the legal sense.1 included as wounds.2 204. Examination, in general. The examination of the wound from the legal point of view, if the person is still living, naturally should not be made so as to compromise in any way the healing of the wound. Bandages and splints should not be removed or probing of the wound done except with the approval of the surgeon in charge. The lines of examination should lead to the determination as to when the wound was inflicted, what the degree of danger of the wound is, with its dangers to life or function, whether the wound was given by the injured man himself, or by some one else, and with what manner of instrument the wound was produced. If the examination is made after death it may be made more searchingly; and to the above questions must be added the determination of the causes of death, and the time of inflicting the wounds,-whether before or after death.

Scratches are not considered serious enough to be

205. Expert examination. Whatever parts of the examination call for the application of special knowledge of which the examining physician may not be possessed should be submitted to an expert in that special branch, and, as far as possible, these experts should be present at the time of the examination, that they may know precisely what processes the specimens submitted to them have gone through. It is entirely impossible for any practitioner of medicine to be even acquainted with all the appliances and new modes of examination which modern science has produced. It is to this cause chiefly, viz., the disparity in the attainments of one physician as compared with another, and also to the natural division of medical science and practice into numerous departments, some of which may be cultivated to the exclusion of others, that the "disagreement of doctors" is really due. Men of equal medical attainments will rarely differ upon an essential point of pathology or practice; but ignorance, or defective knowledge in medicine, does not differ from that in any other branch of science, in being usually associated with presumption and obstinacy. Still, there are few practitioners of medicine who are thoroughly prepared to enter upon an examination of all the medical aspects of a case of violent death; familiarity with the means required to carry through such an investigation can be gained only by special study, for which, to the majority, time is wanting.

Circumstances may, however, impose upon the physician the duty

'Wharton's Law Lexicon.

2

See Reg. v. McLaughlin, 8 C. & P. 635, 34 E. C. L., 561; Reg. v. Wood, 4

C. & P., 381, 19 E. C. L., 430; Com. v. Gallagher, 6 Met. (Mass.), 568; State v. Leonard, 22 Mo., 450.

of making an examination for which he does not feel himself fully competent. In remote or interior parts of the country the means for the successful prosecution of a medico-legal inquiry are usually not at hand; whoever may be obliged to undertake an examination under such circumstances should endeavor to obtain the assistance of a colleague, and should candidly represent to the authorities the necessary imperfection of the examination, and what influence this may have upon the objects of the inquiry.

206. Classification of wounds in general.-In the determination of the instrument which produced the wound, we classify wounds according to their form, as subcutaneous or open. The subcutaneous wounds are represented by the black and blue spots associated with a simple contusion where the skin is not broken, the sprains and dislocations where the ligaments around a joint are torn, and fractures where the bones, or, in a more liberal interpretation of the term, any of the more rigid organs, such as the liver, spleen, or kidneys, are broken. The open wounds are classified as punctured, incised, lacerated, or gunshot; in each of which the name is descriptive of the character of the wound.

207. Subcutaneous wounds.- Subcutaneous wounds are very deceptive on surface examination. There may be a large ecchymosis, a black and blue spot, and but little injury to the deeper tissues, or there may be a very extensive internal injury, giving no evidence on the surface. It may even happen that, although no marks of violence can be found externally, or, at least, none which will explain the person's death, internal injuries may be discovered upon dissection which will render it certain that the death was violent. Indeed, Casper goes so far as to declare that, as a general rule, when death follows an injury, suddenly or speedily, in consequence of internal hemorrhage or other effect of laceration of an internal organ, the signs of external injury are either slight or are entirely wanting. Among numerous instances of this description, furnished by Casper's experience, the following is one of the most striking: On a cold winter's night a wagoner was descending the hill from Spandau with a heavily loaded wagon, and dismounted in order the more easily to guide his team. In doing so, he was thrown violently against one of the poplar trees which line the road, and where, in the course of the night, he was found dead. The only external injuries consisted of a slight abrasion upon the left arm, and a similar one upon the right temple. In the head there was nothing worthy of note, except that the transverse sinus was unusually distended with blood. On opening the

The spinous

The deeper

spinal canal, about a quart of dark fluid blood escaped. process of the first thoracic vertebra was broken off. spinal muscles were ecchymosed, but the spinal cord was uninjured. The left pleural cavity contained about thirty ounces of liquid blood. The pericardium was torn completely across, and the heart, severed from its large vessels, lay almost entirely loose in the cavity of the thorax. The open ends of the aorta and pulmonary artery were distinctly visible. The heart itself was sound and firm, and, on both sides, but in the ventricles especially, contained much dark, coagulated blood. The left lung was entirely torn through its middle portion, and in the right lobe of the liver was a laceration two inches long, by half an inch deep. And yet the exterior of the body presented nothing remarkable.3

A case is reported by Dr. Ellis, of Boston, of a woman who was knocked down and run over by a sleigh. She lived for ten days after the accident, and there was no mark of external injury. On examination after death, the liver was found to be lacerated, the common bile-duct was torn across, and several fractures appeared in the right kidney.*

207a. Ecchymoses.— The ecchymoses which are the usual sign of a contused wound are very slight or absent if the wound was made with an instrument which diffuses the force of the blow over a large area. Such are the contusions produced by a sand bag. Even if the blow is inflicted directly over a bone, where, usually, the ecchymosis is most prompt to appear, the sand bag contusion leaves no mark. Similarly, Balch describes a case examined by him in 1895, of a man who, while drunk and lying on the ground, was jumped upon by another man over the back of the neck. There were no signs externally of injury, although the man died. On examination of the deep tissues clots were found on the brain, said to be due to apoplexy following alcohol, and clots near the spinous process of the fifth cervical vertebra, and surrounding the spinal cord. These later findings were interpreted as being due to the traumatism, and the absence of external signs was explained by the possible protection of the man's clothing. Another point to be considered in connection with the absence of external signs in such traumatisms is that, while the ecchymosis usually appears in a few minutes if the blow is over a bone, on the other hand, if the blow is over soft tissues, and the force of the

'Gericht. Med., Vol. I., p. 122. Balch, Peterson and Haines's TextBoston Med. and Surg. Journ., April, book of Medical Jurisprudence and Tox1860, p. 222. icology, 1903, Vol. I., p. 270.

blow is transmitted to the deeper parts, the discoloration of the skin may not show for a day or more, and then is likely to appear at a distant point. The late appearance of discoloration or its absence is particularly marked in blows upon the abdomen, where there may be rupture of the viscera without any external signs.

207b. Dislocations and fractures.-In regard to the other subcutaneous wounds, we may have in the bruises and dislocations and sprains but little more evidence of the condition of the deep parts than in the simple contusions. Dislocations of the smaller joints are so easily overcome that they may have been reduced before the arrival of a physician. Even dislocations of the shoulder may be reduced in some cases by a layman, and leave nothing for the physician to find but evidence that could not be distinguished from a contusion except by dissection of the injured part. In the diagnosis of fractures of the bones the recent introduction of the Roentgen rays has added materially to the accuracy of our knowledge of the condition of the parts. With its aid we are able to see the outline of the denser structures of the deep parts, and so can determine any break in the bones that is associated with displacement of the broken parts. There may, however, be a splitting of the bone, which will not show in the shadow picture; and, again, when there is a fracture in a region where there are many dense structures, as in the skull or in the pelvis, the skiagraph may be so obscured as to be no aid. Hence, the fact that the diagnosis of fracture cannot be confirmed by the X-ray picture should not be taken as excluding the fracture.

In 1900, White as chairman of a (b) In the regions of the skull, the committee on the medico-legal relations spine, the pelvis, and the hips, the Xof the X-rays, presented to the Amer- ray results have not yet been thoroughican Surgical Association the following ly satisfactory, although good skiagraphs conclusions, which were unanimously have been made of lesions in the last adopted as expressing the views of the three localities. On account of the rarAssociation: ity of such skiagraphs of these parts special caution should be preserved when they are effected, in basing upon X-ray testimony any important diagnosis or line of treatment.

(a) The routine employment of the X-rays in cases of fracture is not of sufficient advantage to justify the teaching that it should be used in every case. If the surgeon is in doubt as to the diagnosis, he should make use of this as of every other available means to add to his knowledge of the case; but even then he should not forget the grave possibilities of misinterpretation. There is evidence that even in competent hands plates may be made that will fail to reveal the presence of existing fractures, or will appear to show a fracture that does not exist.

VOL. III. MED. JUR.-12.

(c) As to questions of deformity, skiagraphs alone, without expert surgical interpretation, are generally useless and frequently misleading. The appearance of deformity may be produced in any normal bone, and existing deformity may be grossly exaggerated.

(d) It is not possible to distinguish after recent fractures between cases in which perfectly satisfactory callus has formed and cases which will go on to nonunion. Neither can fibrous union be

208. Open wounds in general.-The open wounds are classified as punctured, incised, lacerated, and gunshot.

209. Punctured.- Of the open wounds where the skin is penetrated, the punctured are those where the depth of the wound is much greater than its length: such as would be made by a pin, bayonet, or knife-stab. Such wounds may be made for surgical purposes; and under such conditions, while extending to the depth of several inches, as in exploratory aspirations of the pleural cavity, liver, or pelvis, are associated with practically no bleeding, and very little danger. But when accidentally made, or made with the intent to injure, they are often very serious because of puncturing large blood vessels, or leading to internal hemorrhage, while giving very little external evidence of trouble. Vibert quotes an extremely interesting case from Brierre de Boismont, of a suicide having a stab wound of the upper part of the abdomen, who, for several hours after the injury, gave no evidence of the injury. He was taken to the hospital, and the surgeon gave the opinion that the wound had not penetrated. Death, however, came on suddenly, and on the post-mortem examination cuts were found traversing the intestine, opening the inferior vena cava in three

distinguished from union by callus in which lime salts have not yet been deposited. There is abundant evidence to show that the use of the X-ray in these cases should be regarded as merely the adjunct to other surgical methods, and that its testimony is especially fallible. (e) The evidence as to X-ray burns seems to show that in the majority of cases they are easily and certainly preventable. The essential cause is still a matter of dispute. It seems not unlikely, when the strange susceptibilities due to idiosyncrasy are remembered, that in a small number of cases it may make a special individual especially liable to this form of injury. Later experience has shown that while burns occur in only a small minority of cases, those cases can not, with our present knowledge, be anticipated or prevented with absolute certainty.

(f) In the recognition of foreign bodies the skiagraph is of the very greatest value; in their localization it has occasionally failed. The mistakes recorded in the former should easily have been avoided; in the latter they are becoming less and less frequent and, by the employment of accurate mathematical methods, can probably, in time, be eliminated. In the meantime, however, the surgeon who bases an important opera

tion on the localization of a foreign body buried in the tissues should remember the possibility of error that still exists.

(g) It has not seemed worth while to attempt a review of the situation from the strictly legal standpoint. It would vary in different states, and with the different judges to interpret the law. The evidence shows, however, that in many places and in many differing eircumstances the skiagraph will undoubtedly be a factor in medico-legal cases.

(h) The technicalities of its production, the manipulation of the apparatus, etc., are already in the hands of the specialists, and with that subject also it has not seemed worth while to deal. But it is recommended that the surgeon should so familiarize himself with the appearance of skiagraphs, with their distortions, with the relative value of their shadows and outlines, as to be himself the judge of their teachings, and not depend upon the interpretation of others who may lack the wide experience with surgical injury and disease necessary for the correct reading of these pictures.

Brierre de Boismont, Suicide et Folie de Suicide, Paris, 1856; quoted by Vibert, Précis de Méd. Lég., 9th ed., 1896, p. 285.