5. Humid soil, especially when bodies are placed in it one upon the

other. In this case the lowest of them is first changed. When a body has been completely saponified it may remain in this state for years. In one instance, after seventeen years’ burial many of the organs could still be recognized. The time required for saponification to take place is sometimes of medico-legal importance. Three years are _usually_ necessary for bodies buried in the earth. The change occurs more rapidly in water. Cases are recorded where the body of a new-born child was completely saponified in six weeks, and again, the change had commenced in a body which had been in the water about four months; but these are unusual cases. DATA UPON WHICH OPINION AS TO TIME OF DEATH IS FORMED. The changes which take place in a body before putrefaction sets in may enable a medical jurist to form an opinion as to the probable time which has elapsed since death; yet it must be remembered, to pronounce the time which has elapsed can only be done approximately, for very many conditions will have to be considered, which will vary in each individual case. The importance of considering the minutest detail is well illustrated by the death of Prince de Condé, Duke of Bourbon, who was found dead in his bedroom in the chateau of St. Cyr. When discovered at 8 o’clock in the morning, the deceased was found partly undressed, hanging by his cravat to one of the window shutters. The body was cold and the lower extremities rigid. As in asphyxia from hanging the warmth of the body is usually preserved longer than under common circumstances, viz., from twelve to fifteen hours, before which period rigidity is seldom complete, the medical examiner inferred that the deceased must have died very soon after he retired to his bedroom on the previous night. As this was proven to have been 10 P.M., it followed that only ten hours had elapsed—a short time for cooling and rigidity to have taken place. It was thus rendered probable that the hanging took place soon after deceased reached his bedroom. It was alleged that the duke had been murdered, and that his body had been afterward suspended to create a suspicion of suicide. The condition of the body was, among other things, adverse to this opinion. From 10 to 12 o’clock it was proved there were numerous attendants moving about near the duke’s apartments. They would have heard any unusual noise the duke must have made in resisting his assailant. But no noise was heard in the room at that or any other time, and the presumption of this being a homicide was thus strongly rebutted. =Cadaveric rigidity=, while often it will aid to, is not a reliable guide. When once it is established it may remain two, three, or four days, according to the season of the year and other circumstances, and when it exists there is no rule by which it can be determined whether a body has been in this state three hours or three days. =Putrefaction=, while appearing on an average, under a mean temperature, in from three to six days, is yet influenced by many circumstances. The heat and moisture of the surroundings, the age, sex, amount of flesh on the body, mode of death, position and coverings of body, all must be considered. =The temperature= of the body aids us, yet the retention of warmth by the abdominal viscera may be met with in a marked degree twenty hours after death; in one case, personally known to me, the thermometer registered 76° F. seventeen hours after death. The temperature of the body, its rigidity, and the evidences of putrefaction all furnish data from which we can estimate the _probable_ time which has elapsed since death. It must be remembered that no one of them furnishes any positive proof. Some medical jurists have attempted to give a more definite character to these changes in the recently dead body by dividing the interval between the stopping of the heart’s action and the beginning of putrefaction into three periods. In the first, the warmth, pliability, and muscular irritability remain. In the second, these conditions are lost and the body is cold and rigid. In the third, the body is cold and pliant, the muscles are relaxed, and the joints are flexible, the cadaveric rigidity having entirely ceased. There can be no doubt about the existence of these stages, but when we come to define the precise time at which one begins and the other ends, we find it impossible. For example, the first stage embraces a period which cannot be more closely defined than by stating that the person may have been dead from a few minutes to twenty hours—a statement too vague to be upheld by a counsel who defends a prisoner. The changes which take place in these periods and the average time they last have been given as follows by Devergie: FIRST PERIOD, _Few Minutes to Twenty Hours_.—Characterized by warmth of the body and general or partial relaxation of the voluntary muscles. To what portion of this period the special case belongs must be estimated according to the degree of heat in the trunk and extremities and the degree of rigidity in the muscles, the neck and the jaws commonly showing this condition first, the legs last. Warmth of the body rarely remains as long as twenty hours; in general it is sensibly cold in from ten to twelve hours. During this period the muscles are susceptible of contraction under the galvanic current, and in the early stage under the stimulus of blows. SECOND PERIOD, _Ten Hours to Three Days_.—The body is perfectly cold throughout and rigidity is well marked. The muscles no longer respond to stimuli. The duration of this period seems long, yet in one instance the body will be found cold and rigid nine hours after death. Again, cooling and rigidity may not come on for three or four days. THIRD PERIOD, _Three to Eight Days_.—The body is perfectly cold. The limbs and trunk pliant and free from cadaveric rigidity. The muscles are not capable of contracting. In summer this period is much shorter; often it will come on before three days. Putrefaction commences when a body is kept under the most favorable conditions, in from six to twelve days, as a slight greenish discoloration of the abdomen which gradually spreads throughout the body. The time at which putrefaction shows itself and the rapidity with which it advances is dependent upon so many factors, many of which it is impossible often for the medical examiner to ascertain, that too much reliance must not be placed upon it. Casper estimates the following to be the _average_ changes generally found in the periods of time given: TWENTY-FOUR TO SEVENTY-TWO HOURS after death a slight green color is visible over the centre of the abdomen. The eyeballs are soft and yield to external pressure. THREE TO FIVE DAYS after death the green color of the abdomen becomes intensified and general, spreading if the body be exposed to the air or buried in the ground in the following order: genitals, breast, face, neck, upper and lastly lower extremities. EIGHT TO TEN DAYS after death the discoloration becomes more intense, the face and neck presenting a shade of reddish-green. The ramifications of the superficial veins on the neck, breast, and limbs become very apparent. Finally the patches congregate. Gases begin to be developed and distend the abdomen and hollow organs and to form under the skin in the subcutaneous and intermuscular tissue. The cornea falls in and becomes concave. The sphincter ani relaxes. FOURTEEN TO TWENTY-ONE DAYS after death the discoloration over the whole body becomes intensely green, with brownish-red or brownish-black patches. The body is bloated and appears greatly increased in size from the development of gases within the abdomen, thorax, and scrotum, and also in the cellular tissue of the body generally. The swollen condition of the eyelids, lips, nose, and cheeks is usually of such extent as to obliterate the features and to destroy the identity of the body. The epidermis peels off in patches, while in certain parts, more particularly the feet, it will be raised in blisters filled with red or greenish liquid, the cuticle underneath frequently appearing blanched. The color of the iris is lost. The nails easily separate and the hair becomes loosened. FOURTH TO SIXTH MONTH after death the thorax and abdomen burst and the sutures of the skull give way from the development of gases within the head. The viscera appear pulpy, or perhaps disappear, leaving the bones exposed. The bones of the extremities separate at the joints. At an advanced stage the soft parts gradually disappear. In giving an opinion as to how long a time has elapsed since death when a body has undergone marked putrefactive changes, we must consider carefully not only the conditions of the organs, but the mode of death and the “surroundings.” By these I mean the quantity of clothing worn, the depth of the grave in which the body has been interred, the season of the year, the heat and moisture of the atmosphere. The question sometimes presents itself to the medical examiner, Of two persons found dead, which died first? The importance of this point was well illustrated in the “Lizzie Borden case.” By a careful consideration of all the conditions presented by each body in the ways I have indicated, the question will not ordinarily be a difficult one to decide. THE MEDICO-LEGAL CONSIDERATION OF WOUNDS, INCLUDING PUNCTURED AND INCISED WOUNDS, AND WOUNDS MADE BY BLUNT INSTRUMENTS OTHER THAN GUNSHOT WOUNDS. BY GEORGE WOOLSEY, A.B., M.D., _Professor of Anatomy and Clinical Surgery in the Medical Department of the University of the City of New York; Surgeon to Bellevue Hospital; Member Medical Society of the County of New York, New York Academy of Medicine, New York Surgical Society, etc., etc._ WOUNDS. GENERAL CONSIDERATIONS. THE DIFFERENT KINDS OF WOUNDS. THE surgical and medico-legal ideas of wounds are quite different, the latter including the former as well as other varieties of injuries. =Definitions.=—Surgically a _wound_ means a solution of continuity and refers to every such lesion produced by external violence or developing spontaneously. The medico-legal acceptation of the term is much broader and includes any injury or lesion caused by mechanical or chemical means. Vibert[601] quotes Foderé as defining a wound medico-legally as, “Every lesion of the human body by a violent cause of which the results are, singly or combined, concussion, contusion, puncture, incision, tear, burn, twist, fracture, luxation, etc.; whether the cause is directed against the body or the body against the cause.” The same author quotes another definition of a wound as, “Every lesion however slight, resulting in concerning or affecting the body or health of an individual.” Taylor[602] defines a wound in a medico-legal sense as “a breach of continuity in the structures of the body whether external or internal, suddenly occasioned by mechanical violence.” Thus, the term wound in its medico-legal acceptation includes not only surgical wounds but contusions, fractures, burns, concussion, etc. In France at least the voluntary inoculation of syphilis has been considered as coming under the category of wounds.[603] Medico-legally, the severity of a wound is much more important than the kind of wound. Thus we may consider wounds according to their comparative gravity, as mortal, severe, or slight. A _mortal_ wound is one which is directly fatal to life in a comparatively short time, usually from hemorrhage, shock, or the injury of a vital part. A wound may result fatally without being a mortal wound, as when a slight wound causes death on account of some wound infection. _Severe wounds_, or “wounds causing grievous bodily harm,” as they have long been called, do not put life in imminent danger, though they may be inconvenient or detrimental to health. Pollock, C. B., says that a wound causing grievous bodily harm is “any wound requiring treatment.” A medical opinion or certificate may be required as to the danger of a given wound, and on this opinion may depend the question of bail for the prisoner. By the danger of a wound in such a case is usually meant imminent danger, as any wound may be remotely dangerous to life. _Slight wounds_, as already stated, may result fatally under certain conditions. Under the French practice a slight wound is one which does not incapacitate one from work for more than twenty days. Looked at in another way, slight or severe wounds may be classified according as they are completely curable, leaving no infirmity or disturbance of function, or not completely curable. The latter are such as are necessarily followed by permanent or temporary infirmity. The question as to the severity of any given wound may sometimes be left to the jury to decide from the description of the wound, or a medical opinion may be required. Although the intent of the assailant is often of equal or greater importance than the severity or kind of wound, yet this can only occasionally be inferred from the surgical aspects of the wound. The classes of wounds to be treated in the following pages are incised and punctured wounds and wounds with blunt instruments, some of the characteristics of which we will now consider. =Incised wounds= are such as are produced by a cutting instrument, and they are distinguished by the following characteristics: They measure more in length than in the other dimensions. They are usually straight in _direction_, though not infrequently curved, and they may even be zig-zag, especially where the skin lies in folds. The _edges_ of an incised wound are linear, and show no signs of contusion. They are either inverted or everted and the edges and sides of the wound are retracted. The eversion of the skin is due to its elasticity, but in some regions of the body, _e.g._, in the scrotum, etc., the skin is inverted owing to the contraction of the muscle fibres immediately beneath. The gaping of the wound is due to the retraction of the divided muscles and fibrous structures. It varies according as the muscles are cut directly across or more lengthwise, and in proportion to the distance of the wound from the points of attachment of the muscles. The fibrous tissues, fasciæ, and aponeuroses retract less, and so give a somewhat irregular surface to a large wound. Ogston[604] divides incised wounds into three parts, the commencement, centre, and end, of which the end often has two or more serrations differing from the commencement, which has but a single point. There are often one or more slight, superficial, tentative incisions situated almost always, though not invariably, near the commencement.[605] The deepest part of the wound is more often near the commencement. If there are angular flaps on the edges their free angles point to the commencement of the wound. Coagula and clots of blood are to be found in the wound, more or less filling it up if it has not been interfered with. On examination the ends of the divided vessels are found plugged with clots which may protrude somewhat from their openings. If the wound is seen very shortly after its infliction, hemorrhage is in progress, and the divided arteries show their position by their individual, intermittent jets of blood. The severity of incised wounds depends upon the amount of hemorrhage, which is greater the deeper and larger the wound, and the more vascular the tissues in which it occurs, especially if large and important vessels are concerned. In the latter case an incised wound may be very rapidly fatal. Incised wounds present the least favorable conditions for the spontaneous arrest of hemorrhage of any form of wounds. The edges of an incised wound may be quite rough and even dentated or lacerated if the edge of the weapon be rough and irregular. The kind and condition of a weapon which has produced a given incised wound may often be learned by an examination of the characteristics of the wound. Weapons cutting by their weight as well as by the sharpness of their edges, such as axes, etc., may cause a certain amount of contusion about a wound; they crush the soft parts to a certain extent, and the bones may be indented or even fractured. Wounds caused by fragments of bottles, pieces of china, earthenware, or glass, though strictly speaking incised wounds, are often curved, angular, and irregular, and their edges jagged and contused. Wounds caused by scissors may sometimes be of the nature of incised wounds. When they present a double wound of triangular shape, with the apex of the triangle blunt, they are more of the nature of punctured wounds. In general a “tail” or long angle in the skin at one end of an incised wound indicates the end of the wound last inflicted, and some light may thus be thrown upon the inflicter of the wound. Incised wounds present very favorable conditions for healing by primary union, but often fail in this and heal by secondary union. When an incised wound fails to unite by primary union, bleeding continues for several hours or even as long as a day, the blood being mixed more or less with a serous discharge. The latter continues until the third day or so. By the fourth or fifth day the surface has begun to granulate, and there may be a more or less profuse purulent discharge from the surface. The granulating surfaces do not necessarily discharge pus, however. For some days, therefore, after the infliction of an incised wound, or until the surface is covered with granulations, the characteristics of the wound permit of a diagnosis as to the nature of the wound. The _diagnosis_ of an incised wound is generally without difficulty. Some wounds by blunt instruments, however, in certain regions of the body, resemble incised wounds very closely. Such instances are found where a firm, thin layer of skin and subjacent tissue lies directly over a bony surface or a sharp ridge of bone. These are seen most often in the scalp or in wounds of the eyebrow where the sharp supra-orbital ridge cuts through the skin from beneath. The diagnosis of an incised wound can often be made with great probability from the cicatrix. This is especially the case if the wound has healed by primary union and the cicatrix is linear. The _prognosis_ in incised wounds is good as to life unless a large vessel has been divided or unless an important viscus has been penetrated. The prognosis as to function varies with the position and extent of the wound, and the circumstance of the healing of the wound. =Punctured Wounds, Stabs, etc.=—These are characterized by narrowness as compared to depth, though the depth is not necessarily great. They are more varied in character than incised wounds owing to the great variety of form of the weapons by which they may be made. From the form, etc., of a particular wound we may often infer the variety of weapon by which it was produced. According to the weapon used, punctured wounds have been divided into several classes, of which M. Tourdes distinguishes four: 1st. _Punctured wounds by cylindrical or conical instruments_ like a needle. If the instrument be very fine like a fine needle, it penetrates by separating the anatomical elements of the skin, etc., without leaving a bloody tract. Such wounds are generally inoffensive, even when penetrating, if the needle is aseptic, and they are difficult to appreciate. On the cadaver it is almost impossible to find the tract of such a wound. If the instrument be a little larger it leaves a bloody tract, but it is difficult to follow this in soft tissues, more easy in more resistant structures, such as tendon, aponeurosis, cartilage, or serous membrane. If the instrument be of any size this variety of punctured wounds presents a form quite different from that of the weapon. Instead of a round wound it is generally a longitudinal wound with two very acute angles and two elongated borders of equal length, showing but little retraction. This is the shape of the wound even when the instrument producing it is so large that the resulting wound resembles that made by a knife (see Fig. 2). The direction of the long axis of these wounds varies in different parts of the body and is uniform in the same part. Their shape and direction are explained by the tension of the skin or still more clearly by the direction of the fibres of the skin, just as with the same round instrument in a piece of wood a longitudinal opening or split would be made parallel to the grain (see Fig. 1). In some regions, as near the vertebræ, the fibres may run in different directions, and the resulting wound is stellate or triangular in shape as if a many-sided instrument had caused it. As the direction of the fibres of the various tissue layers, such as aponeuroses, serous and mucous membranes, etc., may be different, a deep wound involving several such layers would have a different direction for each layer. In illustration of this, examine the figure of a wound through the wall of the stomach (see Fig. 3). [Illustration: FIG. 1.—Direction of the Long Axis of Wounds of the Back caused by Conical Instruments. (After Langer.)] The wounds above described when large are smaller than the weapon, as the splitting of the skin has certain limits and also owing to the elasticity of the skin, which is put on the stretch by the weapon and relaxed on its withdrawal. When such wounds are small they are larger as a rule than the instrument causing them. [Illustration: FIG. 2.—Slit-like Wound caused by a Pointed Conical Instrument 2.5 cm. in Diameter. Natural size.] [Illustration: FIG 3.—Wounds of Stomach Wall by a Conical Instrument, showing the Different Direction of the Long Axis of the Wounds in Different Layers.] [Illustration: FIG. 4.—Stab-Wound of the Skin with a Knife a Few Minutes before Death.] 2d. _Punctured wounds by instruments both sharp pointed and cutting_, like a knife or dagger. If these wounds are perpendicular to the surface, they have more or less the form of the weapon used. The angles may show whether the knife, etc., had one or two cutting edges, but even though the back of the knife is broad the wound may resemble one caused by a double-edged weapon. Thus stab-wounds from a common pocket-knife show only exceptionally a wedge-shape, but regularly a slit, the edges of which are slightly curved to one another and end in two acute angles. The reason of this lies in the fact that the wound is only caused by the cutting edge of the knife, so that we cannot tell as a rule which angle was occupied by the back of such a knife (Figs. 4 and 5). The depth of these wounds may equal the length of the weapon or be almost any degree less, but the depth may even be greater than the length of the weapon by reason of a depression of the parts at the time of the blow. The wound is often shorter and broader than the weapon causing it, though more often it is larger than the weapon from the obliquity of the wound and the movement of the weapon on being withdrawn. The wound is smaller than the instrument where the parts are on the stretch at the time the wound is inflicted. [Illustration: FIG. 5.—Nine Suicidal Stab-Wounds in the Region of the Heart made by a Knife used for Cutting Rubber.] This variety of punctured wounds may resemble the former class in the direction of its long axis, if the cutting edge of the instrument is blunt. The regularity and smoothness of the edges distinguish them from certain contused wounds. 3d. _Wounds made by instruments with ridges or edges_, files, foils, etc. If the edges are cutting the wound presents more or less the shape of the weapon (Fig. 6). But this is not always so, probably from the instrument puncturing obliquely or from the tissues being unequally stretched (Fig.7). If the edges are not cutting the wound resembles those of the first class, though the edge often presents little tears, and the wound may thus be more or less elliptical with two unequal angles. The wound of entrance and exit may be different. [Illustration: FIG. 6.—Stab-Wounds caused by a Three-Sided Sharp-Edged Pointed Instrument.] 4th. _Irregular perforating instruments_, the wounds from which resemble contused wounds. =Contusions and Contused Wounds.=—A contusion is a wound of living tissues by a blow of a hard body, not sharp-edged or pointed, or by a fall, crushing, or compression, and without solution of continuity of the skin. A contusion usually involves a moderately large surface in comparison to the two other classes of wounds. Contusions are of all degrees of severity. If the blow or injury is slight, there is only slight redness and swelling of the skin with pain, disappearing in a few hours, and leaving no traces. If the blow be harder it produces more or less crushing of the tissues, accompanied by ecchymosis with or without a wound or excoriations of the skin, etc. The contusion may have the shape of the contusing body, such as a whip, the fingers, etc. [Illustration: FIG. 7.—Stab-Wounds caused by an Eight-Sided Sharp-Edged Instrument. Some show a transition stage to wounds made by a conical instrument.] =Ecchymosis.=—This is characteristic, as a rule, of contused wounds. It consists in the infiltration of blood into the tissues, especially the cellular tissues. The source of the blood is from the rupture of blood-vessels, and the size of the ecchymosis varies partly with the number and size of the blood-vessels, or with the vascularity of the part. The size of the ecchymosis also varies with the looseness of the tissues into which it is infiltrated. This looseness of the tissues may be natural as in the scrotum and eyelids, or it may be due to the attrition of the tissues caused by the blow. An ecchymosis is larger when the contused parts cover a bony or resisting surface, and there may be no ecchymosis whatever, even from a severe blow, where the underlying parts are soft and yielding, as is the case with the abdominal parietes. Here we may have rupture of the viscera without any signs of ecchymosis superficially. An ecchymosis may be infiltrative or it may mostly occupy a cavity usually formed by a traumatic separation of the tissues; this is especially the case in the scalp and extremities when the injury is severe. These tumors, which are called _hematomata_, may be rapidly absorbed or they may remain a long time and occasionally suppurate. Sometimes the anatomical conditions, especially of the connective-tissue spaces, allow the extension or migration of the ecchymosis under the action of gravity, even to a considerable distance. When it meets an obstacle it accumulates above it, as in the inguinal region for abdominal ecchymosis and at the knee for those of the thigh. The course along which the ecchymosis travels is indicated externally by a yellowish stain, soon disappearing, so that soon no sign persists at the site of injury, but only below where the blood is arrested. An ecchymosis becomes visible at varying times after the injury according to the depth of the ecchymosis and the thinness of the skin, for the ecchymosis is mostly beneath, not in the skin. If the ecchymosis is superficial it shows in one or two hours or even in less time where the skin is very thin, as in the eyelids and scrotum. In such cases it increases for thirty or forty hours and disappears in a week, but may last longer, _i.e._, as long as fifteen to twenty-five days. An ecchymosis may not show at the point struck, at least not until several days have elapsed, or it may only show on the under surface of the subcutaneous fat until it has imbibed its way, as it were, to the surface. This may explain the discrepancy in the description of an injury examined by two medical experts at different times. If an ecchymosis is extensive and deep, especially if it occupies a cavity, there may be nothing to see in the skin for four or five days, and then often only a yellowish discoloration instead of a dark blue color. In such cases, too, the appearance in the skin may be more or less remote from the injury, having followed the course of the least anatomical resistance. Between these two extremes, an ecchymosis may become visible at almost any time. Rarely an ecchymosis occurs only deeply between muscles (pectorals, etc.) and not superficially at all. The extravasation of blood which forms an ecchymosis has sometimes been given different names, according to its extent or position, for instance, parenchymatous or interstitial hemorrhages or apoplexies, suffusions, ecchymoses, petechiæ or vibices. All such may, however, be called ecchymoses or hematomata. When blood is effused into the serous cavities of the body, special names are sometimes applied according to the position, such as hemothorax, hematocele, etc. The color of an ecchymosis is at first a blue-black, brown, or livid red. This color changes first on the edges, later in the darker centre, and becomes in time violet, greenish, yellow, and then fades entirely. This change in color is owing to a gradual decomposition of the hæmoglobin of the blood. We can tell the age of an ecchymosis from its coloration only within rather wide limits, for the rapidity of change of color varies widely according to a large number of circumstances, especially according to whether the ecchymosis is superficial or deep. We can only say that the first change, _i.e._, that to violet, in a superficial ecchymosis, occurs in two or three days. As an exception to the above color change, we may mention subconjunctival ecchymosis, which always remains a bright red, as the conjunctiva is so thin and superficial that the coloring matter of the blood is constantly oxidized. The form of an ecchymosis often reproduces well enough that of the instrument, except if the latter be large it cannot all be equally applied to the surface, and its form is not distinctly shown by that of the ecchymosis. After its first appearance an ecchymosis spreads radially, the edges becoming less clear. This change occurs more rapidly the looser the surrounding tissues, and at the end of a few days the first form of an ecchymosis may be changed, so that an examination to determine the nature of the weapon should be made as early as possible. Ecchymoses are more easily produced in the young, the aged, and in females, also in the case of such general diseases as scurvy, purpura, hemophilia, etc. In fact, in the last three classes they may occur spontaneously. This fact should never be lost sight of, as the attempt may be made to explain a traumatic ecchymosis in this way. The diagnosis between the traumatic variety and such cases of spontaneous ecchymoses is, in general, easy, for in the latter case their number, form, size, and occurrence on parts little exposed to injury and on the mucous membranes, as well as the general symptoms of the disease, leave little or no room for doubt. From an oblique or glancing blow a considerable area of skin may be stripped up from its deep attachments forming a cavity which may be filled by a clear serous fluid alone, or with some admixture of blood. These cases have been studied especially by Morel Lavallée and Leser, and the fluid has been thought to be lymphatic in origin, hence the name “_lymphorrhagia_.” Carriage accidents, especially where the wheels do not pass directly but obliquely across or merely graze the body, are especially liable to show this form of extravasation, which is thought to be more common than is generally supposed, being often obscured by a small quantity of blood. [Illustration: FIG. 8.—Linear Wound with Nearly Clean-Cut Edges, with Strands of Tissue bridging across at the Bottom and caused by a Fall on the Head on a Smooth Surface.] =Contused Wounds.=—If with the contusion we have a solution of continuity of the skin, then we have a contused wound. This may sometimes resemble an incised wound if the weapon has marked angles or edges, as a hammer, or, as we have already seen, in wounds of the scalp or eyebrow (Fig. 8). Careful examination, however, by a small lens if necessary, is sufficient to distinguish them if they are fresh. If they are four or five days old and have begun to granulate, it may be impossible to distinguish them. Contused wounds present on examination small tears on the edges which are widely separated and more or less extensively ecchymosed. Contused wounds are often irregular, and have thickened or swollen and ragged borders. They may, like simple contusions, show by their shape the form of the instrument which caused them. In contused wounds, unless they be perfectly aseptic, we usually find sloughing of the contused, necrotic tissues. This leaves a cavity to be filled up by granulation like wounds with loss of substance. They therefore often present large cicatrices which may be mistaken for those of ulcers. In contused wounds the bone may sometimes show the impression of the instrument causing the wound. A variety of contused wounds is that where the wound of the skin consists merely of an _erosion_ or _excoriation_ with an ecchymosis beneath. The wound may reproduce the shape of the weapon, _i.e._, finger-nails, etc. After death the skin becomes brownish-yellow, hard, and dry, and then they are called by the French “_plaques parcheminées_.” They are distinguished, as a rule, from those produced after death, by the ecchymosis beneath. =Lacerated wounds= resemble contused wounds very closely, but are not ecchymosed to any considerable extent. The solution of continuity is sometimes very extensive and irregular, and may present several flaps. The bone or bones are often fractured at the same time. They seldom bleed much. The course of repair resembles that of contused wounds as a rule. The prognosis is variable, for there may be slow and extensive cicatrization and impairment of function, etc. These wounds usually result from machinery accidents and accidental tears, etc. They are therefore seldom the occasion of criminal proceedings but more often of a civil suit, and thus require medical examination. The injury which causes a contusion or contused wound may not infrequently produce effects far more serious and more or less remote from the contusion. Some of these effects it may be well to particularize. Blows on the abdomen are sometimes quickly followed by death without visible lesion to account for it. That authentic examples of this exist has been denied by Lutaud, except for cases of rapid death following contusions of the abdomen which had caused extensive rupture of the viscera and abundant hemorrhage. But Vibert gives two cases from his own experience, which are as follows: A young man, twenty years old, received a kick in the stomach at a public ball. Numerous witnesses of the scene testified that he only received this one blow. The man collapsed immediately and died in a few minutes. On autopsy nothing was found but two small ecchymotic spots in the peritoneum covering the intestine, the largest not the size of a bean. In the second case, the injury was also a kick in the stomach and the man died almost immediately. Absolutely no lesion was found on autopsy. Both were in full digestion. König[606] says: “A number of severe contusions of the belly run a rapidly fatal course without the autopsy showing any definite anatomical lesion of the viscera.” He also adds that the less severe cases at first often show very profound shock, which is out of proportion to the force of the injury. The cause of death has been explained, like that of sudden death from a blow on the larynx, by the theory of inhibition. These cases are often illustrated experimentally on frogs, where the same result is obtained under similar conditions. Such cases are the more remarkable from the fact that the fatal blow may cause no ecchymosis or other mark of injury to appear on the abdominal walls. Blows on the head may produce a variety of results besides that of the contusion itself. In fact, death itself may result though the marks of contusion are very slight or even imperceptible. Intracranial hemorrhage, laceration with ecchymosis of the brain, on the same or opposite side to the injury, and concussion of the brain may result. Of these only concussion will be considered now. =Concussion= has been defined as a shock communicated to an organ by a blow or fall on another part of the body, which may or may not be remote, and without producing a material or appreciable lesion. According to Lutaud,[607] English pathologists understand by it a temporary or permanent nervous exhaustion resulting from a sudden or excessive expense of nervous energy. Its effect is observed in the function of an organ and especially in the brain. Concussion of the brain causes stupidity, loss of consciousness, amnesia, coma. The intracranial lesion most often associated with concussion is ecchymosis and laceration on the surface of the brain, but there may be no lesion visible even if the case is a fatal one. Fatal concussion has been observed where the marks of external violence were very slight or even failed entirely, as illustrated by the two following cases cited by Vibert:[608] Vibert made an autopsy on a man who had been struck by a pitchfork, one of the teeth of which struck behind the ear, the other two in the face, only producing slight skin wounds. The man immediately lost consciousness and died in two days in coma. No lesion whatever was found within the skull, and only three slight ones externally. He observed another case where the man fell three or four metres into an excavation, landing on his feet, and died in a short time. On autopsy only slight erosions and no intracranial or extracranial lesions were found. This case belongs to a rare class where the blow is transmitted through the spinal column without sign of injury externally or internally to the head. The following case cited by Vibert is even more remarkable in the production of the severe though not fatal concussion: An officer was riding at full speed on horseback, when his horse suddenly stopped short. By great exertion the officer clung to the horse, but immediately lost consciousness. His fall from the horse was broken by those about him, and the concussion he received was not due to the fall, but to the shock of stopping suddenly when his momentum was great. As a rule, however, the diagnosis of concussion, especially if it is severe enough to be fatal, is easily made by the marks of external violence with or without intracranial lesions. The effects of concussion may be transient and leave no trace, but, on the other hand, they may be prolonged and severe, _i.e._, paralysis, aphasia, loss of memory, imbecility, etc. The medical examiner should be on his guard against simulation in respect to these prolonged effects of concussions. One of the most frequent consequences of concussion is temporary amnesia, which ordinarily succeeds immediately after the injury, but sometimes develops more slowly. The following curious case is quoted from Lutaud as cited by Brouardel: A woman in getting out of a train at Versailles, where she had gone to attend the funeral of a relative, was struck by the door of the compartment. She fell, but did not lose consciousness, and picked herself up, but forgot what she had come for. Another result of an injury which has caused a contusion or contused wound may be a fracture or dislocation. Fractures and dislocations of special parts will be referred to later, in considering injuries of the several regions of the body, but it seems appropriate here to refer to some of those general considerations relating to these injuries which may especially demand the attention of the medical expert. =Fractures= may be produced by blows or falls, or from muscular action. The medical witness may be questioned as to the cause of the fracture or, if it was produced by a blow, whether a weapon was used or not, as the defence is likely to assert that it was caused by an accidental fall. The nature of the associated wounds and contusions, if any exist, may, as we have seen, indicate the weapon used. If anything exists to indicate that a fall which caused the fracture was not accidental, this should be noted, as the assailant is responsible for the effects of the fall. A number of conditions influence the ease with which a fracture is produced and account for a fracture being due to a slight injury, and so are mitigatory circumstances in the case. Fractures are more easily produced in the old and young, especially the former, than in the adult from the same force. This is due to brittleness of the bones in the old and their small size in the young. Certain diseases like syphilis, arthritis, scurvy, carcinoma, and rickets make the bones more frangible, and there is a peculiar brittle condition of the bones known as _fragilitas ossium_, more or less hereditary, in which the bones become fractured from very slight violence. Mercer is quoted by Taylor as stating, but on how good authority it does not appear, that in general paralysis of the insane the bones are particularly liable to fracture. Certain it is that not uncommonly insane patients are found dead with single or multiple fractures, but the attendants are generally convicted. In some parts, like the orbital plate of the frontal bone, the bone is very thin and brittle, but brittleness from any cause only mitigates, it does not excuse. Taylor[609] reports a case in point where it was proved that the bones of the skull were thin and brittle, and the fractured skull proved fatal from inflammation of the brain. The punishment was mitigated owing to the circumstance of the brittleness of the bones. SPONTANEOUS FRACTURES may occur from only a moderate degree of muscular action, and even where there is no disease of the bones, but the above-mentioned condition of fragilitas ossium, rendering the bones more brittle, aids in the production of such fractures. The olecranon, patella, and os calcis are particularly liable to such fractures, but the long bones of the ribs and extremities are sometimes so fractured, as instanced in the following cases cited by Taylor:[610] The humerus of a healthy man has been broken by muscular exertion simply by throwing a cricket ball.[611] In 1858 a gentleman forty years old, during the act of bowling at cricket, heard a distinct crack like the breaking of a piece of wood. He fell immediately to the ground, and it was found that his femur was fractured. Again, in 1846, a healthy man, æt. 33, was brought to Gray’s Hospital with the following history: He was in the act of crossing one leg over the other to look at the sole of his foot, when something was heard to give way; his right leg hung down and he was found to have received a transverse fracture of the femur at the junction of the middle and lower thirds. The writer had a case in Bellevue Hospital during the past winter (1892-93) of a man who stated that he had been well and active until some weeks previously, when, from muscular force alone, he sustained a fracture of the neck of the femur. Something abnormal in the bone may be present in such cases. In cases of spontaneous fractures there are no marks of external violence which, if present, would remove the idea of spontaneity. Fractures of the extremities are not dangerous _per se_, unless they are compound or occur in old, debilitated, or diseased persons, and they are more severe the nearer they are to a joint. The healing of fractures is more rapid in the young than in the old and in the upper than in the lower extremity. It is not proven that adiposity of itself impedes union. The question may be asked, how long before examination a given bone was fractured. As a rule, we can only say as to whether the injured person has lived a long or short period since the injury, as the process of repair varies according to age and constitution. No changes occur until eighteen to twenty-four hours, when lymph is exuded. According to Villermé the callus is cartilaginous anywhere between the sixteenth and twenty-fifth days, it becomes ossified between three weeks and three months, and it takes six to eight months to become like normal bone. The question may also be asked: Has a bone ever been fractured? The existence and situation of a fracture can often be recognized long after the accident, by the callus or slight unevenness due to projection of the edges or ends of the fragments. Where the bone lies deeply covered by soft parts, it is difficult and often impossible to tell, long after union has taken place, whether or where a fracture has occurred. The answering of this question may sometimes be of importance in identifying the dead, especially in the case of skeletons. In the latter instance by sawing the bone longitudinally we can tell by the thickness, irregularity, or structure of the bone tissue whether a fracture existed, and if it were recent or old at the time of death. =Dislocations= call for a medico-legal investigation less often than fractures. They are less common in the old and where the bones are brittle, when fracture occurs more readily. They are seldom fatal _per se_, unless between the vertebræ or when compound. They may occur from disease in the affected joint or even spontaneously. The diagnosis of a dislocation is easy until it has been reduced, and then it may leave no trace except pain in and limitation of the motion of a joint besides swelling and ecchymosis. These effects are transient, and after they have disappeared it may be impossible to say whether a dislocation has existed on a living body, unless, as sometimes occurs, especially in the shoulder joint, there may be a temporary or permanent paralysis of a nerve and muscular atrophy. After death, the existence of an old dislocation may often be recognized on dissection by scar tissue in and about the capsule. EXAMINATION AND DESCRIPTION. The examination of wounds or injuries in a case which is or may become the subject of a medico-legal investigation should be made with particular care and exactness. As the examination of the wounded person is to give most, and in some cases all, the information to the medical expert on which he is to base his testimony, it should be made with reference to all the possibilities of the case. The particular variety of wound as described in the foregoing section should be noted, and any peculiarities as to its situation, shape, extent, length, breadth, depth, direction, and the parts involved. Besides these points, the condition of the edges of the wound, whether swollen and ecchymotic, smooth and straight or dentated and irregular, and whether inverted or everted and gaping, are matters of importance. The presence or absence of coagula and clots, the staining of the tissues with blood, the presence of ecchymosis and its comparative age, as shown by its color, should also be noted. Many of the above points help us in solving another problem, namely, the form of the instrument used. This question will be discussed in a subsequent section, but the basis for our opinion is founded, of course, on an examination of the particulars of the wound. The solution of still another question which often arises and which will be discussed in the next section, namely, whether a wound was produced before or after death, is based upon particular features of the wound such as the fluid or clotted condition of the blood on the surface, or ecchymosed in the tissues, also the amount of the hemorrhage as compared to the vascularity of the part as well as the greater or less staining of the tissues with blood, and the conditions of the edges, whether inverted or everted and whether or not retracted. The question as to whether a wound was directly, secondary or necessarily the cause of death, is determined, in part at least, by examination of the wound. In this connection we take note as to whether a wound has opened or divided a large vein or artery or is situated in such a vascular part as to be fatal from hemorrhage. We also note whether death could have been due to shock from the situation of the wound, or whether an inflammation which was directly responsible for death was necessarily due to the wound, as in case of a penetrating wound of the viscera, etc. Further, we note whether one of the many forms of wound diseases from infection of the wound has complicated the case and caused death in the case of a wound not otherwise necessarily fatal. It may be added that often the necropsy aids us in the solution of the question as to whether the wound was the necessary and direct cause of death, by showing a healthy or diseased condition of the viscera. The question as to which of a number of injuries was first inflicted, also as to the relative position of the victim and assailant, can be answered, if at all, only by an accurate and close examination of the wounds. Finally, the most important question of all, from a medico-legal standpoint, namely, the distinction between homicidal, suicidal, and accidental wounds, is decided or inferred from the characteristics of the wound after careful examination. All the foregoing questions contribute to the solution of this the most important one. The various questions referred to above will be considered at greater length in the subsequent sections. They have been merely referred to in brief above, to show the various lines of thought a medical examiner must have in mind in making an examination. As to the act of examination itself, the physician should conduct it in such a way as not to harm the wounded person. Often simple inspection is the most that can be done, or the examination may have to be deferred altogether until the physician in charge informs the court that an examination may be safely made. It is often necessary for the expert to get information as to the original lesion from the physician in charge. If the wound has been a fatal one and if we are called in after death, we may examine the wound on the dead body with much more freedom. Here we may examine the depth, direction, etc., of a punctured wound by cutting down on a probe or director. After careful inspection of the wound we may examine it by palpation, and go on to the dissection of the wound and the surrounding parts, tracing and noting the various vessels, muscles, etc., involved in the wound, and looking for the presence of any foreign body in the wound. Furthermore, if the cause of death be at all obscure, we should examine not only the wound itself and the parts about the wound, but also, by an autopsy, all the cavities and organs of the body. For death may have been due to natural causes in an organ not examined, if the examination has not included all, and the physician has to disprove it. In examining at an autopsy the depth of a wound in reference to the instrument which caused it, it should be borne in mind that the wound may be deeper than the weapon owing to a depression of the surface by the handle of the weapon. This may appear especially marked in the case of the movable viscera, as at the time of the accident the viscus may have been as near as possible to the surface, and at the examination as far as possible from the surface, as in the case of a given coil of the intestines. Also the thorax when opened at autopsy enlarges or expands a little, so that the measured depth of a wound may be greater than the weapon which caused it. Vibert[612] mentions a case of a penetrating wound of the thorax involving the heart, where the measured depth of the wound was 0ᵐ.035 greater than the length of the instrument. This may also be accounted for by a depression or flattening of the thorax by the blow, as in the case of soft parts. It is often difficult in an examination to measure accurately the depth of a wound, for one may find it hard to determine the precise end of a wound. Also, for exact measurement it is necessary to have the parts in the same position as at the time of the accident, and these parts are more or less displaced by the necessary dissection. Besides the examination of the wound there are other points the examination of which may aid us in solving the problems presented by a case. Among these, the examination of the clothing or dress is perhaps the most important. This may indicate the weapon used in an incised or punctured wound. Contused and lacerated wounds or fractures, etc., may be produced without injuring the clothing. Blood, dirt, or grease on the clothing may throw light on the case. In self-inflicted wounds the wound in the clothing and that on the body may not and often do not correspond, as an intending suicide often (a murderer rarely) opens the clothing to select the spot for the wound. The wound in the dress is then added by a second blow not corresponding to the first. In this way we may sometimes distinguish between a homicidal and suicidal wound, and thus remove a false suspicion of murder or show that a wound was self-inflicted to conceal other crimes or to falsely impute it to another. The suspicion of homicide in accidental wounds may be cleared up by an examination of the dress, as in the following instance related by Taylor:[613] A woman was found dead in bed with two indentations about the middle of the right parietal bone, a large superficial clot here and three ounces of clotted blood between the dura mater and skull, which latter was fractured over an area of four inches. No other cause of death was found. The evidence brought out the facts that she had been knocked down the evening before, about 7:30 o’clock, by a man accidentally running into her. She fell on the back of the head, was stunned, raised up, and stimulated; she then walked home, ate her supper, and was last seen at 9 o’clock by a fellow-lodger who let her in and noticed nothing unusual. The next morning she had evidently been dead some time. Suspicion fell upon the lodger, who had often quarrelled with her, and the two claws of a hammer found in his room corresponded more or less closely with the two indentations found in the skull. At the adjourned inquest, however, the _bonnet_ worn by the deceased at the time of the accident was found to have two indentations on the back of it corresponding to those on the woman’s skull and containing dust and dirt, and rendering probable what from the history seemed unlikely, that the fall in the road caused the fatal injury. The examination of the dress thus avoided an unjust accusation of murder. Contused and lacerated wounds and fractures or dislocations may be produced without injury to the dress, especially if the latter be elastic or yielding. The comparison of the wound in the clothes with that on the body may indicate the position of the body at the time of the blow. The examination of the clothes of the injured person may indicate a struggle which would support the idea of homicide. A blunt instrument may indirectly cause an injury by striking something in or on a person’s clothes. Instances have been reported where a wound has been caused by an article in the pocket, or worn outside the clothing, without any trace of an injury to the clothes or pocket lining.[614] The examination of the dress may further show which of several cuts or stabs was first inflicted. This is shown by the staining of the edges of the cuts in the clothing, the edges of the first cut or stab showing no blood-stain or only on the inner surface, as the knife is clean of blood on entering and all that is removed by the clothing on its withdrawal is found on the inner edges. If the edges of the cuts in the outer layers of clothing are bloody, it is evident that the knife was already bloody when used, and the corresponding wound was not the first inflicted. The imprint of the bloody hand of the assailant may sometimes be found on the clothing of the one injured, and is especially important as evidence, when the hands of the assaulted are not bloody. In the case of a severe wound, especially if it is likely to become the object of a criminal investigation, the physician should always require to see the dress of the wounded. The examination of the clothing which the accused wore at the time the assault took place may give important evidence by showing evidences of a struggle or blood-stains. Absence of the latter would not prove the innocence of the accused, as the clothes actually worn may be destroyed and others substituted, or the marks and stains may be removed. In the latter case, the eye of a medical man may detect traces of blood which otherwise would go unnoticed, and a microscopical and chemical examination would reveal the real character of the stain. Besides the examination of the clothing of the accused, the examination of his person may furnish evidence of his being engaged in a more or less desperate struggle by the scratches, marks of nails, contusions, bites, etc., on the face, neck, front of chest, forearms, and hands. If the accused should attempt to explain these wounds and spots, the latter may or may not verify the explanation, and thus additional evidence may be obtained as to the guilt or innocence of the accused. It is well for the medical expert, as well as for others, to collect the statements of the wounded person relative to the circumstances of the injury. Also, if the accused will vouchsafe any such statements we may compare these with one another and with the facts indicated by the wound, etc. Other points to examine, especially in cases of suspected suicide, may be briefly mentioned. The presence of the weapon in the hand of the victim and firmly grasped in general indicates suicide, if it corresponds to the weapon causing the wounds, for otherwise it may have been used for defence. If not in the hand, note the spot where the weapon was found. In the case of a suicide, the hand as well as the weapon held by it is likely to be bloody, also in case of murder the generally empty hand is apt to be bloody, as the hand is naturally carried to the wound. We cannot further describe the many points which the medical examiner should bear in mind in making an examination in a medico-legal case, without repeating too fully what will be given at greater length in subsequent sections, reference to which should be made for further particulars. Tardieu proposed as a basis for examining and studying wounds, (1) to visit the wounded person and see what state he is in, and to determine (2) the nature, (3) the cause, (4) the consequences of the wound. Also if the wounded person is dead (5) to examine the body for the cause of death in order to see if the latter is due to the wound. Also (6) to determine the circumstances of the affray. =The description= of a wound should be given in plain language, avoiding the use of scientific terms or expressions, so as to be readily understood by judge and jurors. Otherwise the usefulness of the medical expert is very much decreased. The description should also be precise and sufficient to justify the conclusions arrived at as to the cause of a wound, its gravity and results, and the weapon used. With a view to exact statement in description, it is well to take notes as to the result of the examination and not depend merely on memory. The object of the witness should be to be understood and not to be thought thoroughly scientific. WAS THE INJURY INFLICTED BEFORE OR AFTER DEATH? This is a question which may often be asked in cases of fatal injuries, and it is one which must be answered as definitely as we are able, for the defence may rest on the assertion that the wound or injury was post mortem and not ante mortem. What are the means we have to enable us to answer the above question? The most important factor is the condition of the blood and the changes that it undergoes after death. For some hours after death the body retains its animal heat. As long as this is retained rigor mortis does not set in and the blood is more or less fluid. This period varies, but on the average it does not last longer than eight or ten hours. Before this time, however, the blood has begun to undergo certain changes. These changes result in the inability of the blood from a post-mortem wound to coagulate completely. At first the greater part may coagulate, but after a time coagulation is less and less complete, and the coagula are not as firm as those from the blood of a living person. The period at which these changes occur also varies, but they may generally be clearly noticed in from three to four hours after death, or even sooner. In the first two to four hours after death, therefore, as far as the condition of the blood is concerned, it may be difficult or impossible to say whether a wound was made before or soon after death. In other words, this difficulty exists as long as the tissues of the body live after the body as a whole is dead. There are certain general pathological or occasional conditions of the body in which the blood during life does not coagulate at all or only imperfectly, as in scurvy and in the case of the menstrual blood. Also blood in a serous cavity, especially if it be abundant or there exists inflammation, is found not to coagulate or only imperfectly. Post mortem the blood remains liquid long after death in cases of death by drowning, asphyxia, etc., and in such cases hemorrhage may be free in a wound made some time after death. Furthermore, after putrefaction has set in the blood again becomes more or less liquid, and may flow away from a wound like a hemorrhage, but it no longer coagulates. The principal signs of a wound inflicted during life are (1) hemorrhage, (2) coagulation of the blood, (3) eversion of the lips of the wound, and (4) retraction of its sides.