More rarely wounds of the great vessels are not immediately fatal. M. Tourdes is quoted by Vibert[623] as citing the case of a man who descended a flight of stairs and took several steps after division of the carotid artery; also of one who lived ten minutes after a bullet-wound of the inferior vena-cava.
Even wounds of the heart are not as speedily fatal as is commonly supposed, and often permit of a comparatively long survival.
Fischer[624] found only 104 cases of immediate death among 452 cases of wounds of the heart, and healing occurred in 50 cases among 401. Vibert[625] mentions two striking cases of long survival after wounds of the heart. A woman received a stab-wound which perforated the right ventricle, causing a wound one centimetre long. She did not die until twelve days later, when on autopsy there was found an enormous extravasation of blood in the left pleural cavity and pericardium. The second case, though one of bullet-wound, is equally applicable and instructive in this connection. A man received a bullet-wound which perforated the left ventricle, the bullet being found later in the pericardium. After being wounded he threw a lamp at his assassin which set fire to the room. He then went into the court-yard, drew some water, carried it back in a bucket, extinguished the fire, and then lay down on his bed and died.
In studying the wounds of different regions of the body, we may find many other mortal wounds which, though speedily fatal, leave the possibility of more or less activity before death. We see, therefore, that even in those wounds which are commonly supposed to be immediately fatal, even by many medical men where attention has not been called to the exceptions, such exceptional cases are not uncommon in which death is not immediate. Time and even strength may thus be allowed for more or less complicated activity. An alibi cannot, therefore, be allowed without question on the part of the medical expert, who must exercise great caution in expressing an opinion. The second question which may sometimes arise in connection with the last, but having little to do with the subject of this section, is the following:
How Long before Death had the Deceased Accomplished Certain Physiological Acts? For instance, how long after a meal did he die? This is hard to answer with precision, as digestion varies with the individual, and digestion begun during life may go on to a certain extent after death. We may be able to say if digestion has just commenced, is well advanced, or has terminated. What was eaten at the last meal may be learned by the naked eye, the microscope, the color of stomach contents and their odor. The state of the bladder and rectum is sometimes called in question. All the above facts have less bearing on the case than those in relation to the former question.
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.