306

WOUNDS-CAUSE OF DEATH.

might be met with in a case of infanticide or abortion.

1846, t. 1, p. 181.)

(Ann. d'Hyg.,

For a very full description of the methods to be adopted in the examination of supposed blood-stains under various circumstances, the reader is referred to a memoir by Dragendorff. (Maschka's Handb. der Gerichtl Med., bd. i. p. 481, et seq.).

CHAPTER XXVIII.

THE CAUSE OF DEATH FROM WOUNDS.-WOUNDS DIRECTLY OR INDIRECTLY FATAL.-DEATH FROM HEMORRHAGE.-INTERNAL BLEEDING.-DEATH FROM MECHANICAL INJURY-FROM FROM NUMEROUS PERSONAL INJURIES, IRRESPECTIVE OF ANY MORTAL

SHOCK.-DEATH

WOUND.

It is important for a medical witness to bear in mind that, in all cases of wounds criminally inflicted, the cause of death must be certain. No man is ever convicted upon mere medical probability. In general, there is only one real cause of death, although other circumstances may have assisted in bringing about a fatal result. Thus a person cannot die of disease in the bowels and a stab in the chest at the same time, nor of apoplexy from disease and compression of the spinal marrow at the same instant. Hence it is our duty, when several apparent causes for death exist, to determine which was the real cause; and, in stating it to the court, to be prepared to offer our reasons for this opinion. In most cases of local injury, when a person dies speedily, there will be no great trouble in settling whether disease or the injury was the cause. A difficulty may, however, exist when a person has recovered from the first effects of a wound, and has subsequently died. Besides, there may be cases in which the cause of death, in spite of the most careful deliberation, will be still obscure; or sometimes it may happen that the death of a person appears to be as much dependent on bodily disease as on an injury proved to have been received at the time he was laboring under the disease

[Sometimes death is due to want of medical skill, or, worse, wrong treatment by attending physicians. The case of James Fisk, Jr., presented a notable case of this character. Modern surgery would have had no serious obstacle in treating the wound (gunshot wound of the abdomen), then by many regarded as fatal. Had Dr. James R. Wood, the eminent surgeon, who was sworn on the trial as an expert in the case, been in charge, he would have had no serious difficulty in securing a re

covery.

The monograph of Dr. Eugene Perugnet, read before the Medico-Legal Society of New York, demonstrated that the death was directly due to coma, caused by large doses of morphia. The bullet might have caused death, but for want of proper surgical treatment the morphia interposed, and actually caused the death: Series 2, Medico-Legal Papers, p. 294.

The case of President Garfield presents similar considerations and reflections. Did he die from the bullet of the assassin, or was his death due to other causes?]

The course that a

How is an opinion to be expressed in such a case? medical witness ought to pursue, provided he has duly deliberated on the circumstances before he appears in court, and his mind is equally balanced

WOUNDS DEATH FROM HEMORRHAGE.

307

between the two causes, is to state at once his doubt to the jury without circumlocution, and not allow it to be extracted from him in cross-examination. It is the hesitation to assign a satisfactory cause, or the assigning of many causes for death, that gives such advantage to a prisoner's case, even when the general evidence is entirely against him. Occasionally, several causes of death are vaguely assigned by a medical witness, among which some have a tendency to exculpate, and others to inculpate, an accused person in a greater or less degree, and it is left to the jury to select from the number one upon which to found a verdict. In a case of this kind an acquittal is commonly obtained.

Wounds Directly or Indirectly Fatal.-A wound may cause death either directly or indirectly. A wound operates as a direct cause of death when the wounded person dies either immediately, or very soon after its infliction, and there is no other cause, internally or externally, to account for death. In wounds which cause death indirectly, it is assumed that the person survives for a certain period, and that the wound is followed by inflammation, suppuration, pyæmia, gangrene, tetanus, erysipelas, or some other mortal disease which is a direct, and not an unusual, consequence of the injury. Under this head may be also placed all those cases which prove fatal by reason of surgical operations rendered imperatively necessary for the treatment of an injury-presuming that these operations have been performed with ordinary skill and care. We shall for the present consider only the direct causes of death in cases of wounds. They are three in number: 1. Hemorrhage, or loss of blood. 2. Great mechanical injury done to an organ important to life. 3. Shock, or concussion, affecting the nervous centres, whereby the functions of one or more vital organs are arrested, sometimes with but slight injury to the part struck or wounded. From any one of these causes a wounded person may die immediately or within a few minutes.

1. Death from Hemorrhage.-Loss of blood operates by producing fatal syncope (p. 65). A quantity of blood escaping from a vessel, although insufficient to cause death by affecting the heart and circulation, may readily destroy life by disturbing the functions of the organ or part into which it is effused. Thus a small quantity effused in or upon the substance of the brain, or at its base, may prove fatal by inducing fata! compression; and, again, if in a case of wounded throat blood should flow into the windpipe, it may cause death by asphyxia; i. e., by stopping the respiratory process (p. 65). In these cases it is obvious that the blood acts mechanically; and in respect to the last condition a medical man, unless circumspection is used, may involve himself in a charge of malapraxis. If he allows the wound to remain open, the wounded person may die through hemorrhage; if he closes it too soon, the person may die through suffocation; and, in either case, the counsel for a prisoner will not fail to take advantage of a plausible objection of this kind. In wounds of the chest, involving the heart and lungs, death is frequently due, not so much. to the actual quantity of blood effused, as to the pressure which it produces upon these organs. A few ounces effused in the cavity of the bag enclosing the heart (pericardium) will entirely arrest the action of this

organ.

The absolute quantity of blood required to be lost in order to prove fatal, will, of course, vary according to numerous circumstances. The young, the aged, and those who are laboring under infirmity or disease, will perish sooner from loss of blood than others who are healthy and vigorous. Women, cæteris paribus, are more speedily destroyed by bleeding than men. Infants are liable to die from this cause, as a result

308

DEATH FROM INTERNAL HEMORRHAGE.

of slight wounds. An infant has been known to bleed to death from the bite of a single leech, or from the simple operation of lancing the gums. Even the healthy and vigorous, when their vital powers have been depressed by maltreatment or by brutal violence, will sink under the loss of a comparatively small quantity of blood. A medical jurist must not forget that some persons have a predisposition to excessive bleeding from slight injuries; and this condition is often hereditary. The slightest wound or puncture the bite of a leech or the extraction of a tooth-will be attended with a loss of blood which cannot be arrested, and which will slowly lead to death by exhaustion. Cases have been frequently recorded of fatal hemorrhage following the extraction of teeth, when there had been previously nothing to indicate the probable occurrence of death from so trivial a cause. Such cases are without difficulty detected; since a surgeon may always infer from the part injured and the extent of the injury whether the bleeding is likely to be copious or not. When a person bleeds to death from what would, under common circumstances, be a simple wound, the admission of this fact may in certain cases lessen the respon sibility of an accused party.

A sudden loss of blood has a much more serious consequence than the same quantity lost slowly. A person may fall into a fatal swoon from a quantity of blood lost in a few seconds, which he would have been able to bear without sinking had it escaped slowly. This is the reason why the wound of an artery proves so much more rapidly fatal than that of a vein. Death speedily follows the wound of a large artery like the carotid; but it takes place with equal certainty, although more slowly, from wounds of smaller arteries. In a case in which one of the intercostal arteries was wounded by a small shot, hemorrhage caused death in thirty-eight hours. The loss of blood which follows the division of the smaller branches of the external carotid artery is often sufficient to destroy life, unless timely assistance be rendered. If a wound is in a vascular part, although no vessel of any importance be divided, the person may still die from bleeding. It is difficult to say what quantity of blood should be lost in order that a wound may prove fatal. The whole quantity contained in the body of an adult is estimated at about one-thirteenth of its weight—i. e., about twelve pounds (Halliburton's Text-Book of Chem. Physiol., p. 220); of this, one-fourth is considered to be distributed in the heart, lungs, large arteries, and veins. In various animals the proportion of the weight of the blood to that of the body has been found to vary considerably and probably this holds good for man also, within certain limits. According to Watson, the loss of from five to eight pounds is sufficient to prove fatal to adults. But while this may be near the truth, many persons will die from a much smaller quantity; the rapidity with which the effusion takes place having a considerable influence, as well as the age, sex, and bodily condition of the wounded person. It has been found by experiment that a dog cannot bear the loss of more blood than is equivalent to one-twelfth part of the weight of its body.

Internal Hemorrhage.-Hemorrhage may prove fatal, although the blood does not visibly escape from the body. In incised wounds, the flow externally is commonly abundant; but in contused, punctured, and gunshot wounds the effusion may take place internally, and rapidly cause death. In severe contusions, or contused wounds, involving highly vascu lar parts, the effusion may go on to an extent to prove fatal, either in the cavities of the body or throughout the cellular membrane and parts adjacent; several pounds of blood may thus be slowly or rapidly effused. The most fatal internal hemorrhages are those which follow ruptures of the

DEATH FROM MECHANICAL INJURY-SHOCK.

309

organs from violence or disease. Ruptures of the heart, lungs, liver, and kidneys have thus caused death. In Nov. 1864, a man who had been run over was brought to Guy's Hospital. He complained of pain in the back, but there were no symptoms of severe injury, and no marks of violence were seen on the skin of the back. He left the hospital, and walked with some assistance to his home. A few hours afterwards he was found dead in bed. On inspection there was a large quantity of blood effused in the abdomen. This had proceeded from one kidney, which had been ruptured transversely through its whole substance. In these cases the bleeding is not necessarily immediate; but slight muscular exertion may increase it and accelerate death. In death from severe flagellation, blood may be effused in large quantity beneath the skin and among the muscles: this effusion will operate as fatally as if it had flowed from an open wound. The means of ascertaining whether a person has died from bleeding by an open wound are these: Unless the wound is situated in a vascular part, we shall find the vessel or vessels from which the blood has issued, divided; the neighboring vessels empty, and the body more or less pallid; although this last condition is, of course, liable to be met with in certain cases of disease, as also under copious venesection-points easily determined by an examination.. The blood will commonly be found more or less clotted or coagulated on those surfaces on which it has fallen. If, with these signs, there is an absence of disease likely to prove rapidly fatal, and no other probable cause of death is apparent, this may be fairly referred to loss of blood. This opinion may, however, be materially modified in reference to open wounds, by the fact of the body not being seen on the spot where the injury was actually inflicted, by the wound having been sponged, the blood removed by washing, and all traces of bleeding destroyed. Under these circumstances, the case must in a great measure be made out by presumptive proof; and here a medical witness may have the duty thrown upon him of examining articles of dress, furniture, or weapons, for marks or stains of blood. It must not be supposed that all the blood met with round a wounded dead body, or in a cavity of the body, was actually effused during life. As soon as the heart's action ceases, the arteries pour out no more; but the blood, so long as it remains liquid, i. e., from four to eight or ten hours after death, and the warmth of the body is retained, continues to drain from the divided veins and smaller vessels. The quantity thus lost, however, is not considerable, unless the veins implicated are large, or the part is highly vascular, i. e., full of veins. or small vessels.

2. Death from Great Mechanical Injury done to a Vital Organ.-We have instances of this becoming a direct cause of death in the crushing of the heart, lungs or brain, by any heavy body passing over or falling on the cavities, as in railway accidents. The severe mechanical injury is sometimes accompanied by a considerable effusion of blood, so that the person really dies from hemorrhage but in other instances the quantity of blood lost is inconsiderable, and the fatal effects may be referred to shock to the nervous system. Sometimes a slight amount of violence may prove suddenly fatal. These are, however, to be regarded as excep

tional instances.

3. Death from Shock. This is sometimes a direct cause of death under the infliction of external violence; and in this case life is destroyed without the injury being to all appearance sufficient to account for so speedily fatal a result. On several occasions persons have died in railway collisions from no physical injury, but purely from shock to the system. In a collision, which took place in 1873 at the Durham station, a Mrs. Coble

310

DEATH FROM SHOCK.

was among the dead. On a post-mortem examination there was no appearance of external or internal violence. Savory has suggested that death from shock is nothing more than death from temporary exhaustion of nerve-force, the result of a violent, sudden, and excessive expenditure of it. (Lect. on Life and Death, p. 171.) Whatever theory may be adopted to explain it, there is no doubt that a person may die from what is termed shock, without any marks of severe injury being discovered on his body after death. We have examples of this mode of death in accidents from lightning, or from severe burns or scalds, in which the local injury is often far from sufficient to explain the rapidly-fatal consequences. As instances of this form of death from violence, may be also cited those cases in which a person has been suddenly killed by a blow upon the upper part of the abdomen or on the pit of the stomach, an accident which is supposed to operate by producing a fatal impression on the nerves and nerve-ganglia of the cardiac plexus. Whether this be or be not the true explanation, it is admitted by experienced surgeons that a person may die from so simple a cause without any mark of a bruise externally, or physi cal injury internally to account for death. On the skin there may be some abrasion or slight discoloration; but, as it has been elsewhere stated, these are neither constant nor necessary accompaniments of a blow. Concussion of the brain, unattended by visible mechanical injury, furnishes another example of this kind of death. A man receives a severe blow on the head; he falls dead on the spot, or becomes senseless and dies in a few hours. On an inspection, there may be merely the mark of a bruise on the scalp; in the brain there may be no rupture of vessels or laceration of substance, and all the other organs of the body may be found healthy. In railway accidents persons have died under somewhat similar circumstances. There has been no physical indication of a mortal injury, and no cause apparent to account for death. This can be referred only to the shock or violent impression which the nervous system has sustained from the blow or violence-an impression which the vital powers were wholly unable to counteract or resist. A medical witness must give his evidence with caution in such cases; since it is the custom to rely in the defence upon the absence of any visible mortal wound or physical injury to account for death, as a proof that no injury was done—a principle which, if once unrestrictedly admitted, would leave a larger number of deaths, undoubtely occurring from violence, wholly unexplained.

There is another form of shock which is of some importance in medical jurisprudence. A person may have received many injuries, as by blows or stripes, not one of which, taken alone, could, in medical language, be termed mortal; and yet he may die directly from the effects of the violence, either on the spot, or very soon afterwards. In the absence of any large effusion of blood beneath the skin, death is commonly referred to exhaustion; but this is only another mode of expression; the exhaustion is itself dependent on a fatal influence or impression produced on the nervous system. A prize-fighter, after having sustained during many rounds numerous blows on the body, may either at or after the fight sink and die exhausted. His body may present marks of bruises, or even lacerated wounds, but there may be no internal changes to account for death. In common language, there is not a single injury which can be termed mortal ; and yet, supposing him to have had good health previously to the fight, and all marks of disease indicative of sudden death to be absent, it is impossible not to refer his death to the direct effect of the violence. It is a well-ascertained medical fact, that a number of injuries, each comparatively slight, are as capable of operating fatally as any single wound