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.