Medical Jurisprudence, Forensic medicine and Toxicology. Vol. 1

by R. A. Witthaus; Tracy C. Becker

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.