Medical Jurisprudence, Forensic medicine and Toxicology. Vol. 1

by R. A. Witthaus; Tracy C. Becker

Wounds of the brain vary very widely in their immediate results according to the part of the brain injured. Thus sometimes a slight wound of the brain may be instantly fatal and often a severe wound in another part is not so. Extensive wounds may occur especially in the frontal lobes with remarkably slight disturbance. If a person with a wound of the brain survives the first effects of the injury the danger of inflammation remains. This danger may not be removed for a long time, for the inflammation may develop very slowly, not showing itself for from three to ten weeks or even later. Thus Taylor[665] cites the case of a child who was accidentally shot through the brain. The symptoms of inflammation did not appear until the twenty-sixth day and death occurred on the twenty-ninth day.

Fig. 19.—Diagramatic Representation of the Skull and Membranes of the Brain for Exhibition in Court. a, Skull with outer and inner tables and diploë; b, dura mater; c, arachnoid membrane; d, pia mater.

Wounds of the face heal remarkably well on account of its great vascularity. If severe they may leave great deformity or disfigurement, which may be the ground of a civil suit and thus require the testimony of a medical expert. If the wound involves the orbit or its contents it may be more serious, either from a fracture of the thin upper or inner wall of the orbit, separating it from the brain, or from extension of a secondary inflammation of the contents of the orbit to the brain. Wounds of the eyebrow may cause supra-orbital neuralgia or amaurosis from paralysis of the upper lid. Some fractures of the nose, especially those due to severe injury near the root of the nose, may be more serious than they appear. For in such cases, of which the writer has seen several, the fracture is not confined to the nose, but involves also the ethmoid bone and its cribriform plate forming part of the base of the skull. In such a case a fatal meningitis is a common result.

Fig. 20.—Double Fracture of the Thyroid and Cricoid Cartilages of the Larynx, from the Blow of a Flat-Iron.

Wounds of the neck are very rarely accidental, more often homicidal, but most often suicidal. In nature they are most often incised wounds. As we have already seen, the kind and condition of the weapon used is often indicated by the character of the wound. We have also seen that in many cases a suicidal wound of the neck can be distinguished from a homicidal one with more or less probability or even certainty. Wounds of the neck are often dangerous, and they may be rapidly fatal if they divide the main vessels, especially the carotid arteries. Wounds of the larynx, trachea, and œsophagus are grave and often fatal from entrance of blood into the air-passages or from subsequent œdema or inflammation occluding the air-passages. Wounds of the sympathetic and pneumogastric nerves may be fatal, and those of the recurrent laryngeal nerves cause aphonia. The situation of the average suicidal or homicidal cut-throat wound is in front, generally across the thyro-hyoid membrane, sometimes dividing the cricoid-thyroid membrane, and not at the side of the neck where the great vessels lie and would be more easily divided. The force is expended, as a rule, before the great vessels are reached. The epiglottis may be cut or detached and the incision may even reach the posterior wall of the pharynx, but the majority of the suicidal cases recover with proper treatment. The homicidal cases are more often fatal from division of the great vessels, though, as already stated, in either class of cases a fatal result may occur if the air-passages are opened from the entrance of blood into them and the consequent asphyxia.

Contusions of the neck may be so severe as to cause unconsciousness or even death. The latter may be due to a reflex inhibitory action, as in cases of death from a blow upon the pit of the stomach. As a result of such contusions we may have a fracture of the larynx usually confined to the thyroid and cricoid cartilages (see Fig. 20). This may be followed by hemorrhage from the larynx, some of which may pass down into the trachea and threaten death from asphyxia. Later emphysema often develops throughout the tissues of the neck, and there is great danger of œdema of the larynx. The prognosis is serious unless tracheotomy is performed early or the case is closely watched. It is most serious where the cricoid cartilage had been fractured, as this requires a greater degree of violence. Whereas incised wounds of the throat are most often suicidal, contusions are most often accidental or inflicted by another. Among the latter class of injuries may be included the so-called garroting, by which a person is seized violently around the throat, usually from behind, and generally with a view to strangle and rob. In such cases the larynx or trachea may be injured in the same way as by a contusing blow.

WOUNDS AND INJURIES OF THE SPINE AND SPINAL CORD.

Injuries of the spine resemble more or less closely those of the head. Fractures of the spine generally occur in combination with dislocation, as fracture-dislocation. Thus displacement is generally present and causes a fatal compression or crushing of the cord. When the cord has once been crushed at the site of the displacement of the fracture-dislocation there is no hope of its ever healing. Therefore the lower end of the cord is never again in functional connection with the brain. These injuries are more rapidly fatal the higher up they are. If the injury is above the fourth cervical vertebra death is nearly immediate, for then even diaphragmatic breathing is impossible, and the injured person dies of asphyxia. Fracture of the odontoid process of the axis, which regularly occurs in hanging, may occur from falls on the head, etc., and is not always immediately fatal. Thus in one case[666] the person lived fifteen months and in another case sixteen months. In the latter case the fracture was due to the patient turning in bed while his head was pressed on the pillow. In some cases it may be questioned how far this injury may result from disease of the bones or ligaments. Therefore a careful examination of these parts should be made after death, which will usually enable us to answer this question, which may be brought up by the defence. It is hardly necessary for our purpose to enumerate the symptoms of fracture-dislocation of the spine. Of course the patients are almost always unable to walk and so are bed-ridden. A marked feature of fracture-dislocation of the spine is the length of time intervening between the injury and the fatal termination, and yet the injury is wholly responsible for the death of the injured person. This delay may last for months or even for years with careful treatment. But sooner or later the case generally ends fatally, though not necessarily so. Where the cord has been entirely crushed the result is almost always fatal; where the cord is not so injured recovery may and often does occur. According to Lutaud, fractures of the spine are sometimes followed by secondary paralysis coming on after healing of the fracture. At the outset we can seldom give a definite prognosis, which can only be given after watching the developments of the case. The prognosis is more favorable in fracture of the arches alone or when the injury is in the lower part of the spine and not very severe. The commonest cause of fracture-dislocation of the spine is forced flexion of the spinal column. Injuries to the spine are generally the result of falls or blows on the spine, especially in its lower part. Lutaud[667] states that after forced flexion of the spine without fracture paraplegia may sometimes occur, which is attributed to forced elongation of the cord. This paraplegia, which may seem to be grave, is completely recovered from as a rule.