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le for suppressing those points which are against him, and giving an due prominence to others which may be in his favor. This is an unrtunate condition of things, for which at present there appears to be no adequate remedy.

Medical Responsibility for Operations. Malapraxis.-This is a very side subject, but it can here be only glanced at in a few of its leading atures. It was held by Lord Ellenborough that, if a person acting in a dical capacity be guilty of misconduct, arising either from gross ignorare or criminal inattention, by which a patient dies, he is guilty of manSaughter. Faults-such as omissions, or errors in judgment, to which I are liable-are not visited with this amount of criminality. The same The applies to the licensed as to the unlicensed practitioner; but it would appear, from the charge of Williams, J. (Winchester Spring Ass., 1847), at a degree of unskilfulness which might lead to the conviction of a Teased, would justify the acquittal of an unlicensed person. This was in the case of a midwife alleged to have caused the death of a woman on tom she had been called to attend. "The charge," said the judge, "appeared to be that by want of skill or attention to her duties, she had rased the death of the woman upon whom she was attending. In order constitute this offence, it must be shown that the party was guilty of criminal misconduct, either arising from gross ignorance or want of skill, or gross inattention. With respect to the degree of want of skill, he must ay that it was not to be expected that a midwife, who was called in to tend a person in the humble class of the deceased, a soldier's wife, ould exhibit what a regular medical practitioner would call competent sill. It was enough if she applied that humble skill which, in ordinary cases, would lead to a safe delivery. She was not bound to have skill ufficient to meet peculiar and extraordinary exigencies, although in the case of a regular medical man such skill might be required. The class of ais humble practitioner was absolutely necessary for the poorer classes, and, although on the one hand it was fit the law should protect a patient by punishing a person for gross want of skill, yet he thought there would be much to be lamented if it was applied with such severity as to render a party not possessing skill of this kind liable to punishment for manslaughter." These observations would scarcely be strictly applicable in the present day, when certified midwives are generally available, at all events in our large towns.

Charges of manslaughter have frequently been brought against medical practitioners in cases of midwifery. In some instances gross mismanageDent has been proved; the womb, and even parts of the viscera, have en torn away, and in such cases convictions have properly followed. It is well known, however, that much difference of opinion exists among the most eminent practitioners of midwifery respecting the treatment to be pursued in certain cases of difficulty, as where the afterbirth presents placenta prævia). There are eminent accoucheurs who advise in this rase entirely opposite modes of practice, and who look upon that pursued by the other as of the most dangerous kind. When death is really not a result of the medical treatment, an action for damages may be brought against the practitioner on a charge of malapraxis.

It has been a question whether slight deviations from the ordinary de of performing operations should involve a medical men in a charge of malapraxis. We are not aware that this question has been hitherto raised in England.

When on these occasions there is a division of opinion among men of equal experience respecting the necessity for an operation or the proper

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performance of it, a practitioner who is made defendant has a right to e pect that a verdict will be returned in his favor; since it is not to be su posed that, in order to answer a charge of unskilfulness, a man's practi should receive the unanimous approval of the whole of his profession brethren, especially in cases in which there is an acknowledged differen of opinion respecting the treatment. All that appears to be expected is reasonable accordance in treatment with received professional doctrines.

CHAPTER XXXI.

CICATRIZATION OF WOUNDS. EVIDENCE FROM CICATRICES CHANGES IN AN INCISED WOUN -IS A CICATRIX ALWAYS A CONSEQUENCE OF A WOUND-ARE CICATRICES WHEN ON FORMED INDELIBLE?-CHARACTERS OF CICATRICES.-THEIR AGE OR DATE.-CICATRIC FROM BLEEDING.—CUPPING, SETONS, AND ISSUES—CICATRICES FROM BURNS—CICATRIC FROM DISEASE DISTINGUISHED FROM THOSE OF WOUNDS.

Cicatrization of Wounds.-The time at which a particular wound w inflicted may become a medico-legal question, both in relation to the livin and the dead. The identity of a person, and the correctness of a stat ment made by an accused party, may be sometimes determined by a examination of a wound or its cicatrix. So, if a dead body be found wit marks of violence upon it, and evidence adduced that the deceased wa maltreated at some particular period before his death, it will be necessar for a practitioner to state whether, from the appearance of the injurie they could or could not have been inflicted at or about the time assigne A case was tried (Reg. v. Raynon, Taunton Spring Ass., 1851) wherei evidence of this kind served to disprove a statement made by the accuse The prisoner was charged with maliciously cutting and wounding woman. There was a cut upon his thumb, which he accounted for saying it was from an accident that had occurred three weeks before. T medical witness declared, on examining it, that it could not have bee done more than two or three days, which brought the period of its infli tion to about the time of the murderous assault. This with other circun stances led to a conviction.

An incised wound inflicted on the living body, not treated antisept cally, gradually heals by adhesion, when no circumstances interfere prevent the union of the edges. For eight or ten hours the edges remai bloody; they then begin to swell, showing the access of inflammation. the parts are not kept well in contact, a secretion of a serous liquid poured out for about thirty-six or forty-eight hours. On the third da this secretion acquires a purulent character. On the fourth and fifth day suppuration is fully established, and it lasts five, six, or eight days. fibrous layer, which is at first soft and easily broken down, then makes i appearance between the edges of the wound: this causes them graduall to unite, and thus is produced what is termed a cicatrix. Cicatrizatio is complete about the twelfth or fifteenth day if the wound is simple, little depth and width, and affecting only parts endowed with grea vitality. The length of time required for these changes to ensue wi depend: 1. On the situation of the wound; wounds on the legs ar longer in healing than those on the upper part of the body. If a woun is situated near a joint, so that the edges are continually separated by th

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motion of the parts, cicatrization is retarded. 2. On the extent; a deep or wide wound is long in undergoing cicatrization. Wounds involving many and different structures are also longer in healing than those simply afecting the skin and muscles. 3. On the age and health of the wounded person; the process of cicatrization is slow in old persons, as well as in those who are diseased and infirm. In an incised wound the cicatrix is generally straight and regular; but it is semilunar if the cut is oblique. It has been said that the cicatrices of incised wounds are rectilinear, but this is not always the case. In general, they are more or less elliptical, being wider in the centre than at the two ends-this appears to be due principally to the elasticity of the skin and the convexity of the subjacent parts; thus it is well known that in every wound on the living body the dres are more separated in the centre than at the ends, and this physical condition influences the process of cicatrization. When the wound is in a Follow surface, or over a part where the skin is not stretched, as in the armpit or groin, then the cicatrix may be rectilinear, or of equal width throughout. If there were any loss of substance in an incised wound, or if the wound was lacerated or contused, the cicatrix would be irregular, and the healing would proceed by granulation The process might then rupy five, six, or eight weeks, according to circumstances. When Lealed, the cicatrix would be white, and if there had been a loss of substance it would be depressed and present a puckered appearance; the surface of the skin would be uneven. (See Krügelstein Henke's Zeitschr. der S. A., 1844, b. 2, s. 75.) Under antiseptic treatment, suppuration of Wounds is in a great measure avoided.

Is a Cicatrix always a Consequence of a Wound?-Assuming that the term wound" implies a breach of continuity affecting the layers of the true skin (cutis), a cicatrix is always produced in the process of healing. Slight punctures or incisions with a lancet, and even leech-bites, affecting only the surface of the cutis, may leave no trace after a few weeks or tnths. In an even cut made by a very sharp instrument, especially if it is in the direction of the fibres of subjacent muscles, and the parts are kept in close contact, the cicatrix is even, linear, and sometimes so small as to escarcely perceptible; and, if the skin is white, it may be easily overoked. Wounds of this kind are not, however, commonly the subject of medico-legal inquiry. If, on examining a part, where at some previous ime a stab, cut, or burn involving the cutis is alleged to have been inficted, we find no mark or cicatrix, it is fair to assume that the allegation is fal-e, and that no wound has been inflicted, making due allowance for the fact that mere abrasions of the cuticle, or very slight punctures and incisions, often heal without leaving any well-marked cicatrices.

A trial took place at the Old Bailey in 1834, in which a man was Wrongly charged with being a convict, and with having unlawfully returned from transportation. The chief clerk of Bow Street produced a certifi eite, dated in 1817, of the conviction of a person, alleged to be the prisoner, under the name of Stuart. The governor of the gaol in which Stuart was Confined believed the prisoner to be the person who was then in his custody. The guard of the hulks to which Stuart was consigned from the gaol, swore most positively that the prisoner was the man. On the cross-examination of this witness, he admitted the prisoner Stuart, who was in his custody in 1817, had a wen on his left hand; and so well marked was this that it formed a part of his description in the books of the conviet-bulk. The prisoner said his name was Stipler; he denied that he was the person named Stuart, but from the lapse of years he was unable to bring forward any evidence. The recorder was proceeding to charge

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PERMANENCE OF CICATRICES.

the jury, when the counsel for the defence requested to be permitted put a question to an eminent surgeon, Carpue, who happened accidentall to be present in court. He deposed that it was impossible to remove suc a wen as had been described without leaving a mark or cicatrix. Bot hands of the prisoner were examined, but no wen, nor any mark of a we having been removed, was found. Upon this the jury acquitted th prisoner.

The cicatrices resulting from wounds after the performance of surgic operations are commonly well indicated by their regular form and the situation. They may present the characters of punctured or incise wounds, or a mere division of parts for the excision of tumors. As th healing process is assisted by art, the cicatrices are commonly marked b great regularity. The identity of a living person, or of a dead body, ma be proved by the existence of a cicatrix which has been the result of surgical operation. There can be no pretence for saying that such cies trices, when they have involved the true skin, disappear. Whether th part is wrinkled or unusually fat, the cicatrix may be found if it has eve existed.

A case in which this question respecting the permanency of cicatrice from wounds was raised, was referred to the author under the followin circumstances. (Reg. v. Reed and Donelan, Chelmsford Spring Ass 1842.) The medical evidence was to the effect that "there was a woun on the nose of the woman, apparently inflicted by some sharp instrument and the bridge of the nose was broken down. The weapon had entere half an inch, and had caused profuse bleeding. The wound was so dee that if it had entered a little higher up in the eye, it might have cause death." In the defence it was urged that no weapon had been used; an that, although the male prisoner had struck the wounded woman a blow the female prisoner had taken no share in the assault. It does not appea that any medical evidence was called to show in what state the assailed person was at the time of the trial. It was assumed that a weapon mus have been used, and the prisoners were convicted, the one of stabbing and the other of aiding and abetting. About six months after the allege stabbing, and some weeks after the prisoners had been convicted and sen tenced to punishment, the face of the injured woman was examined by two surgeons (one of them a practitioner of twenty-eight years' standing) and they both deposed that there was no mark of a cicatrix from a stab or fracture of the nose, or of any personal injury whatever. Other sur geons were requested to examine her face, but this she declined permitting and, as there was no power to compel her, the medical facts of the cas were referred to Quain, Guthrie, Key, and the author. The evidence of the surgeons at the trial was laid before them, with the statements of the two surgeons who subsequently examined the woman. They all agreed that, if such a wound as that described in the medical evidence had been inflicted, there would have been a visible cicatrix and a ridge or prominence indicative of the situation where the bridge of the nose was stated to have been broken; and as no such marks could be perceived by two well-informed surgeons, they considered it improbable either that such a wound as that described could have been inflicted, or that a weapon could have been used in the assault. The question really to be decided was-Could all traces of such a wound as that above described be effaced in a period of six months or even during the life of a person? Either the wound must have been misdescribed, or some marks of its past existence, in the form of a cicatrix, would unquestionably have been found. In Barnett Roberts (Court of Exch., Nov. 1867), an action was brought by a surgeon,

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be injury resulting from an assault by the defendant. It appeared from the evidence that the defendant struck the plaintiff two violent blows on The head with the handle of his umbrella. It was alleged that this had sed a fracture of the skull, and had produced a long and painful illness. Erbsen and Winslow gave evidence for the plaintiff to the effect that in r judgment the skull was fractured, the brain organically injured, and plaintiff's recovery rendered practically hopeless. On the other hand, the defence, Partridge and Wood, with other witnesses, deposed that skill was not fractured, and that the depression supposed to indicate fracture was congenital and not the result of a blow or accident. Α all with a natural depression in it was produced and shown to the jury. Te plaintiff's head was examined in court by Partridge. He could feel cicatrix in the alleged seat of injury, but there was a thickening over Le depression. On this evidence the jury could not agree. There would no difficulty in such a case if a careful examination was made soon after the assault; but when surgical opinions are taken some weeks or months erwards, the witnesses may disagree. Even if there had been a cicatrix on this occasion, this would not have proved that the skull had been tured. The injury to the brain might well have been a result of the villence, although there had been no fracture.

Characters of Cicatrices. Their Age or Date.-In an early stage a Gatrix is softer and redder than the surrounding skin, but after some months or years it becomes white, hard, smooth, and shining. The abrous substance of which it is formed receives less blood than the un- . Injured skin; hence, on compressing the skin around an old cicatrix, its ituation and form are well marked by reason of the blood not readily entering into it on removal of the pressure. As the age of a cicatrix inerases, it becomes smaller, thicker, whiter, more shining, and less sensitive. It is fibrous in structure, dense, without sebaceous follicles, adipose lls, or hairs, and it contains but few absorbents and exhalants. The time required for these changes to take place cannot be defined. In one person they may be observed in a few months, and in another only after Some years. The tissue of which an old cicatrix is formed is different from that of the skin; it is harder, contains less blood, and is destitute of any colored pigment, so that its whiteness, which is remarkable on the eatrized skin of a negro, is retained through life. If any cicatrices were easily obliterated, it would be those which are even and regular-the salts of incised wounds by sharp instruments; but cicatrices of this kind Lare certainly retained their characters unchanged in one instance for twenty, and in another for twenty-five years. According to the observaTons of Dupuytren and Delpech, the substance of a cicatrix is not converted to true skin-it never acquires a rete mucosum, ie, the membrane which gives color to the skin. Although this is generally true of incised and pinctured wounds, yet contused and lacerated wounds on the legs of persons advanced in life frequently present a brown discoloration. In the ccatrices of lacerated and contused wounds, the form of the weapon with which the wound was inflicted is sometimes indicated. It is not, however, fasy to distinguish the cicatrix of a stab of old date from that produced by a pistol-bullet fired from a distance. In both cases the edges may be Founded and irregular, and the cicatrix puckered, unless the stab has been placed by a broad-bladed weapon. If no mark of cutting can be perived within a few months of the period at which a severe wound is alleged to have been inflicted, it is reasonable to infer that there has been the mistake, or that the circumstances have been exaggerated. Cicatrices increase in size during the process of growth. Adams found, in