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by friction with a coarse brush or cloth, and so as not to be dis-
tinguishable from similar injuries produced during life." "When,"
says Engel, "these excoriations are found upon parts of the body in
which the blood cannot settle after death, the portion of dried integu-
ment acquires a yellowish-brown color, and is translucent at the
edges; en the other hand, if they form in situations where the blood
tends to accumulate, their color is a very dark brown, and they can-
not be distinguished from excoriations produced during life."
Casper insists upon the practical importance of these distinctions,
declaring that the cases are numberless in which ignorance of them
or inattention to them has led to the most erroneous conclusions and
mischievous consequences.

The inference from the considerations here presented is not that
there is no distinction possible between ecchymoses produced before
and after death, but that great caution is necessary in giving an
opinion upon this point. The external bruise must be carefully
compared with the effusion into and under the skin and adjacent
tissues. If the latter be at all extensive, and especially if the blood
be coagulated, we think there need be little hesitation in declaring
that the injury must have been inflicted during life. Moreover,
there are few cases of vital ecchymosis, without attendant swelling
of the skin and other signs of vital reaction. If, while the body is
fresh, the ecchymosed spot be found at all swelled, there can be no
suspicion of post-mortem violence. Also, if the ecchymosis, though
trifling in extent, be accompanied with excoriations or abrasions of
the skin, as is often found in cases of strangulation with the hand,
the fact of the violence having been done upon a living person will
be manifest. The difficulty of discriminating between contusions
made before and after death will be much enhanced by the putre-
factive process, the effect of which is to so alter the consistence and



218 PHYSICAL INJURIES BY FORCE. [§ 250

color of the skin and subjacent parts as to destroy all characteristic
signs.

Devergie 71 has remarked that ecchymoses are often concealed on
the bodies of the drowned, when first they are removed from water,
owing to the sodden state of the skin ; they may become apparent
only after the body has been exposed for some days, and the water
has evaporated.

251. Cadaveric spots. — The spots and blotches (snggillations) pro-
duced by cadaveric changes are more likely to give rise to mistakes.
In persons unaccustomed to inspect the bodies of the dead, the stasis
or congestion of the blood in the capillary vessels of the skin, which
sooner or later invariably occurs, may lead to the suspicion of
violence having been inflicted before death. This lividity is most
apparent and extensive in those who have died suddenly in full
health, by some asphyxiating cause. It occurs in almost any part
of the body, but is usually deeper and more distinct in those which
are the most dependent. The time at which it is developed varies
from the moment of dissolution up to the occurrence of rigidity;
and is, of course, hastened or retarded by various causes, such as the
mode of death, the season of the year, and the age of the subject.
The blood is merely superficially diffused in the outer surface of the
skin, and this mark alone ought to suffice to distinguish these dis-
colorations from those produced by violence, since in the latter the
blood is effused in the whole substance of the cutis and generally,
also, in the subcutaneous cellular tissue, muscles, etc.

The forms assumed by the marks of cadaveric lividity are vari-
ous; sometimes the skin is mottled, at others large blotches spread
over the surface, and at others, again, the lividity is more uniformly
diffused, without necessarily appearing on a dependent part. The
marks of the clothing which the deceased wore, if they have remained
upon him until rigidity has taken place, give a very singular appear-
ance to the skin. Those portions which have compressed the body
tightly will be recognized by the paleness of the surface, while the
intervening spaces may be deeply tinged. The folds of a sheet often
thus communicate to the body an appearance of flagellation, the back
being covered with stripes. These are called vibices, and are familiar
to every one accustomed to the inspection of persons recently dead.
This stage of cadaveric lividity, which is due to the congestion of the
capillary vessels, runs gradually into another at the approach of

" Taylor's Medical Jurisprudence,
sixth American edition.



6 251] WOUNDS. 219

putrefaction. This stage is characterized by the uniform purple
or dark red discoloration of all the depending portions of the body,
and arises from a transudation of the serum and coloring matter of
the decomposed blood. Hence, when an incision is made into parts
thus affected, as, for instance, over the occiput, the skin and sub-
jacent tissues will be found thickened and infiltrated with bloody
serum. But neither of these stages of cadaveric lividity ought to
mislead the physician ; the diffusion, the superficial character of the
infiltration, or, as in the latter case, the peculiar kind of effusion, the
want of any external injury to correspond with the internal marks of
apparently great violence, and many other considerations, which it
is hardly necessary to specify, ought to render the distinction an easy
one. We are disposed to think that the possibility of serious error
arising from the distant resemblance between cadaveric lividity or
the discoloration of the skin caused by certain diseases of the blood
has been in general overestimated by writers upon legal medicine.

252. Post-mortem blisters. — Blisters produced by heat, says Bec-
ker, although when laid open they may disclose a red skin, do not pre-
sent characteristics which enable us to determine whether they were
raised before or after death; for instance, heat produces the same
immediate effect in each. Scalding liquids, however, do not blister
the dead body, they only cause the epidermis to peal off in shreds.
The skull, when subjected to the action of flame, cracks and exfoli-
ates. Brouardel 72 considers, however, that the contents of the blister
differs in two cases. If the burn be inflicted upon the living, the
fluid is what he describes as albuminous. If the body be dead before
the burning, he describes the fluid as serous.

V. Wounds of vakious parts of the body.

253. Head, in general. — Injuries to the head from their frequency
and gravity as well as from the various medico-legal questions to
which they give rise, are deserving of particular attention.

254. Face. — Wounds of the face cannot, in general, be considered
as dangerous to life though they are often followed by serious de-
formity and tedious healing. In addition to the unsightly scars,
wounds to the cheeks, just in front of the ear, are liable to injure the
nerve that goes to the muscles of the face, and cause paralysis of that
side of the face.

255. Eye. — Wounds to the eye 73 may not merely interfere with

72 Brouardel, L'lnfanticide, 1897, p. "For many instances of serious
124. wounds to the eye, see Gould and Pyle's



220 PHYSICAL INJURIES BY FORCE. [8 255

or destroy the vision of that eye, but, if the injury involve the zone
about five millimeters outside of the edge of the iris, there is liable
to follow a sympathetic ophthalmia, with the loss of sight in the
other eye. Moreover, total blindness may follow a traumatism to
the head which leaves no evidence on the surface of the cause of
the blindness. Such instances may be due to destruction of the
optic nerve at its entrance into the orbit by a splinter of bone chipped
off at that point, or by compression of the nerve by a deep blood clot.
Injuries penetrating the socket of the eye also find easy entrance into
the cranial cavity and are thus likely to produce injury to the brain,
and, possibly, death. Injury to the nose is not, as a rule, significant
beyond the deformity, except in those cases of penetration, where the
instrument, going through the nose, may also enter the brain.

256. Ear. — Injury to the ear 74 finds its significance in large part
in the subsequent deafness. In many cases the traumatism to the
ear may merely call attention to a previous deafness that had gone
unnoticed. Such a previous trouble should be ruled out before the
traumatism is accepted as the cause of the newly discovered deaf-
ness. The diagnosis of previous disease is not always clear. If there
is a large, irregular perforation of the drum membrane, with a per-
sistent discharge of pus, extensive involvement of bone, adhesions of
the small bones of the ear, and exuberant granulation tissue (proud
flesh), there can be no question but that the disease has been in
progress for at least several weeks. On the other hand, if the rent
in the drum membrane is fresh, and there is a discoloration of the
tissues, due to eechymosis, the perforation is probably of traumatic
origin. Traumatic ruptures of the drum membrane are usually
found in the upper part of the membrane, and have the appearance
of an irregular slit; very rarely are they the shape of a circular
perforation. Rupture may be due either to direct violence applied
to the drum membrane by an instrument introduced into the auditory
canal, or, as more commonly is the case, through indirect violence,
by compression of the air in the canal from a bknv upon the external
ear. Such a blow is usually followed by more or less hemorrhage,
and possibly by deafness; but even if the drum membrane be rup-
tured, deafness by no means always follows for a ruptured membrane
is perfectly compatible with good hearing in that ear, in spite of
the prevalent opinion among the laity to the contrary.

Anomalies and Curiosities of Medicine, Supplement Heft, 1903. Also Could and

p. 527. Pyle's Anomalies and Curiosities of

74 Sfe Bornhnrdt's article. Viertl- Medicinej p. 537.
jl-r-chr. f. Ger. }led. 3 F., Bd. XXV.,



§ 257] WOUNDS. 221

257. Scalp. — Wounds of the scalp are peculiar in thai they do not
gape open as wounds in most of the other parts of the body do. They
also usually involve the deep structures down almost to the bone.
The process of repair goes on to a distinctly better advantage than
in most other regions of the body, and a large number of the wounds
which elsewhere would suppurate, here heal by primary intention, so
that scalp wounds may, in general, be considered less dangerous than
those of equal extent in other portions of the body. Many instances
of removal of the entire scalp by machinery accidents are on record. 75

258. Skull fractures, in general.— Fractures of the' skull are pe-
culiar in that they involve flat bones, consisting of two lamellae of
compact bony tissue, and an intermediate spongy layer.

259. Vault of skull.— The fracture of the vault of the skull may
involve either one of these layers alone or both layers, depending on
the character of the violence exerted. The fracture, likewise, may
be a simple fissure of the bones, or a distinct depression of an area
of the bone. If there is no open wound to examine it is extremely
difficult to diagnose a fracture of the skull unless there is a distinct
depression of the bone. Von Bergmann says 70, that many, perhaps the
majority, of such fractures remain undiscovered. Fortunately the
danger from a fracture of the skull is not dependent directly upon
the bone lesion, but rather upon the injury to the brain; and it is the
depressed fractures that cause the most injury to the brain. How-
ever, there is always associated with the fracture some violence done
to the brain, independent of the fracture. 77

260. Base cf skull. — Fractures of the base of the skull are much
more serious, because, as a rule, the violence causing such a fracture
is much more severe, since the bones in this region are distinctly
denser than those of the vault. Moreover, the portions of the brain
in contact with this portion of the skull are more intimately con-
nected with the functions of life, and injury to them almost in-
variably causes immediate death. Another great source of danger in
fractures of the skull is the infection of the cranial contents with
the production of meningitis, or brain abscess.

The diagnosis of fractures of the base of the skull is more diffi-
cult than that of those of the vault, and these fractures are all too
often not diagnosed. When a man is picked up unconscious on the
street, among the "possibilities to account for his condition are the

" For instances of scalp avulsion see n Von Bergmann and Bull's System of

Schaeffer, Transactions of the Ninth Practical Surgery, Vol. I., p. 82.

International Medical Congress, Wash- ,7 See §§ 263 et seq., infra.
ington, 1887, Vol. III., pp. 166 et seq.



222 PHYSICAL INJURIES BY FORCE. [§ 260

fairly frequent intoxications, and the injuries to the brain and
skull, of which these fractures of the base are one of the most
evasive in diagnosis. If there is any sign of bleeding from the nose,
mouth, or ears, or any bleeding into the conjunctiva?, or if there is
any sign of paralysis of any of the cranial nerves, the probability
of fracture is great. The escape of brain substance or of serous fluid
from any of the cavities in proximity to the brain — the ear, nose,
mouth — makes the probabilities still greater in favor of fracture of
the skull.

In milder cases, possibly in the course of a few days, symptoms
may develop or disappear so as to clear up the diagnosis.

261. Mechanism of fractures. — The mechanism by which fractures
of the skull are produced is very important from a medico-legal point
of view. A most excellent description of this mechanism is given
by von Bergmann. 78 He describes them as bending or bursting frac-
tures. The bending fractures occur at the site of impact of the vio-
lence, or in parallel circles around that point. The bursting fractures
tend to extend from the point of impact to the diametrically opposite
pole of the skull, and most frequently involve the base of the skull,
because it is less elastic than the vault. The fractures due to the
bending in of the skull at the point of impact are usually depressed.
The others due to bending are in the circles around this point, and the
bursting fractures are regularly fissures of the bone perpendicular to
the circles of the bending fractures.

The fractures occurring at the opposite pole of the skull from the
point of impact (which are commonly called fractures by "contre
coup"), he considers as incomplete bursting fractures. A most
famous fracture of this type was the fracture of the two orbital plates
of the skull after the gunshot injury to the occiput, in the case of
President Lincoln. Compression of the skull between two bodies, as
when the skull is run over by a wagon or hit by a stick of wood while
the head is lying on the ground, produces usually a fissure of the base,
extending from ear to ear (a bursting fracture) in addition to the
depression of the bone at the point of impact of the wagon wheel (a
bending fracture). Similarly a fall upon the occiput is very likely
to cause a fissure from the occiput through the base to the anterior
portion of the skull, as well as the depressed bending fractures at the
site of impact. If the skull is merely struck and hot compressed be-
tween two bodies, the bursting fissures tend to extend from the point

T> Von Borgmann and Bull's System of
Practical Surgery, 1004. Vol. I., p. 70.



5 261) WOUNDS. 223

of impact to the equator. If the fissures are due to compression they
are widest in the equator and least near the poles. Falls upon the
top of the head or blows there produce peculiar ring fractures of the
base, — bending fractures due to the sharper impact from the spinal
column. With these may be associated bursting fractures, running
radially to this ring. Hence he considers that, from the character
of the fracture of the skull, a great deal can be determined about the
manner in which the violence wis inflicted.

262. Gunshot fractures. — Gunshot wounds of the skull are deserv-
ing of special attention on account of their frequency and their pe-
culiarities. The following is quoted from von Bergmann: 79 "In
gunshots fired at very short range the skull cap, together with the
scalp covering it, is torn into many pieces which, with the mangled
brain, are scattered to quite a distance. At a range of 50 meters
(160 feet) the scalp is preserved and continues to hold the skull to-
gether, though the latter is broken into many fragments. The scalp
shows two defects, with lacerated edges, from which the brain tissue
exudes: the wound of entrance and the wound of exit. At a range
of 100 meters (325 feet), the destruction of the skull is somewhat
less, though two zones of comminution can be found, grouped around
the wounds of entrance and exit. The lines of fracture are arranged
in part radially, in part encircling the bullet hole like a scries of
bursting and bending fractures. The fissures may become united
with one another, forming a network spread all over the entire skull.
The diameter of the wound of exit in the skin does not exceed 20 to
30 millimeters. At increasing range the damage done by the pro-
jectile continues to grow less. At a range of 800 to 1,200 meters
(2,600 to 4,000 feet) the fissures encircling the bullet holes disap-
pear and only the radial fissures are present. These disappear at a
range of 1,600 meters (5,200 feet) and upward, except that there is
one fissure connecting the wound of entrance with the wound of exit.
Even this is no longer present at a range of from 1,800 to 2,000
meters (5,600 to 6,500 feet) : at this distance there are clean-cut
bullet holes. It was not until a range of 2,700 meters (8,700 feet)
had been reached that the skull was not perforated, and the bullet
remained embedded in the brain.

"Ordinary pistol shots and revolver shots, even at short range,
produce none, or, at most, only short, radial fissures, and one or two

"Von Berermann and Bull's System
of Praciical Surgery, 1904, Vol. I., p.
113.



224 PHYSICAL INJURIES BY FORCE. [§ 262

concentric fissures about the bole, resulting from the cylindrical bul •
let They rarely traverse the entire skull so as to leave a wound of
entrance and of exit, usually remaining embedded in the brain.
Where there are two openings their appearance is characteristic, and
it is always easy to tell at once which is the wound of entrance and of
exit.

"The wound in the outer table is made by the foreign body itself,
while that of the inner table is caused not only by the bullet, but also
by the fragments of bone broken from the layers of bone already tra-
versed: the external table and the diploe. The internal opening is
not only larger, but is usually irregular in outline, with a notched
and broken edge, owing to the fact that it is produced not by a spher-
ical projectile alone, but by splinters and fragments carried along
with it. Should a bullet penetrate the entire skull from one side to
the other, the o.uter table would be more extensively comminuted than
the inner (in* the wound of exit) for the reason just explained."

263. Brain, in general. — Injuries to the brain may be divided into
three general classes: Concussion, compression, and destruction.

2S4. Concussion of brain. — In concussion of the brain without
any macroscopic or microscopic lesion of the brain, there is, following
a traumatism to the head, a transient depression of all the activities
of the brain ; there is a depression or loss of consciousness, going on
to a state of stupor or coma, slowing of the pulse, and marked slow-
ing of the respirations. This stage gives way to one of exaltation,
with increased frequency of pulse and respiration and elevation of
the body temperature. If the symptoms persist for more than a
couple of days the probability of the presence of some other compli-
cation must be considered. This condition has recently been pro-
duced experimentally by repeated light blows instead of a single se-
vere blow. And in this manner the same condition was produced
without the possibility of any damage to the brain. To these pure
concussion cases the term "commotion" is being applied in place of
concussion.

265. Compression of brain. — Compression of the brain is due
either to depression of a portion of the vault of the skull, or to an in-
crease of the cranial contents, usually of the cerebro-spinal fluid, or,
what is most frequent in traumatic cases, to the extravasation of
blood in the cranial cavity from some ruptured blood vessel. In any
case, if it occurs in a previously healthy person, it is associated with
such traumatism that there appear also symptoms of concussion.
The symptoms of compression alone are similar to those of eoncus-



S 265] WOUNDS. 225

sion, in the depression of the functions of the brain ; hut in the com-
pression cases there is no means of relieving the increased pressure,
so that the symptoms persist for an indefinite time. In the cases of
local compression due to depressed bone, there may be focal symp-
toms pointing to disturbances of the special region of the brain ; but
these symptoms would appear after the clearkig up of the symptoms
of concussion. The regular course of such injuries is, first, the de-
velopment of the symptoms of concussion, with its unconsciousness;
then these symptoms clear up and the person regains consciousness,
at least, temporarily, for a period of a few hours or days, and then,
as the compression of the brain increases, with the gradual extravasa-
tion of blood into the cranial cavity, the symptoms of compression
oonie on, giving loss of consciousness again ; but this time the uncon-
sciousness is of longer duration, and may not clear up at all. This
second period of unconsciousness is associated with the focalizing
symptoms dependent upon the region of the brain injured.

Hofmann cites a case 80 of death from compression of the brain
without any symptoms of concussion, which may be taken as typical
of the compression cases. A man thirty years old was struck on the
left temple with a stone at six o'clock in the afternoon. He did not
lose consciousness, but walked home, ate dinner with the family, and
then went to the theatre and stayed until eleven o'clock that night,
when he came back home. At two o'clock in the morning he first
complained of headache, and at four o'clock that morning he died.
The autopsy showed a depressed fracture of the left temporal bone,
injury to a branch of the middle meningeal artery, a large exudate
between the bone and the dura mater, and a contusion of the cortex of
the brain.

The long latent period before the development of symptoms after
injury to the head is well illustrated by a case given by Taylor, 81 of
a man injured on April 11th, 1853. He suffered from his head, but
worked hard up to June 12; then he became insane. He improved,
but the symptoms relapsed, and on August 17th he died, four months
after the injury. The autopsy showed a shot in the frontal bone, a
clot in the membranes covering the brain, the whole left hemisphere
covered by a false membrane, and another clot in the pons varolii.
The assailant was convicted of manslaughter.

266. Destruction of portion of brain. — Destruction of a portion of

"Hofmann, Ger. Med. (1903) p. 456; "Taylor, Med. Juris, p. 626.
Quoted from Jaunes, Montp&lier Med.,
1885, p. 523.

Vol. III. Med. Jur.— 15.



226 PHYSICAL INJURIES BY FORCE. t§ 266

the brain by traumatism will produce symptoms depending on the
portion of the brain involved. Destruction, however, of large areas
of the brain are perfectly compatible with life. Perhaps the most
astonishing cases of this kind have been in connection with abscesses
of the brain, where the loss has been gradual. Morand reports a
case where one half of the cerebrum was destroyed by suppuration
following a gunshot wound of the head. The man lived for nine and
a half months after he was wounded. Here, in injury to the brain,
more often than in the case of fractures of the skull, the lesion may
be at a point on the opposite side from that at which the violence was
directed. The consequences of destruction of the brain are depend-
ent upon the part of the brain destroyed. In the frontal and occipi
tal regions of the cerebrum the symptoms may be entirely wanting,
while at the base of the brain even small lesions are often fatal,
as is evidenced by the high mortality of fractures of the base of the



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