In the second case, the injury was also a kick in the stomach and the man died almost immediately. Absolutely no lesion was found on autopsy. Both were in full digestion.
König[606] says: “A number of severe contusions of the belly run a rapidly fatal course without the autopsy showing any definite anatomical lesion of the viscera.” He also adds that the less severe cases at first often show very profound shock, which is out of proportion to the force of the injury. The cause of death has been explained, like that of sudden death from a blow on the larynx, by the theory of inhibition. These cases are often illustrated experimentally on frogs, where the same result is obtained under similar conditions. Such cases are the more remarkable from the fact that the fatal blow may cause no ecchymosis or other mark of injury to appear on the abdominal walls.
Blows on the head may produce a variety of results besides that of the contusion itself. In fact, death itself may result though the marks of contusion are very slight or even imperceptible. Intracranial hemorrhage, laceration with ecchymosis of the brain, on the same or opposite side to the injury, and concussion of the brain may result. Of these only concussion will be considered now.
Concussion has been defined as a shock communicated to an organ by a blow or fall on another part of the body, which may or may not be remote, and without producing a material or appreciable lesion. According to Lutaud,[607] English pathologists understand by it a temporary or permanent nervous exhaustion resulting from a sudden or excessive expense of nervous energy. Its effect is observed in the function of an organ and especially in the brain. Concussion of the brain causes stupidity, loss of consciousness, amnesia, coma. The intracranial lesion most often associated with concussion is ecchymosis and laceration on the surface of the brain, but there may be no lesion visible even if the case is a fatal one. Fatal concussion has been observed where the marks of external violence were very slight or even failed entirely, as illustrated by the two following cases cited by Vibert:[608]
Vibert made an autopsy on a man who had been struck by a pitchfork, one of the teeth of which struck behind the ear, the other two in the face, only producing slight skin wounds. The man immediately lost consciousness and died in two days in coma. No lesion whatever was found within the skull, and only three slight ones externally.
He observed another case where the man fell three or four metres into an excavation, landing on his feet, and died in a short time. On autopsy only slight erosions and no intracranial or extracranial lesions were found.
This case belongs to a rare class where the blow is transmitted through the spinal column without sign of injury externally or internally to the head.
The following case cited by Vibert is even more remarkable in the production of the severe though not fatal concussion: An officer was riding at full speed on horseback, when his horse suddenly stopped short. By great exertion the officer clung to the horse, but immediately lost consciousness. His fall from the horse was broken by those about him, and the concussion he received was not due to the fall, but to the shock of stopping suddenly when his momentum was great.
As a rule, however, the diagnosis of concussion, especially if it is severe enough to be fatal, is easily made by the marks of external violence with or without intracranial lesions. The effects of concussion may be transient and leave no trace, but, on the other hand, they may be prolonged and severe, i.e., paralysis, aphasia, loss of memory, imbecility, etc. The medical examiner should be on his guard against simulation in respect to these prolonged effects of concussions. One of the most frequent consequences of concussion is temporary amnesia, which ordinarily succeeds immediately after the injury, but sometimes develops more slowly. The following curious case is quoted from Lutaud as cited by Brouardel:
A woman in getting out of a train at Versailles, where she had gone to attend the funeral of a relative, was struck by the door of the compartment. She fell, but did not lose consciousness, and picked herself up, but forgot what she had come for.