354

FRACTURES IN THE LIVING AND DEAD BODY.

case is remarkable inasmuch as spontaneous fractures of the thigh-bones are very rare, and the man had not suffered from any of those diseases which cause preternatural fragility, and the fracture was not caused by violent muscular exertion. Even the end of the heel-bone (os calcis) has been broken off by the powerful action of the muscles of the calf of the leg in making a false step. (Brit. Med. Jour., 1878, vol. i. p. 128.) The actual condition of the bone was, of course, unknown; but it healed readily, and the man left the hospital at the usual period. In fractures arising from this cause there would be no abrasion of the skin, nor any appearance to indicate that a blow has been struck; while the marks of a blow would, of course, remove all idea of the fracture having had a spontaneous origin. It is most unusual that the ribs should be fractured from muscular exertion; but a case occurred to Groninger, which shows that this accident may really occur. It is one of medico-legal importance, inasmuch as the injury might be easily ascribed to violence; but the absence of any external appearances indicative of a blow would render it probable that this was not the cause.

Fractures of limbs are not dangerous to life unless, when of a compound nature, they occur in old persons or in those who are debilitated by disease or dissipated habits. They may then cause death by inducing irritative fever, erysipelas, gangrene, tetanus, pyæmia, or delirium tremens. Fractures in the Living and Dead Body. It is not always easy to say whether a fracture has been produced before or after death. A fracture produced shortly after death, while the body is warm, and another produced shortly before death, will present similar characters, except that in the former case there might be less blood effused. A fracture caused ten or twelve hours before death would be indicated by a copious effusion of blood into the surrounding parts and between the fractured edges of the bones, as well as by laceration of the muscles; or if for a longer period before death, there may be the marks of inflammation. Fractures caused several hours after death are not accompanied by an effusion of blood. A medical witness may be asked, How long did the deceased survive after receiving the fracture? This is a question which can be decided only by an examination of the fractured part. Unless the person has survived eighteen or twenty-four hours, there are commonly no appreciable changes. After this time, lymph is poured out from the surrounding structures. This slowly becomes hard from the deposition of phosphate of calcium, and forms what is called a "callus." In the process of time, the callus acquires all the hardness of the original bone. The death of a person may take place during these changes, and a medical man may then have to state the period at which the fracture probably happened, in order to connect the violence with the act of a particular person. Unfortunately, we have no satisfactory data, if we except the extreme stages of this process of repair, upon which to ground an opinion. We can say whether a person lived for a long or a short time after receiving a fracture, but to specify the exact time is impossible; since this process of restoration in bone varies according to age, constitution, and many other circumstances. In young persons, bones unite rapidly; in the old, slowly; in the diseased and unhealthy, the process of union is slow and sometimes does not take place at all. In those who are at the time affected with a mortal disease there may be no attempt at reparation. According to Villermé, the callus assumes a cartilaginous structure in from sixteen to twenty-five days; and it becomes ossified in a period varying from three weeks to three months. It requires, however, a period of from six to eight months for the callus to acquire all the hardness, firmness, and power of resisting shocks possessed

FRACTURES-DISLOCATIONS.

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hy the original bone. A force applied to a recently-united bone will reak it through the callus or bond of union, while, after the period stated, the bone will not break there more readily than through any other part. It is generally assumed that the period required for the union of a simple fracture in the adult is, for the thigh-bone, six weeks; for the tibia (leg), he weeks; for the humerus (upper arm), four weeks; and for the ulna and radius (forearm), three weeks; for the ribs, about the same period; ut cases have been known in which the ribs had not perfectly united in two months, and in some fractures of the other bones it was found that on had not taken place in four months. In a case which occurred to Reid, a fracture of the tibia-the principal bone of the leg-healed in three weeks.

Has a bone ever been fractured? This question is sometimes put in reference to the living body. It is well known that a bone seldom unites evenly that the point of ossific union is not indicated by a node or proįction. Some bones are so exposed as to be well placed for this examination, as the radius, the clavicle, and tibia, these being but little covered by kin; in others, the detection is difficult. It is impossible to say when The fracture took place; it may have been six months or six years ago, as, er the former period, the bone undergoes no perceptible change. These farts are of importance in relation to the dead as well as to the living; <nce they will enable us to answer questions respecting the identity of seletons found under suspicious circumstances; and here medical evidence Lay take a wider range, for a fracture in any bone may be discovered, if 5t by external examination, at least by sawing the bone longitudinally trough the suspected broken part, when, should the suspicion be correct, the bony shell will be found thicker and less regular in the situation of the united fracture than in the other parts. So, in such cases, it will be easy to say whether a fracture is recent or of old standing.

Locomotion.—With respect to the power of locomotion after a fracture, it may be observed that, when the injury is in the arm or in the ribsunless many of the ribs are broken or the fractures are on both sides—a person may be able to move about, although he is unfitted for struggling making great exertion. Fractures of the leg generally incapacitate persons from moving, except to short distances. (See case by Syme, En. Med. and Surg. Jour., 1836, vol. 46, p. 255; also another in which one bone of the leg was fractured, and a power of walking some miles was retained, Amer. Jour. Med. Sci., 1845, p. 484.) The reader will find aditional information on this subject in the Ann. d'Hyg., 1839, t. 2, p. 241; 144, t. 2, p. 146; and in Friedreich's Ueber die Knochen in forensischer, Beziehung, Ansbach 1853.

DISLOCATIONS.

Dislocations are not frequent in the old or in those persons whose bones are brittle. They rarely form a subject for medico-legal investigation. A witness is liable to be asked what degree of force and acting in which direction would produce a dislocation-questions not difficult to answer. These injuries, except those of the vertebræ of the neck, are not dangerous to life unless of a compound nature, when death may take place from ondary causes. A dislocation which has occurred in the living body may be known after death by a laceration of the soft parts in the neighborhood of the joint, and by the copious effusion and coagulation of blood. For an account of the appearances presented by dislocation of the shoulder ive days before death, see Lond. Med. Gaz., vol. xxxi. p. 266.) If of old

356

DETECTION OF FRACTURES.

standing a dislocation would be identified by the cicatrices in surrounding structures. Dislocations may occur from natural causes, as from disease and destruction of the ligaments in a joint; also from violent muscular spasm during an epileptic convulsion. Dymock met with an instance of dislocation of the shoulder forwards during puerperal convulsions. (Edin. Med. and Surg. Jour., 1843, vol. 59, p. 302; see also Lancet, 1845, i. p. 440.) A power of locomotion may exist, except when the injury is in the lower limbs; but it has been observed that for some time after a dislocation of the hip-joint considerable power over the limb remains; it is only after a few hours that the limb becomes fixed in one position. Exertion with the dislocated member is in all cases out of the question.

Detection of Fractures. Malapraxis.-There are certain fractures of an obscure kind which closely resemble dislocations. This has been pointed out by Astley Cooper, in relation to fractures of the anatomical neck of the humerus (upper arm-bone). (Guy's Hosp. Rep., 1839, p. 272.) This accident might easily be mistaken for a dislocation of the shoulder. (Lond. Med. Gaz., vol. xxxvi. p. 38.) In attempting to reduce the bone the head continually falls back into the axilla. In such a case an action for malapraxis might be brought against a surgeon. It could only be by a dissection of the part after death that the real nature of the case would be ascertained. It is requisite, therefore, that great caution should be used in giving an opinion. The same observations apply to fractures of the neck of the thigh-bone, although with less force, because this is a more common accident in older persons. It is well known that fractures and dislocations, when cured, are often attended with some slight deformity of the limb, or with some impairment of its functions. This result is occasionally inevitable under the best treatment; but it is commonly set down as a sign of unskilfulness in a medical attendant. An action for malapraxis is instituted, and, in spite of good evidence in his favor, the surgeon is sometimes heavily fined for a result which could not be avoided. There is often great injustice in these proceedings, and the present system of allowing each party to select his own medical witnesses often leads to a conflict of opinion and evidence.

[The law upon this subject may be stated briefly, as follows:— Malapraris may be defined as bad or unskilful practice in a physician or surgeon, whereby the health of the patient is injured.

Negligent Malpractice embraces those cases where there is no criminal intent or purpose, but gross negligence in bestowing that attention which the situation of the patient requires.

Ignorant Malpractice is the administration of medicines, or the treatment of the disease, fracture, or injury in a way calculated to do injury, which actually does harm, and which a properly-educated, skilled, and scientific medical man or surgeon would know, was not proper in the case: Elwell's Malpractice, 198 and 243; 2 Bouv. L. Dict. 139.

Physicians and surgeons, by holding themselves out to the world as such, engage that they possess the reasonable and ordinary qualifications of their profession, and are bound to exercise reasonable and ordinary care, skill, and diligence, but that is the extent of their liability. The burden of proof is upon the plaintiff in actions for malpractice to show that there was a want of due care, skill, and diligence, and that the injury was the result of such want of care, skill, and diligence: Holtzman v. Hey, 19 Ill. App. 459; Baird v. Morford, 29 Iowa, 531; Vanhoover v. Berghoff, 90 Mo. 487; Craig v. Chambers, 17 Ohio St. 253; State v. Housekeeper, 70 Md. 162, and Leighten v. Sargent, 31 N. H. 119; also as to last proposition, Getchel v. Hill, 21 Minn. 464.

DETECTION OF FRACTURES.

357

The reasonable and ordinary care, skill, and diligence which the law pires of physicians and surgeons are such as those in the same general e of practice, in the same general locality, ordinarily have and exercise like cases: Hathorn v. Richmond, 48 Vt. 557; Wilmot v. Howard, Vt. 447; Utley v. Burns, 70 Ill. 162; Ritchie v. West, 23 Ill. 385; A mond v. Nugent, 34 Iowa, 300; Tefft v. Wilcox, 6 Kan. 46; Small v. Howard, 128 Mass. 131; Patten v. Wiggin, 51 Me. 594, and similar decias in Missouri, New Hampshire, Oregon, and Texas.

A different rule has been held in Pennsylvania. In McCandless v. MeWha, 22 Pa. St. 261, the court held that such skill was required

аз

roughly-educated surgeons ordinarily employ," and a similar view was taken in Haire v. Reese, 7 Phila. (Pa.) 138, but the weight of authority sas first above stated.

Tae locality in which the physician or surgeon practises should be taken to account. One in a small town or sparsely-settled country district is tot expected to exercise the care and skill of him who resides and has the pportunities afforded in a large city. He is bound to exercise the average ree of skill possessed by the profession generally in the locality in which he resides and practises: Gramm v. Boener, 56 Ind. 497; Kelsey Hay, 84 Ind. 189; Small v. Howard, 128 Mass. 131; Gates v. Fleischer, Wis. 504; Smothers .v Hauks, 34 Iowa, 286; Haire v. Reese, 7 Phila. Pa.) 138; Nelson v. Harrington, 72 Wis. 591.

P

Physicians and surgeons should, however, keep up with the latest advance in medical science, and use the latest and most improved methods and appliances, having regard to the general practice of the profession in the locality where they practise, and it is a question for the jury to decide m all the circumstances of the case whether the physician or surgeon Las done his duty in that respect: Van Hooser v. Berghoff, 90 Mo. 487. If a physician or surgeon departs from generally-approved methods of practice, and the patient suffers an injury thereby, the medical practitioner wd be held liable, no matter how honest his intentions or expectations were of benefit to the patient: Carpenter v. Blake, 60 Barb. (N. Y.) 488; 50 N. Y. 606; 10 Hun (N. Y.), 358; 75 N. Y. 12; Lampher v. Phipor, × C. & P. 475; Sean v. Prentice, 8 East, 348; Slaler v. Baker, 2 Wils.

959.

Physicians and surgeons are bound to give their patients their best dgment, but they are not liable for mere error of judgment: Tefft v. Wox, 6 Kan. 46; Patten v. Wiggen, 51 Me. 594; Carpenter v. Blake, 10 Barb. (N. Y.) 488; 10 Hun (N. Y.), 358; Wells v. World Disp. M. A, 45 Hun, 588; and see also Fisher v. Nichols, 2 Ill. App. 484.

If the error of judgment is so great as to be incompatible with reasonable care, skill, and diligence, the physician or surgeon would be liable: West Martin, 31 Mo. 375; Howard v. Grover, 28 Me. 97.

If the patient in any way contributes to the injury by his fault or neglect Le cannot recover for malpractice by the physician or surgeon: Haire r. Reese, 7 Phila. (Pa.) 138; McCandless v. McWha, 22 Pa. St. 261; Reler v. Hewing, 115 Pa. St. 599; Polter v. Warner, 91 Pa. St. 362; Am. Rep., 668; Lower v. Franks, 115 Ind. 334; Chamberlain v. Porter, 9 Minn. 200; West v. Martin, 376.

And this doctrine holds where the physical weakness of the patient or his natural temperament is the contributory cause of the injury: Haire Reese, 7 Phila. (Pa.) 138; Simond v. Henry, 39 Me. 155; Bogle v. Winslow, 5 Phila. (Pa.) 136.

Damages may be recovered for pain and suffering produced by the neg

358

GUNSHOT-WOUNDS.

ligence or want of skill of the physician or surgeon, and also for loss of time and expense incurred on account of the improper treatment: Tefft v. Wilcox, 6 Kan. 46; Wenger v. Calder, 78 Ill. 275; Chamberlain v. Porter, 9 Minn. 260; Stone v. Evans, 32 Minn. 243.]

CHAPTER XXXVI.

GUNSHOT-WOUNDS.-IN THE LIVING AND DEAD BODY.-WAS The piece FIRED NEAR OR FROM A DISTANCE?-ACCIDENTAL, SUICIDAL, OR HOMICIDAL WOUNDS.-POSITION OF THE WOUNDED PERSON WHEN SHOT.-WOUNDS FROM SMALL-SHOT.-WOUNDS FROM WADDING AND GUNpowder.

GUNSHOT-WOUNDS are of the contused kind, but they differ from other wounds in the fact that the vitality of the parts struck by the projectile is destroyed, and this leads ultimately to a process of sloughing.

The medico-legal questions which arise out of gunshot-wounds are siniilar to those which have been examined in relation to other wounds. They are dangerous to life, especially when they penetrate or traverse any of the great cavities of the body. Death may take place directly, either from loss of blood or from shock; although immediate or copious bleeding is not a common character of these injuries. Death from shock is occasionally witnessed. Indirectly, these wounds are attended with much danger; sloughing generally takes place uniformly throughout the whole of the parts perforated, and inflammation or fatal bleeding may cut life short. If the person survives the first effects, he may die at almost any period from suppurative fever, erysipelas, gangrene, or from the results of operations absolutely required for his treatment. Gunshotwounds may thus destroy life after long periods of time. A medical witness may be asked whether the wound was inflicted shortly before or soon after death. It is by no means easy to answer this question, unless the bullet has injured some vessel, when the effusion of blood and the forma tion of coagula will indicate that the person was living when it was received. If a gunshot-wound has been produced in a dead body no blood will be effused unless the bullet strikes a large vein.

If the person survives the injury, and the bullet can be felt in an accessible spot, it should, if possible, be removed. (See the case of Reg. v. Kelly, p. 305.) In addition to the use of Nélaton's probe (unglazed china) for detecting a bullet which was used on that occasion, a chemical method has been suggested. Lint moistened with vinegar, and secured to a flexible stem, may be introduced into the wound and allowed to remain for a short time in contact with the supposed bullet. It is then withdrawn and placed in contact with a solution of iodide of potassium. If a leaden bullet was in the wound, it would produce a precipitate of the yellow iodide of lead. Desneux employed this method in three cases.

It must be borne in mind that death may occur from a pistol-shot with no external wound. Ogston, jun., reports a case in which the bullet, in a case of suicidal pistol-shot, had passed through the soft palate, then through the basilar process of the occipital bone, traversed the medulla oblongata at the base of the brain, and, striking the internal occipital protuberance, had passed forwards and upwards through the brain till it reached the