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 subjacent 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 Böcker, although when laid open they may disclose a red skin, do not present 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 exfoliates. Brouardel72 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 VARIOUS 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 deformity 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. 124. 255. Eye.- Wounds to the eye73 may not merely interfere with "Brouardel, L'Infanticide, 1897, p. For many instances of serious wounds to the eye, see Gould and Pyle's 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 ear74 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 deafness. The diagnosis of previous disease is not always clear. If there is a large, irregular perforation of the drum membrane, with a persistent 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 ecchymosis, 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 blow 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 ruptured, 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, p. 527. 74 See Bernhardt's article, Viertl jhrschr. f. Ger. Med. 3 F., Bd. XXV., Supplement Heft, 1903. Also Gould and 257. Scalp.- Wounds of the scalp are peculiar in that 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 peculiar in that they involve flat bones, consisting of two lamella 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 says76 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. However, there is always associated with the fracture some violence done to the brain, independent of the fracture." 260. Base of 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 connected with the functions of life, and injury to them almost invariably 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 difficult 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 Schaeffer, Transactions of the Ninth International Medical Congress, Washington, 1887, Vol. III., pp. 166 et seq. "Von Bergmann and Bull's System of Practical Surgery, Vol. I., p. 82. "See §§ 263 et seq., infra. 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 conjunctivæ, 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. Ia 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 fraetures. The bending fractures occur at the site of impact of the violence, 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 not compressed between two bodies, the bursting fissures tend to extend from the point " Von Bergmann and Bull's System of Practical Surgery, 1904, Vol. I., p. 70. 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 was inflicted. 262. Gunshot fractures.-Gunshot wounds of the skull are deserving of special attention on account of their frequency and their peculiarities. 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 together, 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 series 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 projectile 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 disappear 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 Bergmann and Bull's System of Practical Surgery, 1904, Vol. I., p. |