Medical Jurisprudence, Forensic medicine and Toxicology. Vol. 1 by R. A. Witthaus et al.

vitality and ceases to occur when this is lost a few hours after death. In the retraction of the edges of the wound we have all the parts involved, but unequally. The muscles, arteries, skin, and layers of connective tissue all retract, varying in the degree of retraction according to the order in which they are named. In different parts of the body this comparative order of retraction is liable to more or less variation. Every surgeon is familiar with this retraction of the tissues, which necessitates certain rules in the technique of operations, especially of amputations. Muscles retract the more the longer they are and the farther the incision is made from their attachment. Without specifying a definite time, we may say that, as a rule, this retraction lasts no longer than about two hours after death, consequently when it is absent we may infer that the wound was inflicted two hours or more after death. The amount of retraction grows less and less after death for about two hours, after which it is very slight if it occurs at all, owing to the loss of elasticity of the tissues. This sign is especially useful in the case of a mutilated body where, by examining the degree of retraction of the muscles, we may infer whether the mutilation was done before or after death. The sides of a cut made on the cadaver are comparatively smooth and even, owing to the absence of the unequal retraction of the various elements, which makes the surfaces of a gaping ante-mortem wound uneven and irregular. Relying on these circumstances in the “affaire Ramus,” cited by Vibert,[621] one was able to recognize the order in which the body had been mutilated. OTHER MINOR SIGNS of a wound inflicted during life may be briefly mentioned. If the edges of the wound are swollen, or show signs of inflammation or gangrene, or if pus or adhesive material is present on the edges of the wound, we may infer that the wound was inflicted some little time before death. Of course, if cicatrization has commenced, some days must have elapsed before death after the wound was received. If the blow causing a contusion was inflicted some time before death, there will be more or less of a general swelling of the region, partly due to the blood effused, but also partly due to œdema. It is not always easy to say whether a _fracture_ was produced while the body was living or dead. If the body was still warm when a post-mortem fracture was produced there is little difference from an ante-mortem fracture, except that there may be a little less blood effused. In a fracture produced after rigor mortis has set in there is little or no blood effused. In the case of fractures the presence of callus, indicating the process of repair, shows that the accident occurred during life, and, as we have already seen, we may form some idea of the length of time elapsed between the injury and the time of death. On the cadaver it is said to be harder to cause fractures and lesions of the skin than on the living body. Casper says that fractures of the hyoid bone and the larynx are impossible after death, and he also was not able to rupture the liver or spleen. In distinction to the characteristic signs of a wound inflicted during life, we may mention briefly some of the signs of post-mortem wounds when the wound has been inflicted from two to ten or twelve hours or more after death: (1) The hemorrhage is slight in amount and may fail altogether. (2) The character of the hemorrhage is venous, corresponding to the source of the hemorrhage from the veins, the arteries being nearly empty after death. (3) The edges of the wound are not deeply stained, and this staining may be removed by washing. The spaces between the tissues are not infiltrated with blood. (4) The blood remains either entirely fluid or, if there are clots, these are _softer_ than those in an ante-mortem wound, and only a portion of the blood is thus clotted. There are no clots plugging the open mouths of the arteries on the surface of the wound; the veins may or may not be closed by an imperfect clot. (5) The skin of the edges is not everted or inverted. (6) The sides of the wound do not gape and their surfaces are smooth and even, as the tissues are not unevenly retracted. RÉSUMÉ.—It is very easy from the foregoing to distinguish between a wound inflicted before death and one ten or twelve hours after death. If the hemorrhage has been abundant and arterial, if it has infiltrated between and deeply stained the tissues and the stain cannot readily be washed off; if the blood coagulates completely and the coagula are firm and are found lying in the wound, plugging the vessels, and incorporated with the tissues between which they lie; if the edges of the skin are everted and the sides of the wound are retracted and uneven—under these circumstances, we may be sure that the wound was inflicted during life or a very short time after death. If, on the contrary, the hemorrhage is slight in amount or almost fails altogether; if it is venous in character; if the edges of the wound are only stained by imbibition of the blood, which is not infiltrated between the tissues, and the stain may be washed off; if the blood is not at all or only slightly clotted and the clots are soft; if the skin is not everted and the sides of the wound are smooth and lie nearly in contact; if there are no clots plugging the divided arteries on the surface—then we need have little hesitancy in saying that the wound was produced after death, but probably not later than ten or twelve hours after death. If the wound was inflicted still longer after death and before putrefaction, then we would have a lack of the signs due to hemorrhage, clots, staining, etc. If we find the conditions more or less midway between the first two, we may be left in some doubt as to the date of the injury. Thus if the hemorrhage is moderate, the blood mostly but not altogether clotted and the clots moderately firm, the skin slightly everted, and the sides slightly separated and not altogether smooth on their surface; if the surfaces are fairly deeply stained and the stain cannot be easily washed off—then we can only say that the wound was inflicted during life or within two hours or so after death, and this fact is often enough for the purposes of the medico-legal inquiry. The same is the case with contusions where there is no bleeding externally. If we have a bluish, violet, green, or yellow tumor with or without more or less superficial œdema; if this tumor fluctuates or is hard, but in either case is elastic; if on incision the skin and the tissue spaces are infiltrated with blood which is coagulated, or if there is a cavity filled with clotted blood, the coagulum being firm and the entire amount of blood coagulated—then the wound was inflicted during life. If, however, the surface shows a bluish or violet color, little or no swelling of the skin, which is of natural thickness, and the ecchymosed area is not tense and elastic to the touch; if further the blood is found on incision to be fluid or if coagulated only partly so, and the blood is not infiltrated into the tissue spaces, but merely imbibed by the tissues—then the blow was inflicted after death, and probably more than two or three hours after. In contusions especially we may have difficulty, as the sign of fluidity of the blood may fail and putrefaction may modify the conditions of the wound unless parts deep beneath the surface be examined. We see, then, that in some cases it is very easy to say that a wound was inflicted post mortem. If a wound was not inflicted until ten or twelve hours after death or even sooner, we cannot easily mistake it. But in many cases it may be hard or impossible to say whether a wound was inflicted during life or within an hour or two after death. Here we must be cautious in expressing an opinion which should be guarded. But we should remember that it is important to be able to state that a wound was inflicted before or immediately after death, as no one but a murderer would think of inflicting a fatal injury on a body immediately after death. In such cases a well-guarded medical opinion may often meet all the requirements of the case. Granted that a given wound was produced before death. There are, then, one or two questions which may arise, and which depend for their answer on the length of time the wounded person could have lived and the physiological or muscular acts which he could have performed after receiving the injury and before death. The first of these questions may be expressed as follows: COULD THE VICTIM HAVE PERFORMED CERTAIN ACTS AFTER HAVING RECEIVED HIS FATAL INJURY? The term “certain acts” here refers to almost any thing or things which would require time and strength—in other words, the continuance of life with bodily and mental powers for a certain time after receiving a mortal injury. This question may be raised in relation to an attempted alibi of the accused, who may have been proved to be in the presence of the victim a moment before death. If after this moment the victim has moved from the spot or performed certain acts before death, the attempted alibi may depend upon the answer to the question as to whether the given acts of the victim were compatible with the fatal character of the wound. An alibi can aid in the acquittal of the accused only when the nature of the injury was such that death would be supposed to be immediate or nearly so. Great care should be taken on the part of the medical witness in answering this question, for after very grave wounds, proving speedily fatal, the victim sometimes can do certain acts requiring more or less prolonged effort, as shown by numerous examples. Wounds of the brain are especially noticeable in allowing a survival of several hours, days, or even weeks, during which time the injured person may pursue his occupations. Where the survival has lasted days or weeks, the alibi has no importance, but not if the survival is of shorter duration. The following case is cited by Vibert[1] and may be mentioned in this connection, though the wound was caused by a bullet which traversed from behind forward the entire left lobe of the brain. After the injury the victim was seen by several witnesses to climb a ladder, though with difficulty, for he had right-sided hemiplegia. He was found insensible more than half a mile away, and did not die until six or eight hours after the injury. Severe injury of important organs is sometimes not incompatible with an unexpectedly long survival. Devergie cites two illustrations of this which are quoted by Vibert.[622] A man received several extensive fractures of the skull, with abundant subdural hemorrhage, and rupture of the diaphragm with hernia of the stomach. The stomach was ruptured, and nearly a litre of its contents was contained in the left pleural cavity. Notwithstanding all this, he was able to walk about for an hour or so and answer several questions. He died only after several hours. Another man, crushed by a carriage, received a large rupture of the diaphragm, complete rupture of the jejunum, and rupture and crushing of one kidney. Yet he walked nearly five miles, and did not die until the next day. More rarely wounds of the great vessels are not immediately fatal. M. Tourdes is quoted by Vibert[623] as citing the case of a man who descended a flight of stairs and took several steps after division of the carotid artery; also of one who lived ten minutes after a bullet-wound of the inferior vena-cava. Even wounds of the heart are not as speedily fatal as is commonly supposed, and often permit of a comparatively long survival. Fischer[624] found only 104 cases of immediate death among 452 cases of wounds of the heart, and healing occurred in 50 cases among 401. Vibert[625] mentions two striking cases of long survival after wounds of the heart. A woman received a stab-wound which perforated the right ventricle, causing a wound one centimetre long. She did not die until twelve days later, when on autopsy there was found an enormous extravasation of blood in the left pleural cavity and pericardium. The second case, though one of bullet-wound, is equally applicable and instructive in this connection. A man received a bullet-wound which perforated the left ventricle, the bullet being found later in the pericardium. After being wounded he threw a lamp at his assassin which set fire to the room. He then went into the court-yard, drew some water, carried it back in a bucket, extinguished the fire, and then lay down on his bed and died. In studying the wounds of different regions of the body, we may find many other mortal wounds which, though speedily fatal, leave the possibility of more or less activity before death. We see, therefore, that even in those wounds which are commonly supposed to be immediately fatal, even by many medical men where attention has not been called to the exceptions, such exceptional cases are not uncommon in which death is not immediate. Time and even strength may thus be allowed for more or less complicated activity. An alibi cannot, therefore, be allowed without question on the part of the medical expert, who must exercise great caution in expressing an opinion. The second question which may sometimes arise in connection with the last, but having little to do with the subject of this section, is the following: HOW LONG BEFORE DEATH HAD THE DECEASED ACCOMPLISHED CERTAIN PHYSIOLOGICAL ACTS? For instance, how long after a meal did he die? This is hard to answer with precision, as digestion varies with the individual, and digestion begun during life may go on to a certain extent after death. We may be able to say if digestion has just commenced, is well advanced, or has terminated. What was eaten at the last meal may be learned by the naked eye, the microscope, the color of stomach contents and their odor. The state of the bladder and rectum is sometimes called in question. All the above facts have less bearing on the case than those in relation to the former question. THE CAUSE OF DEATH FROM WOUNDS. The cause of death should be certain and definite. In reality, there is only one real cause, though one or many circumstances may be accessory causes. In most cases of death from the class of wounds which we have been considering, there is no difficulty in determining the cause of death so as to be able to state it definitely. But if the deceased had recovered from the first effects of the wound and then died, or if death seems as much due to disease as to injury, then the _real_ cause of death may be obscure. If the medical witness is in doubt as to which of two causes was the primary cause of death the doubt should be stated at once, as it may weaken the testimony if brought out later. Wounds may be directly or indirectly fatal. They are directly fatal if the victim dies at once or very soon after the wound, with no other cause internally in his body or externally from his environment. Wounds are indirectly or secondarily fatal if the injured person dies from a wound disease or complication, the direct consequence of the wound, or from a surgical operation necessary in the treatment of the case. Wounds may also be necessarily fatal either directly or secondarily, or not necessarily fatal. In the latter case death may be due as much, if not more, to other causes than the wound, and sometimes not at all to the wound itself. Thus death may be due to natural causes, latent disease, an unhealthy state of the body, imprudence or neglect of treatment, or improper treatment, etc. These various degrees of responsibility of a wound as the cause of death we will now consider more at length. I. WAS THE WOUND THE CAUSE OF DEATH DIRECTLY? If so, it must have caused death in one of the following ways: