Text-book of forensic medicine and toxicology

by R. J. M. Buchanan

These may be either external, affecting the integuments; or internal, affecting the brain substance, &c. In the latter, as a rule, there are signs of external violence. An ecchymosed tumour of the scalp may impart a sensation of crepitation to the finger, and may thus be mistaken for a fracture of the skull. The tumour may also pulsate if any large vessel be near it, giving one the idea that the pulsations are due to the movements of the brain. A large wound without fracture points to a more or less oblique blow, a small wound to direct violence. A blow with a heavy blunt weapon may make a clean incised wound, and often in these cases the seat of the bruise does not correspond with the centre of the cut. Dr. Ogston mentions the case of a young lady on whom a cricket ball inflicted a wound across the forehead, immediately above, and of the length of, one of the eyebrows, which he could not distinguish from a wound by a cutting instrument. All injuries to the head are more or less severe and dangerous, and great care is required in forming a prognosis with regard to the ultimate effect of an injury to the head. Inflammation of the brain does not, as a rule, supervene for about a week after the accident, and patients should not be considered safe from danger till two or three weeks after. Be it remembered also that in some cases the inflammatory action may proceed insidiously for some months without giving any distinct evidence of its presence till close upon a fatal termination. Scalp wounds are dangerous, from erysipelas, &c. They should be examined as to their extent, form, depth, and position.

Concussion of the brain may arise from falls on the nates, or from blows on the head. The face becomes pale, the pupils contracted, the pulse weak and small, the extremities cold, the respiration scarcely perceptible, and the sphincters relaxed. The tendency to death is from syncope. Reaction may then occur: the pulse quickens; the skin is hot and dry; there is great confusion of thought, from which the patient ultimately recovers; vomiting is present in most cases. Concussion often passes into compression, due to hæmorrhage from the lacerated cerebral vessels. Concussion and compression differ in this: in the former, the effects are instantaneous; in the latter, a short time elapses before the symptoms make their appearance; and these become more and more marked, whereas in concussion they gradually pass off. It is often a difficult matter to distinguish the effects of compression from those common to drunkenness or narcotic poisoning. The odour of the breath and the history of the case will assist in forming an opinion. Concussion of the brain may prove fatal without either fracture of the skull, effusion of blood within the cranium, or any other change being observed on dissection, death being caused by the shock given to the whole nervous organ, which, being unrelieved, speedily lapses into annihilation of function.

The symptoms of compression—a full, strong, and often irregular or slow pulse; normal heat of surface; muscular relaxation; dilatation, contraction, or inequality of the pupils; stertorous breathing, and paralysis—are not unfrequently retarded, and this consideration should render the opinion very guarded. Bryant records a case (Surgery, vol. i. p. 216) in which a man was thrown out of a gig on to his head. After a short period of insensibility he walked for half an hour, and then gradually again became insensible, and ultimately died. A large clot was found over the left cerebral hemisphere, the blood evidently having flowed from the middle meningeal artery. The short period of insensibility probably arrested the flow of blood from the artery, which recurred on the sufferer walking. The structural form of the cranium may have much to do with the danger to be expected from blows—some skulls being thinner than others—and in a few rare instances the fontanelles may not have become ossified during life.

The possibility of an unhealthy condition—atheroma—of the arteries of the brain, or of disease of the heart, must be taken into consideration before venturing an opinion as to the tendency or ultimate cause of death.

It may be stated that the patient died of apoplexy. Apoplexy is a disease of old age, and seldom occurs in the young, although it is just possible it might occur. The arteries should, in every case, be examined for the presence or absence of disease. When violence is used, the effusion of blood is, as a general rule, on the surface of the brain; but two cases are given by Dr. Abercrombie of spontaneous bursting of a blood-vessel within the head, followed by effusion of blood upon the surface of the brain. “An external injury, coexisting with an extravasation of blood into the cerebral substance, does not necessarily imply cause and effect. The previous condition of the brain, or the outpouring of blood from diseased vessels, may, in fact, have been the cause of the accident” (Hewett). When, however, blood is found effused on the surface of the brain, especially between the dura mater and the skull, either beneath or opposite to an external wound, we may reasonably infer that the hæmorrhage is due to a direct blow. Hæmorrhage so severe as to produce dangerous pressure on the brain, as a rule, comes from a rupture of the middle meningeal artery.

Husband relates a case in the Edinburgh Infirmary in which there was a large clot over the left frontal lobes, accompanied with aphasia and right hemiplegia, with no rupture of the middle meningeal artery, or any signs of external injury. The man had just left the cells on a charge of drunkenness. The source of the hæmorrhage was not clearly made out, but it seemed to be due to the rupture of an artery in a pachy-meningitic patch. Blood may be found in the cavity of the arachnoid in the great majority of severe injuries to the head, and even in trifling cases where least expected. Rupture of the venous sinuses may take place without fracture of the skull. I have met with this in a fatality during a boxing match; a large effusion over the brain, and especially in the temperosphenoidal fossa, taking place from rupture of the left lateral sinus at the junction with the superior petrosal; there was also a vertical hæmorrhage into the pons. The effused blood may, after a time, become changed, and form a false membrane on the parietal arachnoid, seldom on the visceral surface. Blood cysts may even be formed, in the course of time, having all the appearances of a serous membrane. The blood may spread to parts remote from the seat of injury, and the extravasation does not always occur at the exact spot of the application of the blow, but often at a spot directly opposite. Two extravasations may be the result of one blow.

Fits of passion have been advanced as a cause of apoplexy, but this cause is rare. Fracture of the cranial bones may be due to counter-stroke—contre-coup—or to falls on the nates, &c. Fractures of the skull are divided into two groups (Körber): (1) those produced by bilateral compression of the skull; and (2) those resulting from violence applied to one side only. In both groups the line of fracture runs parallel with the axis of compression. Fissures of the base from bilateral compression of the skull are always transverse. Punctured wounds of the cranium are always dangerous, but the patient may survive many days. Dr. Bigelow, Professor of Surgery in Harvard University, U.S.A., relates a case in which an iron bar, weighing thirteen and a quarter pounds, three feet seven inches in length, and one inch thick, was driven through the head, followed by recovery, the patient only losing the use of the injured eye.

Contusion and laceration of the brain may occur from injuries to the head, either at the seat of injury or by contre-coup at some other part. The contused area may exhibit local extravasation of blood, or in the diffuse form, extravasations may be multiple and also on the surface. The symptoms are those of cerebral irritation, coma, or restlessness, paralysis, tonic or clonic spasms. In slight cases recovery may follow, in others some degree of loss of mentality and paralysis may remain.

There is great danger of inflammatory complications. I have met with a case of severe comminuted fracture of the skull with laceration of the brain, the latter substance appearing on the surface of the scalp, with loss of brain substance, in a boy who made a complete recovery without any loss of intelligence or power following the injury.

For the detection of brain substance on weapons the microscope is alone reliable, and then only the cellular portion of the brain is of any use.