CHAPTER V

ASSAULTS, HOMICIDE, AND WOUNDS

=Assault.=--Every act of attack upon the person of another is an assault in law, whether it injure or not; nor is it necessary that the

## act done take effect. Spitting on anyone is an assault. No provocation

by word, whether written or spoken, can justify an assault, though it may mitigate the offence. If a medical man unnecessarily strip a female patient naked, under pretence that he cannot otherwise judge of her illness, it is an assault if he himself take off her clothes (R. _v._ Rosinski, 1 Mood C.C. 12). So, where a medical man had connection with a girl fourteen years of age, under the pretence that he was thereby treating her medically for the complaint for which he was attending her, she making no resistance solely from the _bona fide_ belief that such was the case, this was held to be certainly an assault, and probably a rape (R. _v._ Case, 1 Den. 580; 19 L.J. [M.C.] 174). Such an

## act is now held to constitute a rape.

=Battery.=--This includes beating or wounding. A touch of the finger, however slight, is included under this term.

=Homicide.=--In Scotch law homicide is held to be committed only where a distinctly self-existent human life has been destroyed. Destruction of an unborn child, however short a time before delivery, may be criminal, but is not homicidal. In the same country criminal homicide is divided into two classes:

(1) Murder. (2) Culpable Homicide.

1. _Murder_ is constituted in law by any wilful act causing the destruction of human life, whether plainly intended to kill, or displaying such utter and wicked recklessness as to imply a disposition depraved enough to be wholly regardless of the consequences. Murder may be the result of personal violence, poison, or by the committal of some other serious crime, as where anyone causes the death of a woman in the attempt to procure criminal abortion, rape, or by the exposure of an infant which results in its death. The use of weapons is not essential.

2. _Culpable Homicide._--The name applied in law to cases where the death of a person is caused or materially accelerated by improper conduct of another, and where the guilt does not come up to the crime of murder:

(_a_) Intentional killing of another in circumstances implying neither murder on the one hand, nor justifiable homicide on the other--_e.g._ if a person exceed moderation in retaliation for an injury, or kill another when the danger to which he was exposed is passed.

_Every charge of murder is held to conclude a charge of culpable homicide, and the jury, if they see cause, may find that culpable homicide only has been committed._

(_b_) Homicide, by the doing of any unlawful, or any rash and careless act, from which death results, though not foreseen as probable--_e.g._ using firearms in a public street, &c.

(_c_) Homicide, resulting from negligence or rashness in the performance of a lawful duty--_e.g._ a signalman on a railway forgetting to alter the points, and thus causing a collision, and loss of life. In England this would amount to manslaughter.

=Justifiable Homicide.=--Self-defence; hanging a prisoner properly sentenced to death; killing another to prevent murder, if prevention can avail in no other way. In self-defence, the person killing must be in _reasonable dread_ of death at the hand of his adversary.

In England there is--1. Murder; 2. Manslaughter; 3. Justifiable Homicide.

Murder, according to Lord Coke (3 Inst. 47), is constituted “where a person of sound memory and discretion unlawfully killeth any reasonable creature in being, and under the King‘s peace, with malice aforethought, either expressed or implied.”

In England the killing must be committed with malice aforethought. Malice may be expressed or implied.

In Scotland malice aforethought is not necessary (5 Irv. 525, and 40 S.J. 92, and 5 S.L.R. 20).

The law in both countries appears to differ more in terms than in practice. In England, if an injured party live for one year and a day, and then die, death is not attributed to the injury; but in Scotland, although no definite time is fixed, yet no case would I believe be entertained at any lengthened period after the commission of a homicidal act. The longest interval, according to Taylor, at which conviction has taken place from indirectly fatal consequences was _nine months_.

In the United States, as a rule, the crime of murder admits of two degrees: in the _first_, where the act is intentional or is the result of an attempt at burglary, rape, arson, or by poison; otherwise the crime falls under the _second_ degree.

WOUNDS

=Legal Definition.=--According to the statute (24 and 25 Vict. c. 100, sec. 18), the word “wound” includes incised, punctured, lacerated, contused, and gunshot wounds. But to constitute a wound within the meaning of the statute, the _whole skin_, not the mere _cuticle_, or upper skin, must be divided (R. _v._ M‘Laughlin, 8 C. & P. 635). But a division of the _internal_ skin, _e.g._ within the cheek or lip, is sufficient to constitute a wound within the statute (R. _v._ Warman, 1 Den. C.C. 183). If the skin be broken, the nature of the instrument with which the injury is inflicted is immaterial, for the present statute extends to wounding, &c., “_by any means whatsoever_.” A wound from a kick with a boot is within the statute (R. _v._ Briggs, 1 Mood C.C. 318). Injuries, burns, and scalds--which, in accordance with the above definition of a wound, are not wounds--are provided for under the clause, “or cause any grievous bodily harm to any person.”

Casper defines “an injury” to be “every alteration of the structure or function of any part of the body produced by any external cause.” Taylor proposed the following as the best definition which can be given to the word “wound,” whether in a medical or legal sense, viz. that it is “a breach of continuity in the structures of the body, whether external or internal, suddenly occasioned by mechanical violence.” This would include dislocations, fractures, either simple or compound, injury to the skin or mucous membrane, and to internal organs. Burns and injuries due to the action of corrosives are excluded from the category of wounds.

=Concerning Wounds in general.=--Great care must be taken to ascertain the exact site and course of the injury on the body, as this precaution will greatly assist in answering the questions: _Is the wound dangerous to life?_ _Does it cause grievous bodily harm?_ _Is it suicidal, that is, inflicted by the person on himself; or homicidal, inflicted by another?_ The solution of the question of the dangerous character of the wound is left to the professional knowledge of the witness, who may be required to state his reasons for considering the wound dangerous to life. His mere assertion will not be accepted. “The safest course,” says Elwell, “for the witness, in regard to all these questions, is to give a true and plain account of the wound, describing it minutely, and the probable consequences that may attend it.” In relation to their danger to life (apart from so-called “simple” wounds which are not usually extensive, heal easily, and cause little trouble in their course), wounds may be considered dangerous to life when they are so extensive, or on account of their position and relation to important structures when they would prove fatal without the intervention of surgical skill; and when the danger is _imminent_. A _mortal_ wound is one which is rapidly followed by death. Wounds, however, which in themselves could not be regarded as dangerous to life, may become so by intercurrent complications, such as erysipelas or other infective process. As a general rule, only those wounds in which the danger to life is _imminent_ should be stated as dangerous to life. Compound fracture of the bones of the cranium, injury to any large arterial trunk, or to any of the internal organs, may be considered as “dangerous to life”; but where the danger is more remote, as in the probable supervention of tetanus, erysipelas, &c., the medical opinion must be more guarded. But the medical witness should always bear in mind that death may follow the slightest injury. A case is recorded of death in forty-eight hours after extraction of a tooth. The contrary also holds good, for the most fearful injuries have been followed with recovery.

The following suggestions may help the practitioner in the formation of his opinion as to the probable danger of a wound:

1. The extent of the injury. 2. The character of the instrument used in the infliction of the wound. 3. The violence suffered by the parts. 4. The size and importance of the blood-vessels and nerves injured. 5. Is the wound healing or likely to heal well, and is the constitutional disturbance severe or slight? 6. Age of the sufferer. 7. Is there any constitutional taint likely to render even a slight wound more severe, or even dangerous to life? 8. Has the previous medical treatment been skilful or otherwise?

Should the injured party be found dead, a careful _post-mortem_ examination will alone determine the probable part the injury bore in the production of the fatal result.

Points of Importance to be Noticed in Examination of a Dead Body found Wounded.

1. Note situation, extent, depth, breadth, length, and direction of wound. Take careful measurements, in order to determine the character of the weapon, and the organs of the body injured.

2. Is there any appearance of ecchymosis, or is the effused blood liquid or coagulated?

3. Examine wound as to presence of pus, adhesive inflammation, gangrene, or foreign bodies.

_Why?_ Presence of pus, &c., will show that death must have taken place some time after the wound was inflicted.

4. In all examinations of wounds, be careful to disturb as little as possible their outward appearance, in order to compare the wound with the suspected weapon.

5. All notes should be taken during such examination, or _immediately_ after.

6. Make a careful examination of all the important organs of the body.

_Why?_ In order to disprove the suggestion that death was due to other causes--poison, disease, &c. This is important, as in the case of a girl who, dreading a whipping, swallowed some arsenic, from which she died, yet her father was tried for causing her death by the severity of his punishment.

7. Only facts should be stated in the Report; _no inferences_ should be drawn or suggested.

8. In describing the appearance of wounds use _simple untechnical language_, and avoid superlatives and high-flown words to describe and explain simple facts.

9. In gunshot wounds, note position of body, state and contents of the hands, and the direction of the wound in relation to external objects.

Note also in all kinds of wounds the relationship of the wound to cuts or rents in the clothes of the deceased.

INJURIES OF SPECIAL REGIONS

Injuries of the Head and Spine

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.

_Injuries to the spinal cord_ may cause immediate death; cases, however, occur of life being prolonged for some days, or even longer, after injury to the cord. The symptoms are progressive paraplegia and paralysis of the bladder and rectum, ending in death. Bedsores and septic infection of the bladder and kidneys are complications which add to the gravity of the condition. Spicula of bone in the cord, dislocation of the vertebræ, or extravasation of blood in the membranes of the cord, may be found after death. The presence of blood upon the spinal cord is not necessarily the result of violence, as hæmorrhage may take place spontaneously. The spine should be examined in all fatal cases of supposed injury. Concussion of the spinal cord is a fertile source of differences of opinion in railway cases. In no case should a hasty decision be given as to the probable future result to the patient from the injury.

Wounds of the _face_ are not generally dangerous, unless they penetrate the brain. There is always the possibility of injury to the eye causing detachment of the retina, or inflammation leading to blindness. Punctured wounds in the neighbourhood of the orbit may become septic and lead to secondary meningitis.

Wounds of the Throat and Chest

Wounds of the _throat_ are more or less dangerous, due to the possibility of severe hæmorrhage, emphysema, and bronchitis.

Wounds of the _chest_ are dangerous, on account of the amount of the hæmorrhage which may take place, and the importance of the organs which may be injured. Death may result more from the mechanical action of the blood effused than from the depressing effect of the quantity evacuated. Penetrating wounds of the thorax injuring the lungs cause emphysema, pneumo-, pyo-, or hæmothorax, any of which may prove fatal; pleurisy and pneumonia may occur. A fracture of the ribs may give rise to injury of the lung substance or to inflammation of its coverings. Laceration of the lungs may take place without fracture of the ribs. The ventricles of the heart may be pierced, and yet life may be prolonged for one or two months, permitting of considerable locomotion during that period (Briand et Chaudé, _Med. Leg._, vol. i. p. 511). Wounds of the heart, however, are, as a rule, rapidly fatal. Rupture of valves may follow blows on the chest, and rupture of the heart may occur from crushes or violent blows. Rupture of the heart has taken place during violent exertion, and this is more likely to occur when the muscle is diseased. It is often difficult to make out the direction of the wound, as the lungs change their position during respiration.

Injuries of the Abdomen

Wounds of the _abdomen_, penetrating the intestines, although not necessarily fatal, may cause death from peritonitis, due to the escape of the intestinal fluids. Rupture of the intestine may follow blows or crushing; it is generally fatal from peritonitis unless early surgical treatment is carried out. Hernia may also follow wounds of the abdomen. Rupture of the liver is not of infrequent occurrence, and may occur without any external signs of the injury. The rupture is, as a rule, longitudinal, transverse lacerations being rare. It is often followed by pneumonia if not rapidly fatal. The cœliac plexus may be much damaged by a blow or kick on the stomach, especially if this organ be distended with food, and death may result without leaving any trace of the injury externally or internally. The bladder may be ruptured and death result from extravasated urine. Rupture of the bladder may occur from fracture of the pelvis without sign of external injury. Rupture of the _kidney_ may be recovered from if slight, but when severe is fatal. Rupture of the spleen is usually fatal, and is more likely to occur when enlarged from any cause. Coagulable lymph, the effect of a wound of a serous membrane, may be thrown out in twelve hours or less.

Injuries to the abdomen may cause death by--

1. Shock; without lesion of the internal organs, inflammation, or external signs of injury.

2. Hæmorrhage.

3. Lesion of the internal organs, but without inflammation. Death in these cases seems to be due to depression of the nervous system due to the intense pain following these injuries.

4. By inflammation without lesion of internal organs.

5. Inflammation from lesion of internal organs.

6. Destruction of the natural functions of the organs, and, as a result, malnutrition of the body.

Except in the first case, when death is instantaneous, wounds of the abdomen are not as a rule immediately fatal.

Wounds of the _genital organs_ of the female may cause fatal hæmorrhage, which takes place from the plexus of veins which, in these parts, are devoid of valves. A kick from behind whilst the woman is stooping or kneeling may rupture the labial vessels and death supervene.

Blows and kicks upon the abdomen do not often injure the non-gravid uterus, but during gestation may produce abortion and hæmorrhage. If the pregnancy be advanced the uterus may be ruptured or the placenta separated. Penetrating wounds either through the abdominal wall, or per vaginam in the attempt to procure abortion, cause hæmorrhage and peritonitis with septic infection.

FRACTURES OF BONES

Unless they implicate some special structure, such as the brain and medulla, simple fractures are not considered dangerous to life. When compound, they may be complicated with hæmorrhage and infective processes.

Certain pathological conditions favour the spontaneous fracture of bones, or this occurrence with such slight violence as would not cause fracture in the normal may take place.

In old people bones are more liable to fracture from their brittle condition. Liability to easy fracture occurs in the insane, in nervous lesions as locomotor ataxia and general paralysis of the insane, when the bones are the seat of new growths, in fragillitas ossium, osteopsathyrosis; in the latter disease I have seen the femur fracture by the weight of the leg while resting the foot on a cushion. The liability to fracture depends upon the proportion of organic and inorganic constituents. In disease, the latter may be reduced and predispose to fracture; in the young, the bones are more liable to greenstick or incomplete fracture; and in the old, from excess of inorganic constituents causing brittleness.

A medical man may be required to express an opinion as to whether or not fractures are the result of direct violence, and especially when allegations have been made against attendants on the senile or insane.

The previous predisposing pathological conditions must always be taken into account, and also the amount, if any, of repair that has followed in relation to the time the alleged violence took place.

As the condition of a fracture of the bone of a limb may become a question of considerable importance in medico-legal investigations, the following brief account of the process of repair in fractures is given:

_From the First to the Third Day._--The period of inflammation and exudation. Ordinary signs of inflammation and laceration of the parts. Blood will be found extravasated round the fracture, also in the medullary canal mixed up with the fat.

_From the Third to the Fourteenth Day._--Gradual subsidence of inflammatory action and growth of the soft provisional callus from the periosteum and surrounding structures, and internally in the medulla, forming a fusiform mass holding the broken ends of the bones together with some degree of firmness. This becomes firmer and almost cartilaginous in density. When the bones are kept immovable, or are impacted, the provisional callus may not be formed. In the case of the ribs the provisional callus is always formed, and Dupuytren‘s “ring of provisional callus” is constant. This may also occur in fractures of the clavicle.

_From the Fourteenth Day to the Fifth Week._--Ossification of the provisional callus. The bone is first soft and spongy till the conversion of the soft callus is complete.

_From the Fifth Week to some Months after the Injury._--Complete bony union of the fracture and absorption of the provisional callus.

Although the blood clot completely disappears from the immediate neighbourhood of the fracture at an early period, yet layers of dark coagulum may often be found beneath the superficial fascia for four weeks or more after the accident (Erichsen).

It may be of importance to remember this in medico-legal inquiries. The presence or absence of the signs of vital reaction will help to distinguish fractures caused before or after death.

A fracture taking place immediately after death cannot be distinguished from one immediately before death, but if a few hours after death, the differences are easily recognised, blood is not effused round the ends of the bones unless a large vessel be torn.

In the examination of bones for fracture in the living it is the duty of the examiner to have an X-ray plate taken of the injured bone, especially if the seat of injury is in close vicinity to a joint.

Previous fractures are easily recognisable after death even when the bone does not show manifestations externally; on longitudinal section the seat of fracture is rendered evident.

Is the Wound Suicidal, Homicidal, or Accidental?

An attempt is made to answer this question by a consideration of the wounds in reference to their _position_, _nature_, _extent_, and _direction_.

In reference to their _position_ it has to be borne in mind that one person may wound any part of the body of another, but that to the suicide certain parts only are accessible, and they have a predilection for wounding themselves in favoured regions; the front of the body and vital parts are chosen by the suicide, while wounds on the back point to homicide. Suicidal wounds on the head are generally in front or lateral, and on the neck in front or to one side, in cutting the throat. Accidental head injuries are more often on the vertex, and when there may be no history of a fall on the occiput, wounds in this situation indicate homicide.

Suicides may choose unusual regions, such as cutting of a large vessel as the femoral artery in Scarpa‘s triangle, or by a limited incision, the carotid in the neck, the injury may be about the genitals, and the penis and scrotum have been amputated.

Accidental injuries may occur on any part of the body, but most commonly on exposed parts.

The _nature_ and _extent_ of the wounds does not afford much assistance; with the exception of contused wounds which are usually homicidal or accidental, any other form of wound, particularly incised or punctured wounds, may be suicidal or homicidal, and with regard to gunshot wounds, much depends upon their position and extent. As a rule, the suicide does not make several wounds, and the homicide may not only inflict several but of a greater severity than are necessary to carry out his purpose.

Suicides, especially when insane, may wound themselves severely and cause great injuries by leaping from buildings or similar high positions. In some cases suicides have inflicted several and varied wounds on their bodies.

The _direction_ of suicidal wounds, when the person is right-handed, is generally from above downwards and inwards on the chest, and on the left side. An upward direction points rather to homicide.

=Cut throat wounds=, when suicidal and inflicted by the right hand, are generally oblique from left to right, beginning higher up than they end. They generally cross the thyroid cartilage, and the larger vessels may escape; if made below the thyroid cartilage they are generally smaller and horizontal. The skin is the last structure divided, and there may be several so-called “tentative cuts.” It has been held that when the large vessels are cut the suicide stops, but this is incorrect, as in some cases the wound has reached the spine and the vessels been quite severed. Suicides may try to decapitate themselves from behind, and failing this stab themselves. A homicidal cut throat wound, when made from the front with the right hand, commences on the right side and is carried to the left; they are often deep incisions to the vertebræ and the tissues “undercut” at the ends. A homicidal cut throat wound when made from behind the victim resembles a suicidal one. When wounds are present on the forearms, hands, and fingers, and if there are injuries on other parts of the body also, the inference would be that the hand wounds were received in guarding the throat or other efforts at defence from a homicidal attack.

=Wounds produced by Firearms.=--To distinguish between suicidal, homicidal, and accidental wounds is far from easy. If the weapon be held hard up or close to the body, as in suicide, the skin and hair would be scorched and blackened, as would probably the hand that held the weapon, but this has not occurred in every case. The grasping of the firearm by the hand in cadaveric spasm is certain evidence of suicide, as this cannot be simulated by an assailant placing the weapon in the hand after death. Full investigation should be made by noting the bullet track and surrounding objects which may have been grazed in its course, in order to form a probable estimate of the direction from whence it came. Bullet wounds in the back are usually homicidal.

Duties of a Medical Man When Called to Examine a Wounded Person

The surgeon should at once visit the wounded party, and proceed to examine the injury, for if this be done before swelling occurs, he will be better able to form an opinion of its nature, extent, and severity. If the wound has been dressed, he should, if possible, obtain the attendance of the person who applied the dressings, and who would be able to describe their nature, and the dangers to be avoided in their removal, should that be deemed necessary. In no case should a surgeon remove the dressings applied by a professional brother without his presence and assistance. The condition of the injured party should be carefully noted, and a minute description of the wound written down at the time. The statements of the bystanders are also useful and should be noted. The procedure in the examination of the dead body has been previously described (p. 60).

An important question here arises. Have the wounds found on the body been produced during life or after death? The answer is beset with difficulties, and considerable caution will be necessary, but tables will be given under the different kinds of wounds to assist the diagnosis. Signs of vital reaction are important, as showing the _ante-mortem_ infliction of the wound; but these may, to some extent, be removed by the action of water, as in cases where the body is found in a pond. Under these circumstances the evident signs of drowning--water in the stomach, &c.--will assist the diagnosis. The presence of putrefaction also greatly obscures the diagnosis. The presence of coagulated blood between the edges of the wound is not a trustworthy indication of the _ante-mortem_ infliction of the wound, as experiment has shown that as long as the body remains warm coagulation may take place. Coagulation even in contused wounds, effected before death, may be retarded from various unknown causes--disease, _e.g._ scurvy; mode of death, _e.g._ asphyxia. The amount of hæmorrhage on or around the body is, other things being equal, a safe criterion as to the time when the wound was inflicted; if in considerable amount, arterial blood points to _ante-mortem_ injury; the presence of venous points blood to _post-mortem_ injury.

Care should be taken to record and photograph the body in position where found, and its relation to surrounding objects. Careful note should be made of the surroundings and the character and presence of any blood-stains, footprints, &c. The question may have to be considered as to whether the body is in the place it was when the wounds were inflicted. Blood in any quantity in one place, and the body found in another so seriously injured that locomotion would be impossible, point to the body having been removed.

Signs of a struggle, if any, should be recorded. If a weapon be found near to the body, its position should be noted, and if in the hand, the firmness of the grasp--cadaveric spasm--should be recorded. All clothing should be carefully examined, and the relation of cuts and body wounds noted. All blood-stains on the clothing should be examined and described.

Multiple bullet wounds denote homicide, but suicides have been known to inflict more than one wound. It is strong evidence of suicide if the gun or pistol has burst by the explosion, as suicides have a predilection for overloading the weapon employed.

PRETENDED ASSAULT

How may wounds, alleged to have been the result of an assault, be shown to have been self-inflicted? This has to be done by considering:

(1) The character of the wounds: in these cases they are generally slight, and may consist in a series of small, superficial wounds.

(2) The parts of the body where they are, and those from which they are absent. They are never found on vital parts, but always where there is little danger of doing harm. They are present on parts accessible to the individual. The hands are seldom wounded, and if they be, not severely.

(3) The clothing may not be cut, and if it be, the cuts may not go right through, and if they do, they may not coincide with the position of the wounds. The person should be clothed in order to determine this. Blood-stains on the cuts in the clothing may be erratic in distribution, some being on the inner layer only, some on the outer, and rarely soaking through all, pointing to the probability of its having been artificially applied.

Such self-inflicted wounds are usually produced for the purpose of bringing a fictitious charge of assault, feigning self-defence or provocation on the part of the assailant when accused; and in order to divert suspicion, as in the case of a person who alleges he has received the injuries by an assailant who was committing robbery while he himself is guilty of it.

THE CAUSES OF DEATH FROM WOUNDS

Wounds may prove fatal from results which are (1) =directly= due to injury--_hæmorrhage_, _shock_, or _mechanical injury to some vital organ_, _e.g._ the heart or lung; or (2) =indirectly= from _complications_ which may supervene such as infective processes--erysipelas, tetanus, septic infections, gangrene,--exhaustion, or the effects of surgical operations; or (3) _malum regimen_ (_a_) on the part of the patient, (_b_) on the part of the medical attendant.

1. Direct

Hæmorrhage.--Hæmorrhage may be profuse and cause rapid death if a large blood-vessel, more especially an artery, has been injured. The hæmorrhage may take place internally, in which case it need not necessarily be profuse; it will depend upon the position; a small hæmorrhage into the pericardium or in the brain may prove rapidly fatal.

Shock.--Death from shock is generally associated with severe injury, either a single one, or from several smaller injuries, any of which alone would not be expected to prove fatal. Death may occur from shock when the visible injury may be slight, as in blows over the heart and abdomen, the latter causing fatal syncope from dilatation of the splanchnic vessels. Repeated lesser injuries as in flogging may cause death through shock; and fatal psychical shock may be caused by mental excitement, as, for instance, in an encounter when no physical injuries have been received.

Mechanical Injury to Viscera.--This causes rapid death, more especially when the viscus injured, as the heart or medulla, is necessary for the immediate functions of life; injuries to other organs may not be followed by immediate death unless very severe and with great shock. A wound of the lung may not be followed by death for some time.

In a healthy person the violence necessary to prove fatal ought to be greater than in one diseased, and pathological conditions may be found _post-mortem_, which were pre-existent to the injury, _e.g._ degeneration of blood-vessels, aneurysm, valvular disease of the heart, phthisical cavities which may have bled, gastric ulcer which may have ruptured. Such conditions might influence the findings of a jury, as, for example, it is not always possible to form the opinion that death has been directly due to violence when signs of injury are slight; a man may receive a blow on the head while in the act of falling in a fight, and _post-mortem_ a cerebral hæmorrhage be found with diseased vessels, when it would be difficult to say with certainty that the hæmorrhage was directly caused by the blow or preceded it.

2. Indirect

Fatal Complications.--In English law if death follow injury inflicted by a person within a year and a day, the assailant may be tried and punished; beyond that time the person is not held responsible for the death. The infective processes mentioned above may supervene at any time during the course of wounds with fatal result. Further, as a result of altered conditions left by injuries which in themselves have not proved fatal, and from the immediate effects of which the person has recovered, fatal complications may follow, _e.g._ a person may have received an abdominal wound which after healing may become the seat of hernia which may strangulate; or an injury to the spinal cord, which may cause death at a late date from bedsores and exhaustion.

Septic Processes.--These may cause death at an early date according to their nature and virulence and the power of resistance of the person. In such cases the original injury need not have been dangerous to life. In other cases the infection may persist after the wound has healed, as infective endocarditis might conceivably do.

Surgical Operations.--Should a surgical operation be considered necessary for the treatment of the injury or in order to save life, and the person dies after it, the prisoner will be held responsible for the death. This holds good if the operation has been done in good faith and performed with reasonable skill and care. If, however, it can be shown that the operation was unnecessary, or performed unskilfully and death resulted, the prisoner would not be held responsible unless it can be proved that the injury apart from the operation could have caused death, when the jury might convict.

Where from improper treatment of an injury an operation is called for because of the improper treatment and the person dies, the prisoner would not be held responsible. The main points to be considered in reference to surgical operations for criminal injuries are:

(1) The operation must be absolutely necessary.

(2) The operator must have acted with reasonable skill and care.

(3) That the wound was dangerous to life, and without operation would most probably have proved fatal.

3. Malum regimen

(_a_) On the part of the Person Injured.--If the wound is not in itself sufficient to cause death, but by negligence in the care of it by the injured person, complications arise which cause death, then the punishment would probably be mitigated; but in law a person accused of criminally injuring another is held responsible for the immediate and remote results. “No man is authorised to place another in such a predicament as to make the preservation of his life depend merely on his own prudence.” If, however, it can be proved that death was largely due to the imprudence or recklessness of the deceased, it is probable that this would lessen the punishment.

(_b_) On the part of the Doctor.--A person accused of criminally injuring another being held responsible for the results immediate and remote, may plead that the latter, _i.e._ complications, or the death itself are not due to the injury directly, and endeavour to throw the responsibility on someone else, either the injured person through negligence, or on the doctor for unskilful treatment. In reference to the complications, the medical witness may be asked for his opinion as to the cause and effect of the complication, and how it might have been avoided. Having considered all the facts laid before him and made his deductions, he must give his opinion fairly, and leave it to the Court to decide in what way his opinion may influence its judgment and the amount of punishment for the offence.

When there is an allegation that the treatment has been unskilful or negligent, and contributory to complications and death, and a defence raised accordingly, the prisoner has to prove this to the satisfaction of the Court in order to mitigate the offence and punishment. The medical man is expected to have exercised reasonable skill. If the person treating the injury is a registered medical practitioner, and has applied his treatment in good faith and for cure, even if the treatment were improper, the assailant would be held responsible.

The care which the medical man ought to exercise is that which everyone ought to exercise who has received the statutory education and passed the statutory examinations.

THE SEVERAL KINDS OF WOUNDS

(1) Incised; (2) Punctured; (3) Lacerated and Contused; and (4) Gunshot.

1. Incised Wounds

Made by sharp instruments.

_General Characters._--Incised wounds are somewhat spindle-shaped, their superficial extent being greater than their depth; the edges are smooth and slightly everted, and the wounds are always larger than the weapon which inflicted them--due to retraction of the divided tissues. If a wound be in a line with the fibres of a muscle, there will be less “gaping” than when the wound is directly or obliquely across the muscle. From muscular contraction, or the elasticity of the skin, an incised wound may assume a crescentic form. The cellular tissue is infiltrated with blood, and coagula are found at the bottom and between the edges of the cut. It must be borne in mind that a wound with smooth edges may be made by a _blunt_ weapon over bones near the surface, as on the scalp and over the tibia or shin, but a certain amount of contusion may, in most cases, be detected by careful inspection a short time after the receipt of the injury.

It is often of importance to distinguish where the weapon entered, and where it was drawn out. The end where the weapon entered is usually more abrupt than the other, which is naturally more drawn out. But in some cases I have seen, when the weapon was simply drawn across the part, both ends of the wound alike.

2. Punctured Wounds

The orifice is generally a little smaller than the weapon.

A stab may sometimes present the appearance of an incised wound; the depth will, however, help to distinguish the one from the other. The wound may not at all correspond with the shape of the weapon, and the same pointed instrument may produce very different-shaped wounds in different parts of the body. Much depends upon the movement of the instrument in the action of puncturing; in the case of a double-edged instrument the wound will most probably be fusiform or diamond-shaped. When made with a knife the wound may be wedge-shaped if the knife have a thick back. A circular weapon splits the skin and leaves a slit; broken glass and pottery act in a similar way, but the wounds may have jagged edges and show signs of contusion in them. On dissection, two or more punctures may be found in the soft parts, with only one external orifice; these are due to the weapon being only partially withdrawn at each stab. Punctured wounds are always more dangerous than incised. They cause little, if any, hæmorrhage externally, unless a large vessel, such as the femoral artery, be injured, but they may cause internal hæmorrhage or penetrate a viscus, _e.g._ the lung or heart. These wounds generally heal by suppuration, and not infrequently an abscess is formed in and around the track of the wound. Perforating wounds generally have a large entrance wound with inverted edges, and a small exit with everted edges; if the weapon be rough, the reverse may be the case.

3. Lacerated and Contused Wounds

The edges of these wounds are never smooth, and generally do not correspond at all with the weapon. A considerable amount of contusion or bruising surrounds the solution of continuity of the part. Hæmorrhage from these wounds is usually slight. A point of considerable interest may arise in connection with this class of wounds; the defence may declare that the injury was the result of a fall, and not due to a blow. The history of the case, and the presence of a bruise where no theory of a fall can explain its existence, will often afford the only solution of the difficulty. Lacerated wounds heal by suppuration, generally with more or less sloughing, and leave a permanent scar. Scratches with the finger-nails may be considered as lacerated wounds, but the skin is merely abraded, not divided. They are never important as wounds, but often as a proof of a struggle in cases of rape, &e. Bites are also lacerated wounds. The diagnosis of lacerated and punctured wounds, whether inflicted before or after death, will depend on much the same grounds as those of incised wounds, hæmorrhage, vital reaction, &c.

Table of Differentiation Between Ante-mortem and Post-mortem Wounds:

--------------------------------------------------------------------- Incised Wounds. -----------------------------------+--------------------------------- IN THE LIVING. | IN THE DEAD. | 1. Edges sharply cut and everted, | 1. Edges close, and not everted. the skin and muscles being | retracted. | | 2. Bleeding copious, and generally | 2. Bleeding absent or scanty. arterial. | | 3. There are clots. | 3. There are no clots in most | cases; sometimes a few strial | clots. | 4. There is a good deal of staining| 4. There is little or no staining or diffusion of blood in the | or diffusion of blood in the muscular and connective tissues.| tissues of the wound. | 5. After some hours or days | 5. There will be no attempt at there will be signs of repair or| repair, and no signs of inflammation. | inflammation. There may be | signs of putrefaction. -----------------------------------+---------------------------------- Lacerated Wounds. -----------------------------------+---------------------------------- | 1. There will be more hæmorrhage | 1. There is hardly any hæmorrhage and staining from the blood at | or staining unless large veins first | are torn across. | 2. After a few hours, or days, | 2. No evidence of repair, or there will be suppuration or | inflammation, or gangrene can other sign of repair; | be detected. inflammation or gangrene may | also supervene as in incised | wounds. | -----------------------------------+--------------------------------- Contused Wounds. -----------------------------------+--------------------------------- | 1. There is swelling, and, after | 1. There is little swelling or a few hours or a few days, if | change of colour. deep-seated, the skin changes | colour, particularly at the | edges. | | 2. There is effusion of liquid | 2. Very little blood is effused. blood and lymph in the deeper | There are hardly any clots. parts, and coagula form. | | | 3. The swelling subsides and the | 3. There are no rainbow-like or colours fade after some days, | prismatic changes of colour. or, in some cases, weeks. | | | 4. Abscesses may form, or | 4. No abscesses form, and no ulceration, sloughing, | erysipelas or dangerous or erysipelas set in. | changes are met with. -----------------------------------+---------------------------------

4. Gunshot Wounds

The appearance which gunshot wounds present will to a great extent depend upon the form of the projectile, and the distance at which the firearm was discharged. Round halls make a larger opening than conical. Small-shot, fired within a short distance of the body, make one large ragged opening. The scattering of the shot depends on the calibre of the gun, on the charge of powder, and essentially on the distance. A charge of ordinary (No. 5) shot, to make a single hole, must have been fired at less than _one foot_; but experiments should always be made with the alleged weapon. A patent cartridge would make a single hole at a considerable distance--five or six yards. Round bullets may split, but the conical ones seldom do. The edges of wounds produced by the discharge of firearms are always more or less ecchymosed; this condition appears in about an hour after the infliction of the injury. If the ball strikes obliquely, the edges of the wound may be much lacerated, or the opening may be valvular and of small size, if the skin over the part be in any way tightened, or if a conical ball has been used. The injury to bones is greater from conical than from round balls. The old round balls were easily deflected; the conical are not so easily turned aside. The track of the ball _widens as it deepens._ This is the reverse of an ordinary punctured wound. The ball may either lodge in a part, or perforate it. Should it have lodged, it must be preserved and compared with the alleged firearm. Bits of clothing or wadding may be carried into the wound. The latter should be carefully kept, as they may prove important as a means of identification.

The aperture of entrance and exit must, if possible, be determined. On this point there is much difference of opinion. The wound of _exit_ is always _smaller_ than the wound of _entrance_ (Casper). In this opinion Casper agrees with M. Malle, Olliver d‘Angers, and M. Huguier, but is opposed by Taylor, M. Matthysens, and others. “The characters of a gunshot wound,” says Assistant-Surgeon Neill, “are those of a contusion and laceration of all the tissues. Sometimes they are so simple as to bear resemblance to a punctured wound, particularly if a rifle-ball (conoidal), revolving on its long axis, has passed through the soft parts at a great speed, but within a few hours it resembles a contusion. The wound of entrance, as it has been termed, bears no comparison in size or shape to that of the exit when a rifle-ball has caused the injury. In the former you see the edges of the wound curving inwards, and the circumference small, with little or no hæmorrhage. In the latter, the wound is large, with torn and irregular edges projecting outwards, and perhaps only slight oozing of blood. In a short time, averaging an hour, round the entrance wound slight redness begins, gradually extending to about two inches round its orifice. Again, this colour changes to a blue- or greenish-black, and you see all the appearances of a severe bruise, with a small wound of the skin, its edges still curved inwards. In the exit wound the discoloration of the skin is not apparent.” The probable reason for the discrepancies in the statements of observers, as to the characters of entrance and exit wounds, may be found in the fact that experiments have been conducted with different-sized balls, different kinds of weapons, with varying quantities and qualities of the powder used, the character of the wads, and with varying velocities and distances. As pointed out by M. Roux, the two openings may be equal if the ball preserves the same velocity through the tissues as it possessed before entrance; the _entrance_ hole is smaller than the _exit_, when the ball has lost much of its trajectile force, and enters the softer parts of the body first; the _entrance_ is larger than the _exit_, when the ball first enters through the denser tissues of the body, and leaves through the softer.

The opening of entrance made by the ball has generally, but by no means always, inverted edges. The edges of the exit opening are everted, bloody, and raw; but both the entrance and exit wounds may be everted in fat persons, due to the protrusion of the fat; and this eversion may also result from the expansive power of the gases generated during putrefaction, should this condition be present. Wounds made by _double shots_, as from double-barrelled guns, or pistols, or from slugs fired from one barrel, diverge after their entrance into the body.

Observations during the war in South Africa threw fresh light upon the results of gunshot wounds produced by modern projectiles. Of wounds produced by the Mauser bullet, one correspondent (_The Physician and Surgeon_, 1900, p. 49) states that “the aperture of entrance seldom shows any bruising of surrounding tissue; frequently it has been difficult to locate it, for where the skin is dense and elastic, there is seldom any bleeding. There is never any inversion of the edges, which are sometimes circular in form, and sometimes triangular like a leech-bite. The aperture of exit, where the bullet has not been distorted, is seldom any larger than that of entrance; there is no bruising of surrounding tissue, and no eversion of the edges; bleeding varies, of course, in accordance with the proximity of large, medium, or small blood-vessels in the track, but in the vast majority of cases it is slight.”

The late Sir William MacCormac, quoted by Sir William Stokes (_B. M. J._, vol. i., 1900, p. 1453), says: “I saw a large number of injuries inflicted by the Mauser bullet, which is remarkable for the small wound it produces. In three-fourths, if not a larger proportion, it was impossible to tell the exit from the entrance wound, they were so similar in appearance.”

In the examination of gunshot wounds we have to consider--

1. _Direction in which the Gun was fired._--The track and position of the ball in the body, coupled with the relative position of the body to a window or door through which the gun may have been discharged, and the place where the ball is found, should it have passed through the body, may assist us in forming an opinion. It is often impossible to trace the course of the ball through the cavities of the body, but through the muscles and denser structures this is more easily accomplished. The effects of the ball on surrounding objects may assist very much in finding the direction of its course. Sir Astley Cooper, by a careful consideration of the above suggestions, once correctly determined that a left-handed man had fired the fatal shot.

2. _Distance at which the Charge was fired._--In the case of wounds inflicted by a small shot, the scattering of the shot must be our guide. Dupuytren has related a case in which a fowling-piece charged with powder alone and fired at a distance of two or three feet from the abdomen made a round hole in it and killed the man. If the weapon be fired a short distance, _e.g._ a few inches from the body, the skin will be scorched, smoke-blackened, and tatooed with powder, the flame may singe the hair or clothing. If discharged quite hard up to the body, the edges of the wound are freely lacerated, ecchymosed, and burnt. Smokeless powder will not cause blackening of the skin. The absence of scorching, or marks made round the wound by the half-burnt powder, allows of the assumption that the shot must have come from some distance--rather more than four feet. The absence of any of the above, however, is not an absolute proof that the shot has come from a distance.

There is no means of deciding, from an examination of a pistol or gun, when the weapon was last used. In all cases, medical men, unless sportsmen and familiar with firearms, should hand over the weapon to a gamekeeper or gunsmith, and not attempt to give an opinion on matters about which they know nothing. The following may be of use to students for examination purposes, but for nothing else: Among the products formed when gunpowder is exploded is the sulphide of potassium, but if exposed to the air some portion of this substance is converted into the sulphate of potash. If, then, the gun-barrel be washed out with distilled water, and the washings filtered, and, on the addition of a solution of acetate of lead, a black precipitate of sulphide of lead be formed, this is supposed to point to recent use; if, on the other hand, a white precipitate of sulphate of lead forms, to the use of the weapon at some more distant date than the period alleged.

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