334

DATE OF EFFUSION OF BLOOD ON THE BRAIN.

which is sometimes disposed in membranous layers of a fibrous struc ture, and these are adherent to the dura mater and the brain. The surface of this organ sometimes presents a mark indicative of pressure. When a medical man is required to give an opinion of the date of an effusion found on. the brain, great caution is required. He may not be able to fix the precise date, but it may be in his power to say whether the blood has been effused for a few days, or for weeks, or months.

When a blow on the head is of a heavy, bruising kind, the whole substance of the skull may be fractured without a division of the skin. There is one remarkable circumstance connected with fractures accompanied by depression of bone, which here requires to be mentioned-namely, that the person has been sensible so long as the foreign substance which produced the fracture and depression remained wedged in the brain, and insensibility and other fatal symptoms began to manifest themselves only after its removal. This being admitted, it may be urged in defence that death was really caused by medical interference. But it is a sufficient answer to state that the wounded person must have died from inflammation of the brain if the foreign body had been allowed to remain; and that it is consistent with the soundest principles of practice to remove all such foreign substances without delay. In fractures of the skull with depression, it may become a question whether the surgeon raised the depressed portion of bone so soon as he ought to have done.

In the description of injuries of the head, it is impossible to avoid the use of terms with which members of the legal profession are not likely

Fig. 48.

a

b

d

The skull, with its outer and inner table, and the three coverings of the brain (membranes), seen in section.

to be acquainted. In giving evidence upon the situation of wounds, of the effusion of blood and the effects of fractures, medical witnesses are often compelled to make use of anatomical terms, and are not always successful in explaining them. With the view of removing this difficulty, and supplying, to some extent, the means of following the evidence of a witness in his description of injuries to the head and its contents, a diagrammatic engraving, representing the relative position of the membranes of the brain, is annexed. Fig. 48 represents a section of the bones of the skull, with the three membranes which cover the brain. (a) Section of the skull-bones, with the outer and inner tables, and the intermediate cellular structure or diploë, indicated by the dark shading; the scalp, or skin of the skull, which covers the outer table, is not represented. (b) The dura mater, or outer membrane of the brain; it is thick and fibrous, closely adherent to the inside of the inner table of the skull, but smooth on the side towards the brain. (c) The arachnoid membrane, so named from its delicate web-like structure, forms a closed sac, covering the dura mater-to the inner surface of which it give its glistening aspect-and also the pia mater on the surface of the brain, which it closely covers, without dipping into the convolu tions. (d) The pia mater-the membrane which immediately invests the substance of the brain and dips into all the convolutions. It contains the blood vessels which nourish the hemispheres of the brain. These membranes are, for distinctness, represented as being separated from cach other, but they are naturally in close proximity, and the rough side of the dura mater is closely adherent to the inside of the skull (calvarium). The ordinary seats of the effusion of blood from violence are between the dura

WOUNDS OF THE BRAIN.

335

mater and inner table of the skull, and between the pia mater and the rface, or into the substance of the brain.

In reference to persons found dead with severe injuries to the head, attended with fracture and effusion of blood on the brain, a medical man ay be required to say whether such an amount of violence is or is not consistent with the retention of muscular exertion and power of locomoon by the deceased. For instance, a man may fall from a height, and prodice a severe compound fracture of the skull. He may, nevertheless, be able to rise and walk some distance before he falls dead. Under these circumstances there might be a strong disposition to assert that the desed must have been murdered-the injuries being such that they could Got have been produced by himself, there being at the same time no eapon near, and no elevated spot from which he could have fallen. The overy, after death, of severe injury to the head, with great effusion of od on the brain, must not, however, lead a surgeon to suppose that the erson who sustained the violence had been immediately incapacitated. There are various cases recorded which show that a power to move has been retained under conditions which might be supposed to render a peron incapable of moving from the spot. Full allowance must be made on these occasions for the possible exercise of locomotion by the deceased. Although a large quantity of blood may be found after death pressing on the substance of the brain, it does not follow that this effusion and pressure were the immediate results of the violence. (See case of Reg. v. Saxon, p. 293.)

The importance of these observations will be further seen by the following case: A man was found dead in a stable, with a severe fracture of 'he temporal bone, which had caused a rupture of the middle artery of the train. A companion was accused of having murdered him, but he alleged that the deceased had fallen from his horse the day before, and had thus met with the accident. It appeared, however, that, after the fall, the decased had gone into a public-house before he returned to the stables, and tad remained there some time drinking. The question respecting the guilt of the accused party rested upon the fact whether, after such an exreasive fracture of the skull with extravasation of blood, it was possible for a man to do what the prisoner had represented the deceased to have done. Wallace very properly gave a qualified opinion; he said it was improbale, but not impossible, that, after receiving such an injury, the deceased could have walked into and drunk at a public-house. The extravasation was here the immediate cause of death, and probably this did not take place to the full extent, except as a consequence of the excitement from drinking.

Wounds of the Brain.-Wounds of the brain, even when slight, sometimes prove instantaneously mortal, while in other cases recoveries take pace from contused or punctured wounds of this organ, contrary to all Expectation. When a person survives the first effects of the injury, there are two sources of danger which await him: 1. The production of soad fungus from the exposed portion of the brain. 2. Inflammation and its consequences. The process of inflammation, it must be remembered, is very slowly established in this organ; it may not manifest itself until From three to ten weeks after the injury. In one remarkable case, where & child was accidentally shot through the brain, the ball having traversed both hemispheres, no symptoms of cerebral inflammation manifested themseives for twenty-six days. The child died on the twenty-ninth day. (Lond. Med. Gaz., vol. xxxix. p. 41.)

336

INJURIES TO THE SPINE.

Wounds of the Face.-When wounds of the face are of any extent, they are usually followed by great deformity; and when they penetrate the cavities in which the organs of the senses are situated, they often prove fatal, either by involving the brain and its membranes, or by giving rise to inflammation of this organ. Wounds of the eyebrows are not of so simple a nature as might at first sight be supposed. Besides being attended with deformity when they heal, they are liable, during the process of healing, to cause serious disorders of the neighboring parts. Amaurosis and neuralgia are recorded among the secondary and not unusual consequences of such wounds, when the supra-orbital nerve has become implicated. Under certain conditions of the body, there may be inflammation of the parts within the orbit, extending to the membranes of the brain, and proving fatal by leading to the formation of pus within that organ. Amaurosis in the right eye has been known to occur from a contused wound, not of a violent nature, on the right eyebrow. Wounds apparently confined to the external parts of the face frequently conceal deep-seated mischief. A sharp instrument penetrating the eyelid, and passing upwards with force, will produce fracture of the orbital plate of the frontal bone, which is very thin, and even injure the brain beyond.

Deformity as a Consequence of Wounds of the Face.-Wounds of the face, when at all extensive, are always followed, in healing, by greater or less deformity. A medical witness may, perhaps, find these questions put to him in relation to them-Is the wound likely to be attended with deformity? Could such a wound of the face heal without deformity? or, could the deformity, if it exist, have been produced by any other cause than the wound? These questions are of importance. A person may allege that he was severely wounded in the face, when the medical witness may find no trace of such a wound as that described. Again, a person may seek damages from another in a civil action, alleging that a particular deformity was produced by a wound, when the medical witness may be able to trace its origin to disease, or to some accidental cause.

INJURIES TO THE SPINE.

The spinal marrow is liable to concussion from blows, to compression from fracture of the vertebræ or the effusion of blood, with all the secondary consequences attending such accidents. Concussion of the spinal marrow commonly produces paralysis, affecting the bladder, rectum, or lower limbs. These symptoms may not appear at once, but come on after some hours or days. After death no traces of mechanical injury may be discovered. Blows on the spine, unattended with fracture or dislocation, may be followed by inflammation and softening of the spinal marrow. A slight injury has thus been known to cause death, by giving rise to inflammation of the spinal marrow. This organ is also liable to compression from slight causes, and death may occur from paralysis of the nerves of respiration.

Fractures of the Vertebræ.-These fractures are generally attended with displacement, and thus produce compression of the spinal marrow. They are the more rapidly fatal in proportion as the injury is high up in the vertebral column. The whole of the body becomes paralyzed below the seat of injury, as a result of the compression of the spinal marrow. If the seat of compression is above the fourth cervical vertebra, death is commonly immediate; asphyxia then results from paralysis of the nerves which supply the diaphragm, and which are necessary to respiration. In falls on the summit of the head from a height, it sometimes happens not

FRACTURES OF THE VERTEBRÆ.

337

that the skull is extensively fractured, but that the dentiform process *be second vertebra is broken off, owing to the head being doubled Ser the body. This injury to the second vertebra may be the cause of b. From a case related by Phillips, it would appear that this accident not always attended with fatal compression of the spinal marrow. Eda. Med. and Surg. Jour., Jan. 1838, p. 265.) In one instance the son survived fifteen months (ibid., Oct. 1845, p. 527); and in another, which the fracture was caused by the patient turning in bed while his od was pressed on the pillow, death did not take place for sixteen nths. On several criminal trials, this injury was proved to have been cause of death; and in a case tried in Glasgow (Rex v. Reid, 1835), it me a material question how far such a fracture might result from It may happen that caries of the bone, or disease of the transe ligament, will cause a separation of the dentiform process from the - ad cervical vertebra. The state of the bone in these alleged fatal accints should, therefore, be closely examined. A slight cause may somees produce severe and fatal injury to the neck. A lunatic in a private ylum suddenly threw her head back in order to avoid taking some food was offered to her; and she fell dead, evidently from the compression laced by a sudden displacement of the dentiform process of the second tebra. A woman died suddenly a month after her confinement; she had - suckling her child at one o'clock in the morning, and at four she was ad dead. The viscera of the abdomen, chest, and head were carefully uined, without the discovery of any morbid appearance to account for th, when, as the brain was being returned into the skull, one of the sectors noticed a projection at the foramen magnum. On further exization, the dentiform process of the second vertebra was found to have - displaced, and this had so injured the spinal marrow as to destroy P. (Lond. Med. Gaz., vol. iii. p. 582.) It is not stated whether the e was in a healthy or diseased condition. In fractures of the vertebræ, person is generally so disabled, whatever may be the situation of the fracture, that he cannot walk or exert himself.

Injuries to the spine and its contents are generally the result of falls blows, either on the head or the lower part of the column. The ondary consequences of these injuries are sometimes so insidious as to arm suspicion, and death may take place quite unexpectedly some weeks er the accident. Spicula of bone, separated by fractures, may remain iberent for some time; and by a sudden turn of the head be forced off, nd destroy life by penetrating the spinal marrow, at a long period after e infliction of the injury. This has been known to happen in fractures volving the margin of the foramen magnum, and in such cases death is mediate. The spinal marrow has been in some instances wounded in upper part by sharp-pointed instruments introduced between the verte. Death is an instantaneous result when the wound is above the Ard cervical vertebra: there is no part of the spine where a weapon can easily penetrate as this, especially if the neck be slightly bent forward. Te external wound thus made may be very small, and if produced with y obliquity by drawing aside the skin, it might be easily overlooked, or it ght be set down as superficial.

22

338

WOUNDS OF THE CHEST AND LUNGS.

CHAPTER XXXIV.

WOUNDS OF THE CHEST.-WOUNDS AND RUPTURES OF THE LUNGS AND HEART.—WOUNDS OF LARGE BLOOD VESSELS.-WOUNDS AND RUPTURES OF THE DIAPHRAGM.-DIRECTION OF WOUNDS OF THE CHEST.-WOUNDS OF THE ABDOMEN.—DEATH FROM BLOWS ON THE CAVITY.RUPTURES OF THE LIVER, GALL-BLADDER, SPLEEN, KIDNEYS, INTESTINES. STOMACH, AND URINARY BLADDER.-WOUNDS OF THE GENITAL ORGANS.

Wounds of the Chest.-Wounds of the chest have been divided in those which are confined to the walls and those which penetrate the cavity Incised or punctured wounds of the walls of the chest are rarely followe by dangerous consequences. The bleeding is not considerable, and is generally arrested without much difficulty. They heal either by adhesion or suppuration, and, unless their effects are aggravated by incidental cir cumstances, the person recovers. Contusions or contused wounds of the chest are, however, far more dangerous, and the danger is in a ratio to the degree of violence used. Such injuries, when severe, are ordinarily accon panied by fractures of the ribs or sternum; by a rupture of the viscera within the cavity, including the diaphragm; by profuse bleeding; or, aan after-effect, by inflammation of the lungs, with or without suppuration Fractures of the ribs are dangerous for several reasons: the bones may le splintered and driven inwards, thereby wounding the lungs and causing hemorrhage, or leading to inflammation of the pleura or lungs. The intercostal arteries may also be wounded. In fractures of the upper ribs, the prognosis is less favorable than in those of the lower, because commonly a much greater degree of violence is required to produce the fracture. A simple fracture of the sternum, or chest-bone, without displacement of the bone, is rarely attended with danger, unless the concussion has at the same time produced mischief internally, which will be known by the symptoms When, however, the bone is depressed as well as fractured, the viscera behind may be mortally injured. In a case of depressed fracture of the sternum, the person died after the lapse of thirteen days; and on inspection it was found that the fractured portion of bone had produced a transverse wound of the heart about an inch in length. The cavities of the organ had not been penetrated, but the piece of bone was exactly adapted to the depression produced by it on the parietes. (Devergie, Méd. Lég., t. 2. p. 243.) A witness will frequently be reqired to take into consideration the effects of contusion of the thorax, with or without fracture, in cases of death from pugilistic combats, which formerly gave rise to numerous trials on charges of manslaughter. Wounds penetrating into the cavity of the chest are generally dangerous, even when slight, in consequence of the numerous accidents with which they are liable to be complicated. In these wounds, the lungs are most commonly injured; but, according to the direction of the weapon, the heart, or the great vessels connected with it, as well as the gullet or thoracic duct, may share in the mischief.

Wounds of the Lungs.-The immediate cause of danger from woundof these organs is hemorrhage, which is profuse in proportion to the depth of the wound and the size of the vessels wounded. Should the weapon divide any of the trunks of the pulmonary veins, the individual may speedily sink. The degree of hemorrhage cannot be determined by the quantity of blood which escapes from the wound; for it may flow in