the wound. Absence of blood on the prisoner’s clothes is often made use of by the defence to prove the prisoner’s innocence, whereas, besides the possibilities of having had no spots in the first place, the clothes may have been changed or washed before the examination was made. This has occurred in more than one murder trial. Taylor[648] mentions the following cases in illustration:

It was alleged that the absence of blood-stains on the prisoner’s clothing was a strong proof of his innocence in the trial of Sub-Inspector Montgomery for the murder of Mr. Glasse (Omagh Ass., July, 1873). In this case the weapon was a bill-hook which had produced contused wounds on the head. There was blood on the floor about the body, but the wounds were not likely to have been accompanied by much spurting. Yet it was assumed that the assailant in this case must have been covered with blood. Much stress was laid upon the absence of blood-stains. On the first two trials the jury could not agree, owing chiefly to the absence of blood-stains, but on the third trial he was convicted and afterward admitted that he had removed the blood-stains from the clothes with cold water. Also in the case of Reg. v. Courvoisier (C.C.C., 1840) the accused, who was tried for the murder of Lord William Russel, had no blood-stains on his clothes. All the vessels of the throat of the deceased had been cut to the vertebræ while he was asleep. It was contended most strongly that the accused could not possibly have committed the crime, as he had no blood-stains. But after conviction he confessed that he wore no clothes when he committed the murder, and he only had to wash his hands and the carving-knife he used. Again, in the case of Reg. v. Thompson (Durham Wint. Ass., 1863) the defence mainly relied on the absence of blood on the prisoner’s clothing. The wound in the throat of the wife of the accused was five inches long, directed from left to right, dividing all the vessels and nerves of the neck. The medical witness stated justly that no such wound could be self-inflicted. It was rapidly fatal. No weapon was found near the body. The prisoner was convicted.

The same author cites the case of a prisoner on whose trousers worn soon after the murder no blood-marks were found, but the trousers actually worn by him were found with blood upon them. Juries have even acquitted the prisoner apparently only because no marks of blood were found, though the other circumstances were explicable only on the theory of murder.

It should be remembered in this connection that blood-stains may be found on the clothing of many, especially on the coarse clothing of working-people. This may be accounted for by the occupation, flea-bites, accidental circumstances, or it may occur without definite explanation. Such persons may be accused of murder and yet the blood-stains be consistent with innocence. Too much importance should not, therefore, be attached to them, even if the accused cannot satisfactorily explain them and if he does not attempt to do so in a suspicious way. That blood on the clothing even under suspicious circumstances may be consistent with innocence is illustrated by the case of a suicide by cutting the throat, in 1872, cited by Taylor.[649] In this case the son first found his father dead, and thought that he had broken a blood-vessel. He raised the body, staining his hands and clothes, then went for help. At the inquest he was closely questioned as to the presence of the blood-stains, but there could be no doubt that the case was one of suicide.

In general, we may say that a murderer is much more likely to escape without blood-stains in contused wounds, and more likely in the case of punctured wounds than in incised wounds, for in punctured wounds the bleeding is much less free and is less likely to spurt from the wound. In the case of incised wounds he is most apt to escape without stains if he is behind or to the side of the victim when he inflicts the wound—in other words, when a part of the body of the deceased was between the assailant and the wound inflicted. Furthermore, the assailant is more likely to escape without blood-stains if there is a single wound than if there are several, and each additional wound makes it more likely that he will be spotted with blood.

The examination of the ground or floor and the furniture, etc., may furnish some evidence as to the nature of the crime, and also help the witness to answer the questions which may sometimes be asked, i.e., At what spot was the victim wounded? and Where did he die? This question is sometimes settled by examination of the spot where the deceased lay and the furniture, etc., about. Sometimes the floor or ground and the furniture or surrounding objects at a distance give the requisite evidence. The examination of the cracks and corners of the floor and furniture should not be neglected, and Taylor instances a case where the hair of a dog helped to clear up the case. If the body has not been disturbed the most blood is usually found where the deceased died. If the victim succumbs at the spot where he was wounded, blood is found only in the immediate neighborhood, except for arterial jets, which may be as far distant as two metres. The separate blood-spots of an arterial jet are circular if the jet strikes the object perpendicularly, oval or wedge-shaped with the larger end away from the body if it strikes the object obliquely.

If the blood-stains are more diffused and are found in other places, careful notice should be taken as to whether the different places communicate with one another by traces of blood. If they do not communicate, it goes to show that the body was moved after active bleeding had ceased, that is, after death, but this indication is not absolutely positive. If traces of blood do connect the larger blood-spots, it is of interest and importance to know where the deceased was wounded and where he died, also whether he moved or if he was moved before or after death. This question is not always capable of solution. Some injuries exclude the possibility of active motion. Stupefying contused injuries of the head or an incised wound opening a great artery are both inflicted where there is the greatest hemorrhage, and the spot where the deceased was wounded and died should be identical. In such cases a second large spot of blood, connecting or not with the first wound, indicates that the body has been moved. But if the wound does not bleed much or rapidly, the wounded person may fall at a distance from the spot where he was injured, and death occurs, as a rule, where there is the greatest amount of blood; for a certain amount of bleeding occurs for a short time after the victim falls or even after death. One can find in many places the signs of arterial jets marking the movement of the deceased from one blood-spot to another. This is quite different from the tracks caused by dragging a bleeding body. All this it is important to notice, for the dragging or passive moving of the body strongly indicates murder. Blood at a distance may indicate the occurrence of a struggle, or that the body was moved, or it may show the tracks of a murderer. As to the latter point, the imprints of the hands and feet, whether bloody or not, may indicate murder and establish the identity of the murderer. We have already seen how they may occur on the deceased and indicate a struggle, and thus be presumptive of murder. When the marks are made by the naked foot, it is well to examine it by lining it off in squares, and so to compare it with the imprint of the foot of the accused. Simple inspection can sometimes give the required evidence. We may even get an impression of such imprints in the snow. Imprints of the boots or shoes worn by the accused compared with those imprints found at and near the scene of the crime may sometimes help to clear up the case, but this may perhaps be considered outside of the sphere of the medical witness. Such and other signs of a struggle about one of the blood-spots would indicate that the wound was received there, though death may have occurred at another spot. In such a case it would be well to examine to see if there was much blood where the body was found, for if there was not it would indicate that the body had been moved there after death, and thus be strongly presumptive of murder.

As furnishing some evidence which may help to distinguish between suicide and homicide in the origin of wounds, the question may be asked, What was the position of the victim when injured or dying? and also, What were the relative positions of the victim and assailant?

The position of the victim at the moment of the injury is sometimes indicated by the position of the wound, the direction of its tract, and the direction from the wound of the blood on the body and clothes. On the neck or extremities the course and form of the wound may indicate the position of these parts when the wound was inflicted, for sometimes in flexions of these parts the skin lies in folds, and a wound inflicted when these parts were so flexed would be irregular, wavy, or zig-zag. Further, the position and movement of these parts necessary to restore directness to the wound may indicate the position of the parts when the wound was inflicted. The examination of the relative positions of the wound in the clothes and the body may help to indicate the position of the body when wounded. The position of the blood on the body and the direction of the blood from the wound, whether below or at the sides, etc., tends to show the position of the body when bleeding. Thus if the body was at any time in the erect position, some of the blood-stains will be vertically below the wound, or if the victim was lying on the back then the stain would be at the sides only and not below the wound, except such stains as indicate that they were produced by arterial jets. Few suicides cut the throat in the recumbent position; therefore it may be considered in the light of an indication of homicide if the blood-stains show that the victim was not erect after the wound was inflicted. It is well also to note the form, direction, and obliquity of the blood-spot. This would indicate, by comparison with the wound, the relative position of the wounded person and the blood-spot, and thus show whether the body had been moved or not, as, for instance, by the murderer for the purpose of robbery. The force of the bleeding is also indicated by the form of the spot, and this would indicate how rapidly death probably ensued. This fact might thus help us to judge whether the victim probably died where he was wounded, and whether other and remote blood-spots would not be presumptive of murder. If the victim is found in night-clothes, this fact would help to show that he was lying down when wounded. The medical evidence as to the position of the victim when injured is, therefore, circumstantial and not very positive; that in regard to the relative position of the victim and assailant is even less positive. We presuppose in this question that the case is one of murder. We are not to prove murder or refute suicide. We can rarely be positive as to the relative position of the assailed and the assailant. A wound in the back may be caused by some one in front with an arm behind. The direction of the wound would indicate this, for if the assailant is right-handed and inflicts a wound on the back from in front, a stab-wound would almost always be directed from left to right, an incised wound from right to left, both from above downward. With a left-handed murderer the direction would most likely be from right to left and from above downward for a stab-wound, and from left to right and from above downward for an incised wound. If the assailant were at the back of the victim and wounded him in front, the direction of these wounds would be the opposite of the above, i.e., from right to left for a stab-wound and from left to right and from above downward for an incised wound with a right-handed assailant and vice versa with a left-handed assailant. These wounds occur more commonly than those of the back, and are especially noticeable in incised wounds of the throat. In the case of these incised wounds of the throat inflicted from behind, the direction from left to right and from above downward resembles that of self-inflicted wounds in the same situation. As a general rule, wounds are on the same side of the victim that the assailant was; the facts given above help to show us the exceptions. Thus a wound on one side is presumptive that the murderer was on that side, or possibly at the front or back and only exceptionally on the opposite side. The presence of wounds on one side only may help to confirm the testimony of a witness that the victim was against a wall or some other obstacle which protected the other side. The question of the relative position of the combatants in duels and the nature of the weapons used as shown by the wounds has sometimes come up, especially in other countries, to determine whether the combat was regular and fair.

In all cases of suspected suicide, but where a doubt exists between suicide and murder, or even accident, hereditary disposition and organic affections of the body, such as alcoholism, incurable or painful diseases, chronic inflammation of the brain and meninges or of the genito-urinary organs—all such and hereditary predisposition may support the idea of suicide.

Imputed or Self-Inflicted Wounds.

Closely allied with the question of the suicidal or homicidal origin of wounds is the question whether a wound imputed to another is self-inflicted or inflicted by another. These wounds are seldom fatal. In discussing the question whether a wound is self-inflicted or inflicted by another, we have referred occasionally to suicidal wounds where the circumstances were such as apparently purposely to imply murder and impute the cause of death to some one else. This happens more often in cases of unsuccessful suicide. Here we have recourse to the same evidence that we have gone over in the present section which helps to distinguish between a suicidal and a homicidal wound. The case may be somewhat more difficult, as the unsuccessful suicide may manufacture evidence against the accused and hide to some extent the evidence of suicide. These cases can usually be decided, however, in connection with the circumstantial and other evidence. The majority of cases of imputed but self-inflicted wounds are very superficial, often not below the true skin. Being self-inflicted they have many of the characters of suicidal wounds. Thus they are usually situated in front and on the left or right according as the wounded person is right or left handed, and the direction is usually similar to that in suicidal wounds. Such wounds are generally incised or punctured wounds, seldom contused wounds, and in this respect they resemble suicidal wounds. As exceptions to this rule, Bergeret[650] mentions some cases where females in attacks of hysteria have inflicted severe contusions on themselves, and have preferred charges of attempted murder against innocent persons. Like suicides also the hands are seldom injured, though they may be much so in resisting homicide.

In other respects, however, these wounds differ from suicidal wounds. Thus they are not usually situated over a “mortal” spot, and they are often numerous and scattered, sometimes parallel and sometimes not. The wounds in the dress do not correspond even as often as in suicide. In comparing cuts in clothing with those on the body, it is important to find what articles were worn at the time the assault was alleged to have taken place, and to make sure that the clothes examined were those worn or alleged to have been worn. It may not be necessary that the clothes examined should have been really worn, for if they were alleged to have been worn and were not, the examination of them will almost always show the deception or the self-inflicted nature of the wounds. Then take careful note of the position, direction, form, and size of the cut and the apparent sharpness of the weapon in the several layers, and see if they correspond with one another and with the wounds on the body in those various particulars. In imputed wounds the clothes are generally cut when off the body and can seldom be done so as to deceive a careful examiner. Several wounds cannot exist in the same region of the body without some being bloody and showing the marks of it on the clothes. Even a single wound of the clothes generally shows blood on the inner surface if there is a corresponding wound of the body underneath. In simulated and imputed injuries the blood-stain may be on the outside of the clothing instead of on the inside, showing that it was artificial and not natural. An impostor may either do too much or too little, and the medical witness should be on guard against both alternatives. Taylor[651] mentions a case which occurred in London some time ago, in which there were two cuts in the shirt near together exactly alike in size, form, and direction, making it evident that the weapon had gone through a fold of the shirt. This proved that the shirt could not have been worn at the time it was cut, for if the shirt was folded while on the body the weapon must have gone through the fold and then through another layer of shirt, making three cuts instead of two, or five instead of four, before it could have reached the body. This and other facts made self-infliction of the slight wound on the chest probable. The same author cites another case showing the imperfect manner in which the cuts in the clothes are made in imputed wounds, the clothes being off the body at the time. The case occurred in Nottingham in 1872, the accused being charged with wounding the plaintiff on the highway by stabbing him in the arm, though there was no robbery or other motive for the act. The coat and shirt sleeve were found cut, but there was no corresponding cut in the lining of the coat sleeve. The charge was clearly false, and was trumped up by the youth who was the plaintiff because he wished to leave the place where he had been sent for private study.

In examining a case where the self-inflicted nature of imputed wounds is in question, the following are some of the many points to keep in mind in the examination and to be ascertained by the examination: (1) The relative position of the plaintiff and the assailant at the time of the alleged attack. This can be compared with the position as stated by the plaintiff or other witnesses. (2) The situation, direction, depth, nature, and number of the wounds. (3) The situation and direction of blood-marks or wounds on the dress or person of either or both. (4) The marks of blood and the quantity of it at the spot of the alleged struggle. (5) The signs of a struggle and the various other points of circumstantial evidence gone over in considering suicidal and homicidal wounds.

Though a severe blow may cause a slight mark, it does not follow that a slight mark implies a severe injury, else the exception is made the rule. The inconsistency of the story of the plaintiff is generally so palpable that imposture is evident, but prejudice and unjust suspicion are often excited against those accused. Thus Taylor[652] states that “a strong suspicion was raised against the then Duke of Cumberland, in 1810, in reference to the death of Sellis, when a skilful examination of the wounds on the deceased would have shown that they might have been self-inflicted.” The same author also cites the case of M. Armand, a merchant of Montpelier, who at Aix in March, 1864, was tried for an alleged murderous assault on, or imputed murderous strangulation of, his servant. The excoriation on the back of the neck was so slight as to escape the observation of some medical men, and it was evidently self-inflicted, either accidentally or purposely, as the facts showed. The assertions of a number of medical men were taken by the court to support the servant’s story to the effect that his master had struck him a severe blow on the back of his neck, rendering him insensible for many hours from concussion of the brain. The evidence given chiefly by Tardieu for the defence showed the story of the complainant to be a fabrication, and the accused was justly acquitted.

Was a Wound Accidental?

In answering this question we must distinguish accidental wounds from those self-inflicted and those inflicted by another. These three classes comprise all wounds. In case of a trial for murder it may be alleged by the defence that the wound was caused by accident or that it was due to suicide from a fall, falls being a common class of accidental wounds. So we have to judge between accident on the one hand and homicide and suicide on the other hand. The question arises especially in cases where the injury causing death is one commonly due to accident.

As to the QUESTION BETWEEN ACCIDENTAL AND SUICIDAL WOUNDS, they are often easily distinguished, especially if the body has not been disturbed. In suicide there is clear evidence of design, and the circumstantial evidence helps to make the case clear. It may not always be possible to decide, however, as an accidental wound may sometimes resemble a suicidal or homicidal one. Accident is often shown by the nature of the wound. Thus it is rare for an accidental mortal wound to be caused by a knife or similar weapon held in the hand and forced into the body by a fall, the blow of an opening door, etc. But such exceptional cases have been reported. Incised and punctured wounds are, therefore, very rarely accidental, and most accidental wounds are contused wounds or contusions.

Again, accident is often shown by the situation of the wound, which should be on an exposed part of the body unless the accident is due to a fall from a height, when the wound may be almost anywhere. But such injuries are easily shown to be due to falls. The fall, of course, may be accidental, suicidal, or homicidal. Some wounds in exposed parts forbid accident on account of their nature, i.e., deep incised wounds of the throat. If the deceased has a life insurance, suicide is less probable, as the insurance is not paid in case of suicide. In fine, accidental wounds are distinguished from suicidal by—(1) Their nature; accidental wounds are almost always contused, suicidal very rarely so, only in cases of lunatics and delirious persons and where suicide is accomplished by a fall. (2) The situation of the wound or wounds indicates their origin. We have already studied the situation of suicidal wounds and have also seen that accidental wounds are only on exposed parts, except when the injury clearly indicates a fall from a height. The evidence from the direction of wounds rarely applies, as this is valuable only in incised and punctured wounds, which are seldom accidental. Both kinds of wounds are usually few in number except in case of a fall from a height or a crush, though sometimes suicidal wounds are multiple.

The evidence from weapons, if there be any, points strongly to suicide. The signs of a struggle are hardly consistent with either suicide or accident. The only case in which they might occur would be where a struggle occurred to prevent a suicide from throwing himself off a height or before a vehicle or railway train. In such a case accident would be excluded by the signs of a struggle, and the question would lie between homicide and suicide. The examination of the clothes of the deceased would furnish no evidence unless some letter or paper were found stating the purpose of committing suicide. Little or no evidence would be furnished by the position of the body when found in cases which might otherwise be doubtful. Organic lesions or other facts predisposing to suicide would furnish presumptive evidence against the wounds being accidental. Of all these various points the first, as to the nature of the wounds, is by itself the most valuable and conclusive. But this gives us no assistance in clearing up a case where it is doubtful whether a fall from a height or a crush by a vehicle or railway train was accidental or suicidal. Some of the other points mentioned may aid us in such a case, and also the fact that such injuries are far more often accidental than suicidal. But in these cases, also, certain circumstances may show that the fall was not the result of accident.

Accidental wounds are generally caused by a fall or a crush, and the fact of their accidental character is generally established by the circumstances of the event. Certain accidental wounds present characteristics which allow the true nature of the wounds to be determined. But in some cases a suspicion may arise and the question may be asked as to WHETHER THE WOUND WAS ACCIDENTAL OR HOMICIDAL. For instance, if a person receives fatal homicidal injuries, and just before or after death the body is thrown from a height or is run over and crushed, it may be hard to determine the murderous element among the many wounds. This is the case if the homicidal wounds were contusions or were caused by blunt instruments, but rarely, if ever so, if they are incised or punctured wounds or both. But even in the former instance, a close examination of the lesions and of the locality of the injury can often clear up the case. Thus in a case mentioned by Vibert,[653] as cited by Hofmann after Taylor, a woman was found dead at the foot of some stairs in a cave. She had died of a fracture of the skull and of the spine, produced by the fall. But about four or five feet above the level of the top step there was found on the wall the fresh marks of an arterial jet of blood. Examination showed a wound in the right temporal region which had opened the temporal artery, and it was therefore thought that the woman was wounded at the top of the stairway and then thrown down, which was afterward proved to be true. In another case, reported by M. Tourdes, a man knocked down and killed by an axe, which crushed his skull and caused the brain to exude, was placed in a road frequented at night by heavy wagons. The head was placed in the rut, but the coagulated blood and brain formed a puddle which did not appear on the wheels or their track, and no bloody furrow was caused by their passage. The same author mentions the case of a woman plainly strangulated by the hands and then thrown into the ditch of the fortifications of Paris.

It is especially with regard to fractures of the skull that the question often comes up as to the accidental or homicidal nature of the injury, as to whether it is due to a fall or a wound. Sometimes a depressed fracture may show the form of the instrument. An extensive comminuted fracture of the skull may indicate greater violence than would be received from a fall from the little height which the circumstances may allow. As to the slighter degrees of fracture, the disposition of the fracture itself often shows less than the form and site of the ecchymosis, the lesion of the scalp, and the place and position of the body when found. In such cases the traces of a struggle, the existence of other wounds, etc., may be of great importance. In distinguishing between homicide and accident, as in distinguishing between the latter and suicide, the most obscure and difficult cases are those where the injury has been caused by a fall from a height or by a crush.

This is illustrated by the case of Madame de Tourville, which is quoted by Taylor.[654] She was killed in July, 1876, by a fall from a precipice. Her husband, a lawyer, was accused of murder committed by pushing her over a precipice in the Stelvio Pass. The place where her dead body was found was at a considerable depth below, and the injury was chiefly in the head, which had been crushed by the fall. The body showed no evidence of intentional violence. The prisoner’s guilt was established on the following points: (1) The false and inconsistent statements made as to the occurrence; (2) the marks of the body having been dragged some distance so that a part of the dress was found, in a bloody condition, some way from the body; (3) there were marks of blood on the prisoner’s hands and clothing. After a long trial he was convicted, though the sentence was afterward commuted to imprisonment for life. Of course, as we have already stated, if a person is responsible for a fall he is also responsible for the results of the fall. This applies to many of the contused injuries and deaths from falls in prize-fights and drunken brawls.

We may sum up the points of evidence which help us to distinguish between an accidental and a homicidal injury much as we did when the question lay between accident and suicide. (1) The evidence from the nature of the wound is not quite so conclusive as when the question lies between suicide and accident. For contusions and contused wounds are far more often homicidal than suicidal, and accidental wounds are almost always of this class. If, however, the wounds are incised or punctured, this fact points almost certainly to homicide. (2) As to situation, a homicidal wound may be situated almost anywhere; an accidental wound, except in falls from a height, only on an exposed place. (3) The direction of the wound can seldom help us in the case of contused wounds which, practically, are the only ones in question, though it may possibly be incompatible with accident. (4) As to the number of wounds, homicidal wounds are far more apt to be multiple either in a small area or scattered in such a way that an accident could hardly account for them all. (5) A weapon may give evidence more often here than when suicide is in question, for a weapon may be used to inflict contused wounds which may resemble those received in a fall. The evidence furnished by a weapon or blood, hair, etc., on the weapon, etc., is strongly in favor of murder. (6) The evidence from a struggle is also more important because it is more often found. A struggle may occur in homicide, and only in homicide, as a rule, so that signs of a struggle are strong evidence of murder and against the idea of accident. (7) The examination of the clothes and body of the deceased may give valuable evidence, showing, as it may, signs of a struggle or other marks of an assailant and indicating murder. (8) Examination of the position and attitude of the body and of the spot where it lay and the ground around may furnish more or less proof of murder, as in the case quoted above. Thus the track of the murderer may be discovered or the body may have been interfered with and moved or robbed, all indicating homicide.

In any case, whether it is desired to distinguish accidental from suicidal or homicidal wounds, those cases present the most difficulty which result from falls from a height or crushes. But, as the case of Madame de Tourville shows, the above given and other circumstances may often show even then that the fall or the crush was not the result of accident.

Falls from a height may, therefore, be the result of suicide, homicide, or accident. The injuries are similar in all three cases. A fall of six to eight metres causes, as a rule, numerous lesions, and shows such a traumatism that the case usually excludes the possibility or, at least, the probability that the wounds resulted from blows. Sometimes, however, the gravity of the lesion is not proportional to the height of the fall. Thus Vibert[655] relates the case of a man, afterward employed for several years in the École de Médicine, who jumped from the top of the column of the Bastile, a height of fifty metres. He rebounded on to some canvas stretched at the foot of the monument, then fell to the ground, and was able to get up and walk away. Curiously enough, he killed himself later by jumping from the top of an omnibus in motion. In the case of falls from a height, it is especially true that with grave lesions internally the skin may be intact or only slightly ecchymosed or eroded, or the ecchymosis may be only deeply seated so as not to appear superficially. In the latter case, if life had continued the ecchymosis might have shown itself at some spot on the surface in a few days, but these falls from a height are fatal as a rule. In falls from a height, besides ecchymoses, which may occur where there are no other injuries or may fail where there are many injuries, the lesions consist of fractures of bones and ruptures of internal organs, with or without surface wounds. The fractures may be of a number of bones, and especially of those which first touched the ground, though the skull may be fractured at some part whether or not it was struck in the fall. These fractures are often comminuted, especially fractures of the skull and pelvis, and when the fall is from a great height. Ruptures of muscles may occur with the fractures.

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

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

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

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

Of more than One Injury which was the First Inflicted?

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

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

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

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

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