Chapter XXIX: Section 6: ,216, same as 303, N. Y. P. C (10)

In other respects, however, these wounds differ from suicidal wounds. Thus they are not usually situated over a “mortal” spot, and they are often numerous and _scattered_, sometimes parallel and sometimes not. The wounds in the dress do not correspond even as often as in suicide. In comparing cuts in clothing with those on the body, it is important to find what articles were worn at the time the assault was alleged to have taken place, and to make sure that the clothes examined were those worn or alleged to have been worn. It may not be necessary that the clothes examined should have been really worn, for if they were alleged to have been worn and were not, the examination of them will almost always show the deception or the self-inflicted nature of the wounds. Then take careful note of the position, direction, form, and size of the cut and the apparent sharpness of the weapon in the several layers, and see if they correspond with one another and with the wounds on the body in those various particulars. In imputed wounds the clothes are generally cut when off the body and can seldom be done so as to deceive a careful examiner. Several wounds cannot exist in the same region of the body without some being bloody and showing the marks of it on the clothes. Even a single wound of the clothes generally shows blood on the inner surface if there is a corresponding wound of the body underneath. In simulated and imputed injuries the blood-stain may be on the outside of the clothing instead of on the inside, showing that it was artificial and not natural. An impostor may either do too much or too little, and the medical witness should be on guard against both alternatives. Taylor[651] mentions a case which occurred in London some time ago, in which there were _two_ cuts in the shirt near together exactly alike in size, form, and direction, making it evident that the weapon had gone through a fold of the shirt. This proved that the shirt could not have been worn at the time it was cut, for if the shirt was folded while on the body the weapon must have gone through the fold and then through another layer of shirt, making three cuts instead of two, or five instead of four, before it could have reached the body. This and other facts made self-infliction of the slight wound on the chest probable. The same author cites another case showing the imperfect manner in which the cuts in the clothes are made in imputed wounds, the clothes being off the body at the time. The case occurred in Nottingham in 1872, the accused being charged with wounding the plaintiff on the highway by stabbing him in the arm, though there was no robbery or other motive for the act. The coat and shirt sleeve were found cut, but there was no corresponding cut in the lining of the coat sleeve. The charge was clearly false, and was trumped up by the youth who was the plaintiff because he wished to leave the place where he had been sent for private study.

In examining a case where the self-inflicted nature of imputed wounds is in question, the following are some of the many points to keep in mind in the examination and to be ascertained by the examination: (1) The relative position of the plaintiff and the assailant at the time of the alleged attack. This can be compared with the position as stated by the plaintiff or other witnesses. (2) The situation, direction, depth, nature, and number of the wounds. (3) The situation and direction of blood-marks or wounds on the dress or person of either or both. (4) The marks of blood and the quantity of it at the spot of the alleged struggle. (5) The signs of a struggle and the various other points of circumstantial evidence gone over in considering suicidal and homicidal wounds.

Though a severe blow may cause a slight mark, it does not follow that a slight mark implies a severe injury, else the exception is made the rule. The inconsistency of the story of the plaintiff is generally so palpable that imposture is evident, but prejudice and unjust suspicion are often excited against those accused. Thus Taylor[652] states that “a strong suspicion was raised against the then Duke of Cumberland, in 1810, in reference to the death of Sellis, when a skilful examination of the wounds on the deceased would have shown that they might have been self-inflicted.” The same author also cites the case of M. Armand, a merchant of Montpelier, who at Aix in March, 1864, was tried for an alleged murderous assault on, or imputed murderous strangulation of, his servant. The excoriation on the back of the neck was so slight as to escape the observation of some medical men, and it was evidently self-inflicted, either accidentally or purposely, as the facts showed. The assertions of a number of medical men were taken by the court to support the servant’s story to the effect that his master had struck him a severe blow on the back of his neck, rendering him insensible for many hours from concussion of the brain. The evidence given chiefly by Tardieu for the defence showed the story of the complainant to be a fabrication, and the accused was justly acquitted.

WAS A WOUND ACCIDENTAL?

In answering this question we must distinguish accidental wounds from those self-inflicted and those inflicted by another. These three classes comprise all wounds. In case of a trial for murder it may be alleged by the defence that the wound was caused by accident or that it was due to suicide from a fall, falls being a common class of accidental wounds. So we have to judge between accident on the one hand and homicide and suicide on the other hand. The question arises especially in cases where the injury causing death is one commonly due to accident.

As to the QUESTION BETWEEN ACCIDENTAL AND SUICIDAL WOUNDS, they are often easily distinguished, especially if the body has not been disturbed. In suicide there is clear evidence of design, and the circumstantial evidence helps to make the case clear. It may not always be possible to decide, however, as an accidental wound may sometimes resemble a suicidal or homicidal one. Accident is often shown by the _nature_ of the wound. Thus it is rare for an accidental mortal wound to be caused by a knife or similar weapon held in the hand and forced into the body by a fall, the blow of an opening door, etc. But such exceptional cases have been reported. Incised and punctured wounds are, therefore, very rarely accidental, and most accidental wounds are contused wounds or contusions.

Again, accident is often shown by the _situation_ of the wound, which should be on an exposed part of the body unless the accident is due to a fall from a height, when the wound may be almost anywhere. But such injuries are easily shown to be due to falls. The fall, of course, may be accidental, suicidal, or homicidal. Some wounds in exposed parts forbid accident on account of their nature, _i.e._, deep incised wounds of the throat. If the deceased has a life insurance, suicide is less probable, as the insurance is not paid in case of suicide. In fine, accidental wounds are distinguished from suicidal by—(1) Their _nature_; accidental wounds are almost always contused, suicidal very rarely so, only in cases of lunatics and delirious persons and where suicide is accomplished by a fall. (2) The situation of the wound or wounds indicates their origin. We have already studied the situation of suicidal wounds and have also seen that accidental wounds are only on exposed parts, except when the injury clearly indicates a fall from a height. The evidence from the direction of wounds rarely applies, as this is valuable only in incised and punctured wounds, which are seldom accidental. Both kinds of wounds are usually few in number except in case of a fall from a height or a crush, though sometimes suicidal wounds are multiple.

The evidence from weapons, if there be any, points strongly to suicide. The signs of a struggle are hardly consistent with either suicide or accident. The only case in which they might occur would be where a struggle occurred to prevent a suicide from throwing himself off a height or before a vehicle or railway train. In such a case accident would be excluded by the signs of a struggle, and the question would lie between homicide and suicide. The examination of the clothes of the deceased would furnish no evidence unless some letter or paper were found stating the purpose of committing suicide. Little or no evidence would be furnished by the position of the body when found in cases which might otherwise be doubtful. Organic lesions or other facts predisposing to suicide would furnish presumptive evidence against the wounds being accidental. Of all these various points the first, as to the nature of the wounds, is by itself the most valuable and conclusive. But this gives us no assistance in clearing up a case where it is doubtful whether a fall from a height or a crush by a vehicle or railway train was accidental or suicidal. Some of the other points mentioned may aid us in such a case, and also the fact that such injuries are far more often accidental than suicidal. But in these cases, also, certain circumstances may show that the fall was not the result of accident.

Accidental wounds are generally caused by a fall or a crush, and the fact of their accidental character is generally established by the circumstances of the event. Certain accidental wounds present characteristics which allow the true nature of the wounds to be determined. But in some cases a suspicion may arise and the question may be asked as to WHETHER THE WOUND WAS ACCIDENTAL OR HOMICIDAL. For instance, if a person receives fatal homicidal injuries, and just before or after death the body is thrown from a height or is run over and crushed, it may be hard to determine the murderous element among the many wounds. This is the case if the homicidal wounds were contusions or were caused by blunt instruments, but rarely, if ever so, if they are incised or punctured wounds or both. But even in the former instance, a close examination of the lesions and of the locality of the injury can often clear up the case. Thus in a case mentioned by Vibert,[653] as cited by Hofmann after Taylor, a woman was found dead at the foot of some stairs in a cave. She had died of a fracture of the skull and of the spine, produced by the fall. But about four or five feet above the level of the top step there was found on the wall the fresh marks of an arterial jet of blood. Examination showed a wound in the right temporal region which had opened the temporal artery, and it was therefore thought that the woman was wounded at the top of the stairway and then thrown down, which was afterward proved to be true. In another case, reported by M. Tourdes, a man knocked down and killed by an axe, which crushed his skull and caused the brain to exude, was placed in a road frequented at night by heavy wagons. The head was placed in the rut, but the coagulated blood and brain formed a puddle which did not appear on the wheels or their track, and no bloody furrow was caused by their passage. The same author mentions the case of a woman plainly strangulated by the hands and then thrown into the ditch of the fortifications of Paris.

It is especially with regard to fractures of the skull that the question often comes up as to the accidental or homicidal nature of the injury, as to whether it is due to a fall or a wound. Sometimes a depressed fracture may show the form of the instrument. An extensive comminuted fracture of the skull may indicate greater violence than would be received from a fall from the little height which the circumstances may allow. As to the slighter degrees of fracture, the disposition of the fracture itself often shows less than the form and site of the ecchymosis, the lesion of the scalp, and the place and position of the body when found. In such cases the traces of a struggle, the existence of other wounds, etc., may be of great importance. In distinguishing between homicide and accident, as in distinguishing between the latter and suicide, the most obscure and difficult cases are those where the injury has been caused by a fall from a height or by a crush.

This is illustrated by the case of Madame de Tourville, which is quoted by Taylor.[654] She was killed in July, 1876, by a fall from a precipice. Her husband, a lawyer, was accused of murder committed by pushing her over a precipice in the Stelvio Pass. The place where her dead body was found was at a considerable depth below, and the injury was chiefly in the head, which had been crushed by the fall. The body showed no evidence of intentional violence. The prisoner’s guilt was established on the following points: (1) The false and inconsistent statements made as to the occurrence; (2) the marks of the body having been dragged some distance so that a part of the dress was found, in a bloody condition, some way from the body; (3) there were marks of blood on the prisoner’s hands and clothing. After a long trial he was convicted, though the sentence was afterward commuted to imprisonment for life. Of course, as we have already stated, if a person is responsible for a fall he is also responsible for the results of the fall. This applies to many of the contused injuries and deaths from falls in prize-fights and drunken brawls.

We may sum up the points of evidence which help us to distinguish between an accidental and a homicidal injury much as we did when the question lay between accident and suicide. (1) The evidence from the nature of the wound is not quite so conclusive as when the question lies between suicide and accident. For contusions and contused wounds are far more often homicidal than suicidal, and accidental wounds are almost always of this class. If, however, the wounds are incised or punctured, this fact points almost certainly to homicide. (2) As to situation, a homicidal wound may be situated almost anywhere; an accidental wound, except in falls from a height, only on an exposed place. (3) The direction of the wound can seldom help us in the case of contused wounds which, practically, are the only ones in question, though it may possibly be incompatible with accident. (4) As to the number of wounds, homicidal wounds are far more apt to be multiple either in a small area or scattered in such a way that an accident could hardly account for them all. (5) A weapon may give evidence more often here than when suicide is in question, for a weapon may be used to inflict contused wounds which may resemble those received in a fall. The evidence furnished by a weapon or blood, hair, etc., on the weapon, etc., is strongly in favor of murder. (6) The evidence from a struggle is also more important because it is more often found. A struggle may occur in homicide, and only in homicide, as a rule, so that signs of a struggle are strong evidence of murder and against the idea of accident. (7) The examination of the clothes and body of the deceased may give valuable evidence, showing, as it may, signs of a struggle or other marks of an assailant and indicating murder. (8) Examination of the position and attitude of the body and of the spot where it lay and the ground around may furnish more or less proof of murder, as in the case quoted above. Thus the track of the murderer may be discovered or the body may have been interfered with and moved or robbed, all indicating homicide.

In any case, whether it is desired to distinguish accidental from suicidal or homicidal wounds, those cases present the most difficulty which result from falls from a height or crushes. But, as the case of Madame de Tourville shows, the above given and other circumstances may often show even then that the fall or the crush was not the result of accident.

FALLS FROM A HEIGHT may, therefore, be the result of suicide, homicide, or accident. The injuries are similar in all three cases. A fall of six to eight metres causes, as a rule, numerous lesions, and shows such a traumatism that the case usually excludes the possibility or, at least, the probability that the wounds resulted from blows. Sometimes, however, the gravity of the lesion is not proportional to the height of the fall. Thus Vibert[655] relates the case of a man, afterward employed for several years in the École de Médicine, who jumped from the top of the column of the Bastile, a height of fifty metres. He rebounded on to some canvas stretched at the foot of the monument, then fell to the ground, and was able to get up and walk away. Curiously enough, he killed himself later by jumping from the top of an omnibus in motion. In the case of falls from a height, it is especially true that with grave lesions internally the skin may be intact or only slightly ecchymosed or eroded, or the ecchymosis may be only deeply seated so as not to appear superficially. In the latter case, if life had continued the ecchymosis might have shown itself at some spot on the surface in a few days, but these falls from a height are fatal as a rule. In falls from a height, besides ecchymoses, which may occur where there are no other injuries or may fail where there are many injuries, the _lesions_ consist of fractures of bones and ruptures of internal organs, with or without surface wounds. The _fractures_ may be of a number of bones, and especially of those which first touched the ground, though the skull may be fractured at some part whether or not it was struck in the fall. These fractures are often comminuted, especially fractures of the skull and pelvis, and when the fall is from a great height. Ruptures of muscles may occur with the fractures.

Ruptures of internal organs are not rare in such cases. According to Vibert,[656] the order of frequency of rupture of the various organs is as follows: liver, spleen, kidneys, lungs, heart, stomach, intestines, bladder, brain. Rupture of the liver occurs especially on the anterior and inferior surfaces and the bleeding is rather abundant. The healthy spleen does not rupture readily, except from a severe traumatism, but if it is hypertrophied it may rupture spontaneously from muscular violence. The lung may be ruptured internally without showing the rupture on the surface and with the ribs intact. Two such cases are mentioned by Vibert,[657] and he refers to others mentioned by Nelaton and Holmes. Rupture of the brain without fracture of the skull is very rare, though cases have been observed and reported, among others by Casper-Liman. In falls from a height the rupture of the aorta, mesentery, diaphragm, and larynx have been noted. It should be remembered in this connection that rupture of the liver, intestine, bladder, etc., may be caused by contusions without sign of violence externally, and such cases cannot, therefore, be attributed to falls unless there are other signs of the latter.

In _crushes_ caused by a heavy vehicle, the lesions resemble in many respects those due to a fall from a height. Thus we find fractures and internal ruptures, but we more often and regularly find subcutaneous ecchymoses and ecchymoses between the muscles. The skin is often stripped up extensively and the injuries are generally limited to the region injured. It is rare to find that the cause of the injury leaves no trace on the skin, for it usually gives the form to the erosions or ecchymoses. Sometimes, for instance, the marks of a horseshoe are clearly visible. Ruptures of internal organs may occur here too when there are slight external marks of violence or even none at all. Thus Vibert[658] relates the case of a man with the head crushed, but with no signs of injury to the trunk save a few erosions at the level of the sternum, who had not only rupture of the kidneys, the liver, and the spleen, but also of the lungs and of the heart. In the heart the apex was completely detached and floating in the pericardium, which was intact. There was no fracture of the ribs nor subcutaneous or sub-muscular ecchymoses. The age of the subject was thirty-two, so that the costal cartilages were not probably ossified, which may have accounted for the absence of fracture of the ribs.

_Crushes by the fall of heavy weights_ resemble the latter class of crushes, and differ from falls from a height in the fact that the wounds are usually limited to one region. The lesions themselves are more or less similar. Similar internal lesions may be caused by the compression of the chest and body by the knee of a murderer, which may occasion rupture of the internal organs, fractures of ribs, etc. Thus, too, from the pressure of a crowd the ribs may be fractured and the lungs injured. It is particularly in these cases of injury from crushes or falls from a height that we may have most difficulty, as far as the medical evidence goes, of distinguishing between accident, suicide, and murder. But the various points and considerations mentioned above will sometimes enable the medical witness to clear up the case. In some cases the non-medical evidence, circumstantial and otherwise, may be sufficient of itself, or at least in conjunction with the medical evidence.

In falls from a less high place the difficulty is somewhat different, for here there may arise the question between a fall and a contusion or contused wound, and the question generally lies between accident and murder, or, very rarely, between accident and suicide. We have referred to both of these questions above, and from the facts mentioned the case can often be solved.

OF MORE THAN ONE INJURY WHICH WAS THE FIRST INFLICTED?

We can sometimes tell the order in which wounds were received, but the question is rarely answerable with certainty. If one wound is mortal and one or more are not, whether the wounds are suicidal or homicidal, it has sometimes been considered that the former must have been inflicted last. But we cannot admit that as a general rule the most grave wound was the last inflicted. For the murderer or suicide, especially the former, may go on wounding after the infliction of a mortal wound, especially as it is the exception, and not the rule, to die instantly after a mortal wound. Several assailants may have inflicted wounds at the same time, which would still further increase the difficulty. The question might then arise, Which assailant had inflicted the mortal wound or which had first inflicted a mortal wound? Under such circumstances, it would not be easy to give a specific answer. There are several signs which may indicate which wound was first inflicted in certain cases. An instrument may become duller or even bent or twisted after and on account of the first wound, and the subsequent wounds would vary accordingly. The wound of the clothes corresponding to the first stab-wound may be and often is only bloody internally, while the second and following wounds are bloody on both sides. The following case quoted by Taylor[659] from the _Annales d’Hygiene_, 1847, p. 461, illustrates this point. A man received three stabs from an assailant, one in the back at the level of the eighth rib, traversing the lung and heart and causing rapid death, and two on the left elbow, cutting the coat and shirt but only grazing the skin. The first one was evidently the first inflicted, for both the wounds in the clothing on the arm were bloody externally at the edges, although there was no blood effused here. The correctness of this opinion was confirmed at the trial.

The point of a knife arrested and broken off in a bone may show that this was the last wound. The amount of bleeding may show which was the first wound. Thus if several severe wounds have been inflicted, all or several of which would naturally cause profuse hemorrhage, and one showed signs of such hemorrhage while another did not, the former would be likely to be the first wound inflicted. Or if one showed slight hemorrhage where much would be expected, this fact would indicate that it was one of the last inflicted. The absence of the signs of spurting blood may tell which of two or more fatal wounds were first inflicted, for this would indicate that this wound was inflicted when the heart action was weakened by loss of blood or even after death, and the other wound or wounds which did not present this sign would have been the first received. In fact, if any of the signs are present about a wound which we have seen to indicate that a wound was inflicted at any time after death, this would show that this wound was not the first received, and that the other or others were inflicted earlier.

Questions as to the CONSEQUENCES of WOUNDS NOT FATAL may often be brought up in civil actions for damages. In certain countries the question of the consequences as to _incapacity_ may determine whether an injury shall be the ground of a criminal as well as of a civil action. Thus in France an injury which involves an incapacity of twenty days or more subjects the assailant to a criminal action. The term “incapacity” in this instance refers to general incapacity and not to incapacity for fine and professional work. The latter, however, comes in under the civil action which may be instituted against the assailant or those directly or indirectly responsible for the injury. The amount of the incapacity, its causes, whether due wholly or partly or not at all to the given injury, the probable duration of the incapacity, the treatment which it has and will necessitate, and many other such questions form part of the medical testimony required in such cases. Sometimes with slight wounds the results, accompaniments, and complications may prolong the incapacity very greatly, as also the state of health and the habits of the wounded person, the neglect of treatment, improper treatment, etc.

Any bodily or mental infirmity or ill-health which may result from an injury and its necessary treatment in the past and future, all these questions and many more unnecessary to mention may be required of the medical witness. No general rules can be laid down for all such cases. In giving his testimony the medical man must depend in any particular case upon his knowledge, judgment, and experience.

We can seldom give a precise solution of the _question of survival_ to determine the succession or inheritance if several of a family die together in an accident. In case of death from inanition, cold or heat, or in drowning especially, if some have wounds more or less grave in themselves, we can sometimes form an opinion. With wounds we cannot often do so, although in case of murder, the nature of the wounds, the position of the bodies, the examination of the spot of the accident or tragedy, may sometimes help us to form an opinion.

INCISED AND PUNCTURED WOUNDS AND WOUNDS OF BLUNT INSTRUMENTS REGIONALLY CONSIDERED.

The several varieties of wounds which we have been considering vary considerably in their nature, their effects, their danger, and in many other ways according to the region of the body in which they are situated. Some of these varieties are common in one situation and almost never occur in others. Although the nature of wounds found in the several regions of the body is not as important for a medical jurist as their danger and their influence in causing death, we will now consider the differences they exhibit on account of the region in which they occur.

WOUNDS OF THE HEAD.

These are often characterized by their apparent harmlessness and their real gravity sooner or later. We might almost make the opposite statement and say that those apparently grave are often virtually harmless, though this would be true only in a limited sense and in certain cases.

As to their _nature_, we find punctured wounds extremely rarely, incised and lacerated wounds often, while contusions and contused wounds are still more common. _Incised and lacerated wounds_ of the head involve the scalp almost exclusively. These wounds heal remarkably well, even when the attachment is merely by a narrow pedicle, owing to the abundant blood-supply. Hemorrhage from the incised wounds is often free, for the vessels cannot retract, but it is seldom dangerous unless the wounds are very extensive. The only way in which they differ materially from similar wounds elsewhere is in the greater frequency of complicating erysipelas here than elsewhere. This is probably owing to the presence of septic conditions, as the head is generally dirtier than other parts of the body, and slight wounds especially are neglected. If the scalp is shaved over a wide margin and cleaned like other parts of the body, erysipelas is found little or no oftener than with similar wounds elsewhere. The density of the scalp is so great that the redness and swelling accompanying inflammations is comparatively slight. If erysipelas follows slight wounds of the head, there is some reason to suspect constitutional predisposition or careless treatment. From infection of such wounds of the scalp abscess or diffuse cellulitis of the scalp may develop as well as erysipelas. The constitutional symptoms in such a case may be marked or even severe, but the prognosis is favorable. In very rare cases necrosis of the skull may result or the inflammation may even extend to the brain. These incised and lacerated wounds of the scalp are usually accidental or inflicted by another; they are rarely self-inflicted. _Contusions and contused wounds_ are the most common forms of injury to the head. These two kinds of injuries are almost invariably inflicted by another or are accidental. We have already seen that contused wounds of the scalp or over the eyebrow may closely resemble incised wounds in these localities. This fact should be borne in mind, as careful examination can usually distinguish them if they are fresh and until they begin to granulate. These wounds are liable to the same complications as incised wounds, in fact more liable, as the contusion makes the wound more susceptible to inflammation and the edges are more apt to be infected at the time of the injury.

One of the _results_ of contusions of the head is the extravasation of blood, most often between the aponeurosis of the occipito-frontalis muscle and the pericranium. These extravasations are usually in the form of a hematoma. Such hematomata often present a hard circular or oval rim with a softer centre, and may readily be mistaken for fracture of the skull with depression. The diagnosis between hematoma and depressed fracture is not usually difficult, however, for with hematoma the ridge is elevated above the level of the skull and is movable on the surface of the skull; also the wounded edges often pit on pressure. With depressed fracture, on the other hand, the edge is at or about the level of the rest of the skull; it is sharper, more irregular, and less evenly circular. Contusions and the resulting hematoma may occasionally end by suppurating, but this event is rare. Contusions and contused wounds may occasionally show the marks of a weapon, indicating that they were inflicted by another. Also the position of the injury will indicate its origin, whether it is accidental or inflicted by another, for the former would not naturally occur on the vertex unless the fall was from a considerable height.

Another result of injuries to the head, especially of contusions and contused wounds, is FRACTURE OF THE SKULL. This may be simple or compound, depressed or not, etc. Fractures are serious inasmuch as they imply a degree of violence which may do damage to the brain. The fracture itself, especially if properly treated, affords a good prognosis, irrespective of any brain lesion. One variety of fracture of the skull offers an exception to this favorable prognosis, and that is fractures of the base of the skull. These may be fatal directly from injury of the vital centres at the base of the brain or soon fatal from hemorrhage in these parts. Or the fatal result may be secondary to an inflammation or meningitis which good treatment is often unable to prevent. It should not be considered that these fractures are uniformly fatal, for quite a considerable proportion recover. Fracture of the base usually occurs as the result of a fall. The injured person may land on the feet or buttocks, and yet receive a fracture of the base of the skull, the force of the fall being transmitted through the spine to the base of the skull. Fracture of the base of the skull usually occurs from an injury to the vault, not by _contre coup_, but by extension of a fissure found higher up in the skull. This extension takes place in the same meridian line of the skull with that of the force which produced the fracture, and in this way the base of the skull is fractured in different parts according to the point and direction of the application of the force. Thus in case the force compresses the skull antero-posteriorly the fracture will pass antero-posteriorly toward the base from the front or the back, whichever received the blow (see Fig. 13). Fractures of the vault of the skull occasionally occur opposite to the point struck; this may occur by _contre coup_, but not always so, as not infrequently in such rare cases a close examination may reveal an extension of a fissure from the point injured to the opposite pole of the skull. The shape and rarely the size of a fracture of the skull, especially if punctured in character, may show the shape and more rarely the size of the instrument or object which produced it. Apart from fracture of the base, the prognosis in fracture of the skull is serious, mainly on account of the danger of inflammation, which is greater in compound fractures, and also on account of the more remote danger of irritation from depressed fragments causing epilepsy, insanity, etc., at a later period.

A circumstance that Taylor[660] says is connected with fracture of the skull with depression—namely, that the person, sensible as long as the object producing the fracture remained wedged in, became insensible and began to manifest other fatal symptoms as soon as it was removed—must be extremely exceptional. It may be explained, if it occurs, by the occurrence of hemorrhage after the object which occluded an open vessel by its presence or its pressure was removed. For it should be remembered that the symptoms of compression in a depressed fracture of the skull are very rarely due to the compressing effect of the depressed bone, but rather to an injury of the brain, intracranial hemorrhage, or a local and temporary interference with the circulation.

We may truly say that wounds of the head are dangerous in proportion as they affect the brain. The existence of affection of the brain may be hard to tell from the appearances, for an injured person may recover from the first effects of a comparatively slight wound and yet die suddenly later.

=Concussion= is the name applied to one of the effects on the brain of a more or less violent blow directly on the head or transmitted indirectly to the head. Though the term “concussion” implies a functional rather than an organic lesion, yet in the majority of cases it is equivalent to laceration of the brain. With laceration of the brain there is usually more or less effusion of blood which may be limited to a very thin layer. Concussion may exist without laceration of the brain. Even death has been known to occur from concussion of the brain without any visible signs of injury to the brain, so that the concussion must have been functional and the fatal result due to shock of the nervous system. Fatal concussion does not, therefore, necessitate the existence of compression or visible injury of the brain. Concussion may sometimes be due to a violent fall upon the feet, in which case the shock is transmitted through the spinal column to the head with or without fracture of the base of the skull. It was in this way that the Duke of Orleans, the son of Louis Philippe, died.

The _symptoms of_ concussion show all degrees of severity. Thus the injured person may become confused and giddy with or without falling, he may become pallid and nauseated and may vomit, but after a short period he recovers gradually.

With a more severe injury, with which there is generally some laceration of the brain, the injured person falls and lies quiet and relaxed, apparently unconscious, though often he can be partly roused. Paralysis and anæsthesia are absent. The heart is feeble and fluttering, the skin cold and clammy. The pupils, as a rule, react to light, but otherwise vary considerably. Urine and fæces may be passed involuntarily. As he begins to regain consciousness, vomiting usually occurs. Consciousness usually returns within twenty-four or forty-eight hours, when headache and indisposition to exertion are complained of, and this may last for a long time. Occasionally the symptoms instead of abating increase, and coma supervenes, often indicating meningitis, encephalitis, or intracranial hemorrhage. In other cases the person may die almost immediately on the spot where he fell, while in still others apparent recovery takes place and death occurs later either suddenly or after a reappearance of symptoms. In such cases, _abscess of the brain_ may occur and be the cause of the fatal result. These abscesses are the result of the injury, which may be almost anything from a compound fracture to a slight contusion not leaving any scar. The abscess may occur within a week[661] or not until after months or years. This interval of apparent recovery may lead to the false supposition that death was not due to the injury, but to some intervening cause. It is well to bear in mind that about half of the cases of abscess of the brain are not traumatic. A large majority of these are due to suppuration in the middle ear, a few to septic diseases or tuberculosis. The situation of the abscess often distinguishes between the traumatic and non-traumatic varieties. The traumatic variety is usually found beneath the injury or sometimes directly opposite, where the brain is injured by a kind of focussing of the radiated effects of the blow. The cases of abscess of the brain due to ear disease are usually found in the temporal lobe of the brain lying over the position of the ear or in the cerebellum behind it. The uncertainty of the nature and the extent of the cerebral injury in so-called contusion of the brain renders it necessary to be very careful in giving a _prognosis_. Any injury should be considered serious which has produced unconsciousness, for such an injury may produce enough laceration of the brain to render serious danger possible or even probable. We have seen that as a rule the symptoms of concussion come on immediately, but it is possible that symptoms at first so slight as to escape notice may become serious in a few hours or days. A gradual hemorrhage may sometimes account for this. The knowledge of certain acts performed or a conversation held at the last moment before the injury may be retained after recovery from concussion of the brain. This is not necessarily the case, for instead of remembering up to the moment of the injury, the injured person may remember only up to a certain time shortly before, or a part and not everything may be remembered.

The _diagnosis_ of concussion of the brain _from alcoholism_ is sometimes a matter of medico-legal interest or importance. Concussion may be so slight as to simulate intoxication. The history often clears the case up. The history of a blow or a fall or the presence of marks of violence on the head indicates concussion, though the blow or fall may not have caused the symptoms, which may be due to alcoholism. The odor of the breath may indicate alcoholism, but here too we may have both present and the concussion may be responsible for the symptoms. Or again the alcohol may have been given as a heart stimulant after the accident. This combination often occurs. If there is no odor in the breath, the presumption is in favor of concussion. As mistakes are still not infrequently made in diagnosis, those cases in which there is any ground for doubt should be carefully watched for developments. In general, the existence of concussion is more often overlooked than the coexisting alcoholism, so that if there is any doubt in a given case it should be treated as one of cerebral injury. The injury which causes the concussion in such cases is often due to the alcoholism. We may be able to verify this supposition if the injury is such as would be likely to be caused by a fall. There may be nothing found in the brain after death to distinguish between concussion and alcoholism. A bruise on the head only indicates a probability of concussion, for the bruise and alcoholism may both be present, the former perhaps due to the latter. The presence of alcohol in the stomach would indicate the existence of alcoholism.

Another effect of an injury which has caused concussion of the brain is an _extravasation_ or _effusion of blood_. Extravasation of blood in or on the brain is one of the commonest causes of death from injury to the head. It may occur with or without marks of external injury. A person suffering from such an extravasation of blood may recover from the first effects of the injury, and at a varying time afterward the symptoms may return and increase so as to result fatally. In such a case the opening of the bleeding vessel may have become plugged until some exertion, emotion, or excitement on the part of the injured person has loosened the plug. A hemorrhage may have ceased from partial syncope and return with a stronger heart action due perhaps to the administration of alcohol. This effusion may occur on the surface of the brain in connection with a superficial laceration of the brain or just beneath or outside the dura mater and not involving the brain directly. The latter cases are almost always due to the effects of violence, though there is at least one case of apparently spontaneous rupture of the middle meningeal artery. The violence which causes a rupture of the branches of this artery may be so slight as to leave no bruise or so severe as to cause fracture of the skull. The most important symptom of such extradural hemorrhage is a period of consciousness after recovery from the first effects of the injury, then stupor may appear and deepen into coma. A subdural hemorrhage may cause almost the same symptoms, though the injury is usually such as has produced a depressed fracture. This hemorrhage is most often due to the rupture of a number of small vessels under the fracture, though if one larger vessel is ruptured it is most often the middle cerebral. A thin layer of hemorrhage in connection with a superficial laceration of the brain is of frequent occurrence with or without the other two forms of intracranial hemorrhage. If the brain is lacerated we may have convulsions in addition to other symptoms. Death occurring during or soon after a prize-fight may occur from some of the above classes of intracranial extravasations. It may be questioned whether the blows or a fall caused the hemorrhage. It is generally due to a fall in such cases, but may be due to blows, but the guilt is the same unless the fall was accidental. As the result of severe traumatism the vessels of the interior of the cerebrum may be ruptured or hemorrhage may occur into the ventricles of the brain. In such cases the symptoms will resemble those of ordinary apoplexy, only the cause is different from the latter and the injury is usually so severe as to leave no doubt as to the existence of a traumatism. The following question may arise in cases of intracranial hemorrhage and especially in the latter class of such cases, _i.e._, in cerebral hemorrhage:

WAS THE EXTRAVASATION OF BLOOD DUE TO DISEASE OR VIOLENCE?—It may be alleged in defence that the hemorrhage was the natural result of disease. Where the hemorrhage is extradural or subdural or in connection with a superficial laceration of the brain, the cause is almost always traumatic. We have referred to one case of extradural hemorrhage from spontaneous rupture of the middle meningeal artery.[662] Subdural hemorrhage may occur from _Pachymeningitis hæmorrhagica interna_, but this condition is readily diagnosed on post-mortem examination and often with considerable certainty during life. A history of alcoholism, headache, impaired intellect, unsteady gait, occasional losses of consciousness, stupor increasing to coma, etc., indicates such a condition.

It is in cases of cerebral hemorrhage that there is the most difficulty in discriminating between that due to disease and that due to injury. It may be alleged that the hemorrhage was from diseased vessels, or that the effects of a blow, which cannot be denied, were aggravated by disease of the cerebral vessels or by excitement due to intoxication or passion. Cerebral hemorrhage from disease is rare before 40 years of age, except in alcoholics. When the hemorrhage is due to disease the blood-vessels are diseased. The most frequent site of such hemorrhages is the course of the lenticulo-striate artery in the ganglia of the base or the white substance of the centrum ovale.

When injury is the cause of the hemorrhage it is usually found beneath the point injured or directly opposite to this. External signs of the blow are generally visible if it be severe enough to cause a cerebral hemorrhage. The vessels may be perfectly healthy and the victim quite young if the hemorrhage is due to an injury, also the ruptured vessels may be plainly torn. The most difficult cases are those where there is the history of an injury and at the same time such a condition of disease of the cerebral vessels, etc., as would account for spontaneous hemorrhage. Where the injury was slight in the case of alcoholics or aged people the medical witness should be especially careful in stating that a cerebral hemorrhage was due to the injury. Then, too, in the act of falling from the occurrence of a cerebral hemorrhage due to disease the head may be injured and show marks of violence. It should be borne in mind that an injury to the head may be inflicted when disease of the brain, vessels, or membranes already exists. In such a case a slight blow might cause extensive hemorrhage, but as that which accelerates causes, death, even though it might sooner or later have occurred in the same manner without injury, is due to the injury inflicted.

From the above considerations we see that spontaneous cerebral hemorrhage and that due to disease are not always easily distinguished from that due to violence. In severe injuries the structure of the brain is plainly bruised, etc., but the greatest difficulty exists in cases of slight violence where arteritis of the cerebral blood-vessels coexists. The spontaneous extravasation of blood in or upon the brain from excitement does not usually occur except with diseased vessels, old age, or alcoholism. It is rare, therefore, in the young and healthy. If there is any doubt as to the origin of the hemorrhage, the medical witness should state the cause most probable in his judgment. Taylor[663] supposes the case of a man excited by passion, alcohol, or both, who becomes insensible and dies after being struck a blow so slight that it would not have affected a healthy person. If examination reveals a quantity of blood effused into the substance of the brain, there can be little doubt in the mind of the medical man that the excitement was the principal cause of the effusion. On the other hand, if a severe blow or a violent fall on the head had been received in a personal conflict with another and it is found that death was due to an effusion of blood upon the surface, there can be little doubt in the mind of the medical examiner that death was due to the blow, which would satisfactorily account for the conditions found without reference to coexisting excitement, etc. In fact, in all cases where a question is raised as to the cause of the hemorrhage, it is most important to consider whether the violence was not sufficient to account for the hemorrhage without the coexistence of disease or excitement. It is also most important to bear in mind that after severe injuries, as after a fall, causing extensive fracture of the skull, followed or not with extravasation of blood, the injured person may walk about and die some distance from the place of the accident and where no chance for a similar accident exists. In this way the suspicion of murder may be occasioned, as illustrated in the following case cited by Taylor:[664] A man was accused of the murder of his companion, who was found dead in a stable with fracture of the temporal bone which had caused rupture of the middle meningeal artery. The accused stated that the deceased had been injured by falling from his horse the day before. After the fall, however, the deceased had gone into a public-house, where he remained some time drinking before returning to the stable. The extravasation had here taken place gradually, as is characteristic of hemorrhage from the middle meningeal artery, and perhaps the excitement due to the drinking had influenced it.

THE DATE OF AN EFFUSION OF BLOOD may sometimes be a matter of importance in determining whether a given extravasation of blood in or on the brain was caused by a recent blow or had existed previously. The color and consistence of these effusions indicate whether they are old or recent; the precise date we cannot state, but the information we can give is often all that is required. The color of recent effusions is red, which changes after some days to a chocolate or brown, which generally turns to an ochre color (see Plate I.). This latter color may be met with from twelve to twenty-five days after the injury. The consistence of the coagula also becomes firmer with age, and as the coagula become firmer they are more or less laminated and the expressed lymph may lie between the laminæ or around the coagula.

EXTRAVASATIONS IN SEVERAL PORTIONS OF THE ARACHNOID, WITH HEMORRHAGES IN NEIGHBORING PORTIONS OF THE BRAIN. DEATH IN FOUR DAYS.

CEREBRAL ABSCESS. EPILEPSY, PARESIS. DEATH 3¼ YEARS AFTER THE INJURY.

RECENT AND OLD CEREBRAL EFFUSIONS.]

On account of the many layers of the brain coverings, a rough diagram of the coverings as given by Taylor[1] may be of much use to the medical expert in illustrating his evidence so as to make it clear to the court (see Fig. 19).

=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.