Text-book of forensic medicine and toxicology

by R. J. M. Buchanan

INJURIES OF SPECIAL REGIONS

Injuries of the Head and Spine

These may be either external, affecting the integuments; or internal, affecting the brain substance, &c. In the latter, as a rule, there are signs of external violence. An ecchymosed tumour of the scalp may impart a sensation of crepitation to the finger, and may thus be mistaken for a fracture of the skull. The tumour may also pulsate if any large vessel be near it, giving one the idea that the pulsations are due to the movements of the brain. A large wound without fracture points to a more or less oblique blow, a small wound to direct violence. A blow with a heavy blunt weapon may make a clean incised wound, and often in these cases the seat of the bruise does not correspond with the centre of the cut. Dr. Ogston mentions the case of a young lady on whom a cricket ball inflicted a wound across the forehead, immediately above, and of the length of, one of the eyebrows, which he could not distinguish from a wound by a cutting instrument. All injuries to the head are more or less severe and dangerous, and great care is required in forming a prognosis with regard to the ultimate effect of an injury to the head. Inflammation of the brain does not, as a rule, supervene for about a week after the accident, and patients should not be considered safe from danger till two or three weeks after. Be it remembered also that in some cases the inflammatory action may proceed insidiously for some months without giving any distinct evidence of its presence till close upon a fatal termination. Scalp wounds are dangerous, from erysipelas, &c. They should be examined as to their extent, form, depth, and position.

Concussion of the brain may arise from falls on the nates, or from blows on the head. The face becomes pale, the pupils contracted, the pulse weak and small, the extremities cold, the respiration scarcely perceptible, and the sphincters relaxed. The tendency to death is from syncope. Reaction may then occur: the pulse quickens; the skin is hot and dry; there is great confusion of thought, from which the patient ultimately recovers; vomiting is present in most cases. Concussion often passes into compression, due to hæmorrhage from the lacerated cerebral vessels. Concussion and compression differ in this: in the former, the effects are instantaneous; in the latter, a short time elapses before the symptoms make their appearance; and these become more and more marked, whereas in concussion they gradually pass off. It is often a difficult matter to distinguish the effects of compression from those common to drunkenness or narcotic poisoning. The odour of the breath and the history of the case will assist in forming an opinion. Concussion of the brain may prove fatal without either fracture of the skull, effusion of blood within the cranium, or any other change being observed on dissection, death being caused by the shock given to the whole nervous organ, which, being unrelieved, speedily lapses into annihilation of function.

The symptoms of compression—a full, strong, and often irregular or slow pulse; normal heat of surface; muscular relaxation; dilatation, contraction, or inequality of the pupils; stertorous breathing, and paralysis—are not unfrequently retarded, and this consideration should render the opinion very guarded. Bryant records a case (Surgery, vol. i. p. 216) in which a man was thrown out of a gig on to his head. After a short period of insensibility he walked for half an hour, and then gradually again became insensible, and ultimately died. A large clot was found over the left cerebral hemisphere, the blood evidently having flowed from the middle meningeal artery. The short period of insensibility probably arrested the flow of blood from the artery, which recurred on the sufferer walking. The structural form of the cranium may have much to do with the danger to be expected from blows—some skulls being thinner than others—and in a few rare instances the fontanelles may not have become ossified during life.

The possibility of an unhealthy condition—atheroma—of the arteries of the brain, or of disease of the heart, must be taken into consideration before venturing an opinion as to the tendency or ultimate cause of death.

It may be stated that the patient died of apoplexy. Apoplexy is a disease of old age, and seldom occurs in the young, although it is just possible it might occur. The arteries should, in every case, be examined for the presence or absence of disease. When violence is used, the effusion of blood is, as a general rule, on the surface of the brain; but two cases are given by Dr. Abercrombie of spontaneous bursting of a blood-vessel within the head, followed by effusion of blood upon the surface of the brain. “An external injury, coexisting with an extravasation of blood into the cerebral substance, does not necessarily imply cause and effect. The previous condition of the brain, or the outpouring of blood from diseased vessels, may, in fact, have been the cause of the accident” (Hewett). When, however, blood is found effused on the surface of the brain, especially between the dura mater and the skull, either beneath or opposite to an external wound, we may reasonably infer that the hæmorrhage is due to a direct blow. Hæmorrhage so severe as to produce dangerous pressure on the brain, as a rule, comes from a rupture of the middle meningeal artery.

Husband relates a case in the Edinburgh Infirmary in which there was a large clot over the left frontal lobes, accompanied with aphasia and right hemiplegia, with no rupture of the middle meningeal artery, or any signs of external injury. The man had just left the cells on a charge of drunkenness. The source of the hæmorrhage was not clearly made out, but it seemed to be due to the rupture of an artery in a pachy-meningitic patch. Blood may be found in the cavity of the arachnoid in the great majority of severe injuries to the head, and even in trifling cases where least expected. Rupture of the venous sinuses may take place without fracture of the skull. I have met with this in a fatality during a boxing match; a large effusion over the brain, and especially in the temperosphenoidal fossa, taking place from rupture of the left lateral sinus at the junction with the superior petrosal; there was also a vertical hæmorrhage into the pons. The effused blood may, after a time, become changed, and form a false membrane on the parietal arachnoid, seldom on the visceral surface. Blood cysts may even be formed, in the course of time, having all the appearances of a serous membrane. The blood may spread to parts remote from the seat of injury, and the extravasation does not always occur at the exact spot of the application of the blow, but often at a spot directly opposite. Two extravasations may be the result of one blow.

Fits of passion have been advanced as a cause of apoplexy, but this cause is rare. Fracture of the cranial bones may be due to counter-stroke—contre-coup—or to falls on the nates, &c. Fractures of the skull are divided into two groups (Körber): (1) those produced by bilateral compression of the skull; and (2) those resulting from violence applied to one side only. In both groups the line of fracture runs parallel with the axis of compression. Fissures of the base from bilateral compression of the skull are always transverse. Punctured wounds of the cranium are always dangerous, but the patient may survive many days. Dr. Bigelow, Professor of Surgery in Harvard University, U.S.A., relates a case in which an iron bar, weighing thirteen and a quarter pounds, three feet seven inches in length, and one inch thick, was driven through the head, followed by recovery, the patient only losing the use of the injured eye.

Contusion and laceration of the brain may occur from injuries to the head, either at the seat of injury or by contre-coup at some other part. The contused area may exhibit local extravasation of blood, or in the diffuse form, extravasations may be multiple and also on the surface. The symptoms are those of cerebral irritation, coma, or restlessness, paralysis, tonic or clonic spasms. In slight cases recovery may follow, in others some degree of loss of mentality and paralysis may remain.

There is great danger of inflammatory complications. I have met with a case of severe comminuted fracture of the skull with laceration of the brain, the latter substance appearing on the surface of the scalp, with loss of brain substance, in a boy who made a complete recovery without any loss of intelligence or power following the injury.

For the detection of brain substance on weapons the microscope is alone reliable, and then only the cellular portion of the brain is of any use.

Injuries to the spinal cord may cause immediate death; cases, however, occur of life being prolonged for some days, or even longer, after injury to the cord. The symptoms are progressive paraplegia and paralysis of the bladder and rectum, ending in death. Bedsores and septic infection of the bladder and kidneys are complications which add to the gravity of the condition. Spicula of bone in the cord, dislocation of the vertebræ, or extravasation of blood in the membranes of the cord, may be found after death. The presence of blood upon the spinal cord is not necessarily the result of violence, as hæmorrhage may take place spontaneously. The spine should be examined in all fatal cases of supposed injury. Concussion of the spinal cord is a fertile source of differences of opinion in railway cases. In no case should a hasty decision be given as to the probable future result to the patient from the injury.

Wounds of the face are not generally dangerous, unless they penetrate the brain. There is always the possibility of injury to the eye causing detachment of the retina, or inflammation leading to blindness. Punctured wounds in the neighbourhood of the orbit may become septic and lead to secondary meningitis.

Wounds of the Throat and Chest

Wounds of the throat are more or less dangerous, due to the possibility of severe hæmorrhage, emphysema, and bronchitis.

Wounds of the chest are dangerous, on account of the amount of the hæmorrhage which may take place, and the importance of the organs which may be injured. Death may result more from the mechanical action of the blood effused than from the depressing effect of the quantity evacuated. Penetrating wounds of the thorax injuring the lungs cause emphysema, pneumo-, pyo-, or hæmothorax, any of which may prove fatal; pleurisy and pneumonia may occur. A fracture of the ribs may give rise to injury of the lung substance or to inflammation of its coverings. Laceration of the lungs may take place without fracture of the ribs. The ventricles of the heart may be pierced, and yet life may be prolonged for one or two months, permitting of considerable locomotion during that period (Briand et Chaudé, Med. Leg., vol. i. p. 511). Wounds of the heart, however, are, as a rule, rapidly fatal. Rupture of valves may follow blows on the chest, and rupture of the heart may occur from crushes or violent blows. Rupture of the heart has taken place during violent exertion, and this is more likely to occur when the muscle is diseased. It is often difficult to make out the direction of the wound, as the lungs change their position during respiration.

Injuries of the Abdomen

Wounds of the abdomen, penetrating the intestines, although not necessarily fatal, may cause death from peritonitis, due to the escape of the intestinal fluids. Rupture of the intestine may follow blows or crushing; it is generally fatal from peritonitis unless early surgical treatment is carried out. Hernia may also follow wounds of the abdomen. Rupture of the liver is not of infrequent occurrence, and may occur without any external signs of the injury. The rupture is, as a rule, longitudinal, transverse lacerations being rare. It is often followed by pneumonia if not rapidly fatal. The cœliac plexus may be much damaged by a blow or kick on the stomach, especially if this organ be distended with food, and death may result without leaving any trace of the injury externally or internally. The bladder may be ruptured and death result from extravasated urine. Rupture of the bladder may occur from fracture of the pelvis without sign of external injury. Rupture of the kidney may be recovered from if slight, but when severe is fatal. Rupture of the spleen is usually fatal, and is more likely to occur when enlarged from any cause. Coagulable lymph, the effect of a wound of a serous membrane, may be thrown out in twelve hours or less.

Injuries to the abdomen may cause death by—

1. Shock; without lesion of the internal organs, inflammation, or external signs of injury.

2. Hæmorrhage.

3. Lesion of the internal organs, but without inflammation. Death in these cases seems to be due to depression of the nervous system due to the intense pain following these injuries.

4. By inflammation without lesion of internal organs.

5. Inflammation from lesion of internal organs.

6. Destruction of the natural functions of the organs, and, as a result, malnutrition of the body.

Except in the first case, when death is instantaneous, wounds of the abdomen are not as a rule immediately fatal.

Wounds of the genital organs of the female may cause fatal hæmorrhage, which takes place from the plexus of veins which, in these parts, are devoid of valves. A kick from behind whilst the woman is stooping or kneeling may rupture the labial vessels and death supervene.

Blows and kicks upon the abdomen do not often injure the non-gravid uterus, but during gestation may produce abortion and hæmorrhage. If the pregnancy be advanced the uterus may be ruptured or the placenta separated. Penetrating wounds either through the abdominal wall, or per vaginam in the attempt to procure abortion, cause hæmorrhage and peritonitis with septic infection.

FRACTURES OF BONES

Unless they implicate some special structure, such as the brain and medulla, simple fractures are not considered dangerous to life. When compound, they may be complicated with hæmorrhage and infective processes.

Certain pathological conditions favour the spontaneous fracture of bones, or this occurrence with such slight violence as would not cause fracture in the normal may take place.

In old people bones are more liable to fracture from their brittle condition. Liability to easy fracture occurs in the insane, in nervous lesions as locomotor ataxia and general paralysis of the insane, when the bones are the seat of new growths, in fragillitas ossium, osteopsathyrosis; in the latter disease I have seen the femur fracture by the weight of the leg while resting the foot on a cushion. The liability to fracture depends upon the proportion of organic and inorganic constituents. In disease, the latter may be reduced and predispose to fracture; in the young, the bones are more liable to greenstick or incomplete fracture; and in the old, from excess of inorganic constituents causing brittleness.

A medical man may be required to express an opinion as to whether or not fractures are the result of direct violence, and especially when allegations have been made against attendants on the senile or insane.

The previous predisposing pathological conditions must always be taken into account, and also the amount, if any, of repair that has followed in relation to the time the alleged violence took place.

As the condition of a fracture of the bone of a limb may become a question of considerable importance in medico-legal investigations, the following brief account of the process of repair in fractures is given:

From the First to the Third Day.—The period of inflammation and exudation. Ordinary signs of inflammation and laceration of the parts. Blood will be found extravasated round the fracture, also in the medullary canal mixed up with the fat.

From the Third to the Fourteenth Day.—Gradual subsidence of inflammatory action and growth of the soft provisional callus from the periosteum and surrounding structures, and internally in the medulla, forming a fusiform mass holding the broken ends of the bones together with some degree of firmness. This becomes firmer and almost cartilaginous in density. When the bones are kept immovable, or are impacted, the provisional callus may not be formed. In the case of the ribs the provisional callus is always formed, and Dupuytren‘s “ring of provisional callus” is constant. This may also occur in fractures of the clavicle.

From the Fourteenth Day to the Fifth Week.—Ossification of the provisional callus. The bone is first soft and spongy till the conversion of the soft callus is complete.

From the Fifth Week to some Months after the Injury.—Complete bony union of the fracture and absorption of the provisional callus.

Although the blood clot completely disappears from the immediate neighbourhood of the fracture at an early period, yet layers of dark coagulum may often be found beneath the superficial fascia for four weeks or more after the accident (Erichsen).

It may be of importance to remember this in medico-legal inquiries. The presence or absence of the signs of vital reaction will help to distinguish fractures caused before or after death.

A fracture taking place immediately after death cannot be distinguished from one immediately before death, but if a few hours after death, the differences are easily recognised, blood is not effused round the ends of the bones unless a large vessel be torn.

In the examination of bones for fracture in the living it is the duty of the examiner to have an X-ray plate taken of the injured bone, especially if the seat of injury is in close vicinity to a joint.

Previous fractures are easily recognisable after death even when the bone does not show manifestations externally; on longitudinal section the seat of fracture is rendered evident.

Is the Wound Suicidal, Homicidal,
or Accidental?

An attempt is made to answer this question by a consideration of the wounds in reference to their position, nature, extent, and direction.

In reference to their position it has to be borne in mind that one person may wound any part of the body of another, but that to the suicide certain parts only are accessible, and they have a predilection for wounding themselves in favoured regions; the front of the body and vital parts are chosen by the suicide, while wounds on the back point to homicide. Suicidal wounds on the head are generally in front or lateral, and on the neck in front or to one side, in cutting the throat. Accidental head injuries are more often on the vertex, and when there may be no history of a fall on the occiput, wounds in this situation indicate homicide.

Suicides may choose unusual regions, such as cutting of a large vessel as the femoral artery in Scarpa‘s triangle, or by a limited incision, the carotid in the neck, the injury may be about the genitals, and the penis and scrotum have been amputated.

Accidental injuries may occur on any part of the body, but most commonly on exposed parts.

The nature and extent of the wounds does not afford much assistance; with the exception of contused wounds which are usually homicidal or accidental, any other form of wound, particularly incised or punctured wounds, may be suicidal or homicidal, and with regard to gunshot wounds, much depends upon their position and extent. As a rule, the suicide does not make several wounds, and the homicide may not only inflict several but of a greater severity than are necessary to carry out his purpose.

Suicides, especially when insane, may wound themselves severely and cause great injuries by leaping from buildings or similar high positions. In some cases suicides have inflicted several and varied wounds on their bodies.

The direction of suicidal wounds, when the person is right-handed, is generally from above downwards and inwards on the chest, and on the left side. An upward direction points rather to homicide.

Cut throat wounds, when suicidal and inflicted by the right hand, are generally oblique from left to right, beginning higher up than they end. They generally cross the thyroid cartilage, and the larger vessels may escape; if made below the thyroid cartilage they are generally smaller and horizontal. The skin is the last structure divided, and there may be several so-called “tentative cuts.” It has been held that when the large vessels are cut the suicide stops, but this is incorrect, as in some cases the wound has reached the spine and the vessels been quite severed. Suicides may try to decapitate themselves from behind, and failing this stab themselves. A homicidal cut throat wound, when made from the front with the right hand, commences on the right side and is carried to the left; they are often deep incisions to the vertebræ and the tissues “undercut” at the ends. A homicidal cut throat wound when made from behind the victim resembles a suicidal one. When wounds are present on the forearms, hands, and fingers, and if there are injuries on other parts of the body also, the inference would be that the hand wounds were received in guarding the throat or other efforts at defence from a homicidal attack.

Wounds produced by Firearms.—To distinguish between suicidal, homicidal, and accidental wounds is far from easy. If the weapon be held hard up or close to the body, as in suicide, the skin and hair would be scorched and blackened, as would probably the hand that held the weapon, but this has not occurred in every case. The grasping of the firearm by the hand in cadaveric spasm is certain evidence of suicide, as this cannot be simulated by an assailant placing the weapon in the hand after death. Full investigation should be made by noting the bullet track and surrounding objects which may have been grazed in its course, in order to form a probable estimate of the direction from whence it came. Bullet wounds in the back are usually homicidal.

Duties of a Medical Man When Called
to Examine a Wounded Person

The surgeon should at once visit the wounded party, and proceed to examine the injury, for if this be done before swelling occurs, he will be better able to form an opinion of its nature, extent, and severity. If the wound has been dressed, he should, if possible, obtain the attendance of the person who applied the dressings, and who would be able to describe their nature, and the dangers to be avoided in their removal, should that be deemed necessary. In no case should a surgeon remove the dressings applied by a professional brother without his presence and assistance. The condition of the injured party should be carefully noted, and a minute description of the wound written down at the time. The statements of the bystanders are also useful and should be noted. The procedure in the examination of the dead body has been previously described ([p. 60]).

An important question here arises. Have the wounds found on the body been produced during life or after death? The answer is beset with difficulties, and considerable caution will be necessary, but tables will be given under the different kinds of wounds to assist the diagnosis. Signs of vital reaction are important, as showing the ante-mortem infliction of the wound; but these may, to some extent, be removed by the action of water, as in cases where the body is found in a pond. Under these circumstances the evident signs of drowning—water in the stomach, &c.—will assist the diagnosis. The presence of putrefaction also greatly obscures the diagnosis. The presence of coagulated blood between the edges of the wound is not a trustworthy indication of the ante-mortem infliction of the wound, as experiment has shown that as long as the body remains warm coagulation may take place. Coagulation even in contused wounds, effected before death, may be retarded from various unknown causes—disease, e.g. scurvy; mode of death, e.g. asphyxia. The amount of hæmorrhage on or around the body is, other things being equal, a safe criterion as to the time when the wound was inflicted; if in considerable amount, arterial blood points to ante-mortem injury; the presence of venous points blood to post-mortem injury.

Care should be taken to record and photograph the body in position where found, and its relation to surrounding objects. Careful note should be made of the surroundings and the character and presence of any blood-stains, footprints, &c. The question may have to be considered as to whether the body is in the place it was when the wounds were inflicted. Blood in any quantity in one place, and the body found in another so seriously injured that locomotion would be impossible, point to the body having been removed.

Signs of a struggle, if any, should be recorded. If a weapon be found near to the body, its position should be noted, and if in the hand, the firmness of the grasp—cadaveric spasm—should be recorded. All clothing should be carefully examined, and the relation of cuts and body wounds noted. All blood-stains on the clothing should be examined and described.

Multiple bullet wounds denote homicide, but suicides have been known to inflict more than one wound. It is strong evidence of suicide if the gun or pistol has burst by the explosion, as suicides have a predilection for overloading the weapon employed.