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 {Reprinted from the Montreal Medical Journal, January, 189S.) 
 
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 FRACTURE OF THE SKULL FROM THE DISCHARGE 
 
 OF A SHOT-GUN INTO THE LEFT ORBIT. 
 
 By Wyatt Johnston, M.D., Montreal. 
 
 (From the Pathologiosl Laboratory of McGill University. ) 
 
 Owing to the meagre amount of medical literature about the 
 above-mentioned injury, which must be fairly common, and which 
 is of considerable importance from a medico-legal point of view, 
 I have given the results of the autopsy in some detail. 
 
 The leading points of the case in point are briefly as follows : 
 George Clay, a coi ured man, aged 39, Pntlman car porter, in 
 easy circumstances and with no known enemies, left his house 
 at 11 A.M. on Wednesday, April 20th, 1891, to go shooting 
 muskrats and pike in the creeks near Lachine, P.Q. He was 
 thought to have about $60 in his purse, and carried a revolver 
 in addition to an old double-barreled, muzzle-loading shotgun. 
 Having expressed the intention of returning for supper the same 
 evening his friends were alarmed when he did not appear. Two 
 days later his body was found, face downwards, in a creek near 
 Lachine, at a point where it passed into a railway culvert, and 
 where a rough bridge was formed by a telegraph pole and a 
 plank lying obliquely upon it. A substance resembling blood and 
 brains was found on the upper surface of this plank and the body 
 lay beneath it in the water. His hat lay in a bush close at 
 band. A suspicious feature of the case was that the gun was 
 
 i.>^ 
 
found twenty feet from the body, lying propped up against the 
 railway embankment. The right barrel had been fired. Neither 
 money or revolver were found on the body, though the watch 
 was not missing, and was found to have stopped at six o'clock. 
 
 The other circiiinstances of the case are irrelevant for my 
 present purpose. 
 
 A medical man practising in the parish having been called 
 upon to perform an autopsy, deposed to the presence of a 
 gunshot wound of the left orbit, passing in a direction obliquely 
 upwards to the vertex, and an appearance resembling a burn of 
 the left cheek ; also a very extensive comminuted depressed 
 fracture of the skull without accompanying hemorrhage. A 
 partial examination only was made, the brain not being removed. 
 About twenty grains of shot were found near the vertex. 
 
 The opinion given was to the effect that the gunshot was acci- 
 dental and had caused death, but that after death the head had 
 been subjected to violence, leading to the fracture of the skull. 
 This finding not being satisfactory to the jury, an examination 
 of the body was ordered, and I happened to be the person 
 selected to perform it. 
 
 The only really suspicious element in the case was the distance 
 from the body at which the gun was found, but this was subse- 
 quently reconciled with the theory of accidental death by the 
 deposition of a body of Oblat Fathers from a neighbouring 
 monastery, who, while out taking a walk in the afternoon of the 
 day following the tragedy, and twenty-four hours previous to 
 the finding of the body by the deceased's relatives, saw the gun 
 lying on the plank beneath which the body lay. These gentle- 
 men did not feel at liberty to mention the fact of their having 
 seen the body at all until about a week later. 
 
 This explanation of the gun being found at a distance from the 
 body was compatible with a theory of accidental death, and the 
 experimental evidence that a gunshot could produce all the in- 
 juries found in the deceased of course disposed of the idea of 
 injury to the skull being due in any part to blows on the head 
 inflicted after death, and led subsequently to a verdict of acci- 
 dental death being rendered. 
 
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8 
 
 KBPORT OF THE REEXAMINATION OF THE BODY OF GEORGE CLAY. 
 
 \ 
 
 
 Hxamination made on the premises of Mr.. Armstrong ^ under- 
 taker J ofLachine, at 3 p.m. on April 25<A, 1892, five days 
 after presumed date of death. 
 
 Tho body, which was identified in my presence as that of the 
 deceased George Clay, aged 39, was that of a well-built, well- 
 nourished coloured man, of middle height. Rigor mortis present 
 at all joints. No signs of decomposition. The previous exami- 
 nation had been confined to an examination of the injuries in the 
 head, the only dissection made being an incision in the scalp 
 extending from the root of the nose across the forehead as far 
 back as the vertex. This incision had been closed with sutures. 
 The body was lying in a coffin and was dressed in burial clothes. 
 The face bore signs of having been cleaned since the discovery 
 of the body. A careful examination of the whole body after 
 removal of all the clothes failed to show any injuries or marks 
 of violence excepting those subsequently mentioned in the head. 
 None of the bones were fractured. The hands were open and 
 showed no marks to indicate a struggle. The dirt beneath the 
 nails appeared undisturbed. 
 
 Head. — In the region of the left orbit is a large, rounded, 
 lacerated wound, If inches in diameter, extending from between 
 the left eyebrow to the level of the malar prominence. The 
 edges of the wound are thin, torn and blackened, and show traces 
 of small black grains apparently gunpowder. The entire left 
 eyeball and the contents of the left orbit had been displaced. 
 The hair and eyebrows were not burned. There were no signs 
 of the skin of the face being burned except at the margins of 
 the wound.* The nostrils were filled with clotted blood. The 
 outline of the cranium showed flattening and depression over the 
 
 ^> 
 
 * In the report of the previous autopsy a statement was made to the effect that 
 there was a burn on tho loft cheek. I was not able to find any trace of this at the 
 time when I made tlie second autopsy. The explanation of this apparent discrepancy 
 probably is that the appearance described us a burn wtts due to blackening of t le 
 face by soot from the powder-sui&ke. This might be mistaken for a burn. The soot 
 had probably been washed off by the undertaker in laying out the body. In my experi- 
 ments with gunshot wounds of dead bodies I found always extensive blackening of 
 the skin from smoke, but no burning. 
 
 A 
 
vertex and in the region of the left temple. On pressing lightly 
 with the hands, the cranial bones could be felt to move and crepi- 
 tate on one another. Owing to the previous examination having 
 disturbed the relation of the parts I was unable to determine 
 what the exact position of the bones had been immediately after 
 the injury as a direct consequence of it. 
 
 r.'he scalp was reflected in the usual manner after making an 
 incision from behind the ears passing over the vertex. The 
 scalp was found to be remarkably thick and dense. It showed 
 no trace of external injury. The tissues between the scalp and 
 the bone showed nothing abnormal except a slight amount of 
 ccchymosis in the left parietal region, near the vertex. 
 
 After removing the skull-cap by sawing around it below the 
 level of the orbit, the brain was examined. All the pieces of 
 bone were carefully preserved, but it was subsequently found 
 that the portions of bones corresponding to the left lower parietal 
 and frontal regions were missing. Whether this was due- to 
 their having been removed at the first examination and not re- 
 placed I am unable to say. From the appearance of the soft 
 tissues in this region it appeared as if the injury to the bones 
 had been more severe in this region than elsewhere. 
 
 The dura mater, especially in the anterior portion of the falx, 
 appeared to be much lacerated, but the disturbance due to the 
 previous examination made it impossible to state how much of 
 this laceration was due to the effects of the gunshot. 
 
 From beneath the skull-cap and in the brain tissue near the 
 vertex I removed 48 grains of No. 4 shot. Most of the grains 
 were much flattened. They weighed altogether half an ounce. 
 Some of the grains were found in the fissures caused by the 
 fractures in the bone. 
 
 The brain was found to be firm and in good condition ; it had 
 not been removed or disturbed at the previous examination. It 
 showed a lacerated area of between two and four inches in dia- 
 meter, extending obliquely upwards and backwards from the 
 left orbit to the vertex. The laceration was confined to the 
 neighbourhood of the median line, and involved the anterior ex- 
 tremity of the corpus callosum and the inner surface of both 
 
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hemispheres anteriorly. The left hemisphere was more exten- 
 sively lacerated than the right, but the inner frontal and orbital 
 lobes on both sides were almost completely disintegrated. 
 
 There was very little hemorrhage along the course of the 
 wound, and no large blood-clot was seen. The brain tissue con- 
 tained a considerable <iuantity of blood in its vessels and was not 
 pale. The ventricles were normal and free from blood-dot. 
 The ganglia at the base lay outside the track of the wound and 
 were not injured. 
 
 After the removal of the brain the posterior half of the left 
 eyeball with the optic nerve attached was found lying to the 
 right of the optic chiasm. 
 
 At the base of the skull there was found extensive laceration 
 and fracture in the vicinity of the left orbit, the injury extending 
 over an inch to the right of the median line. The bones of the 
 orbital plate of the frontal, together with the lesser wing of the 
 sphenoid on the left side and the turbinated and ethmoid bones, 
 were comminuted into minute fragments. Except in this region, 
 the base of the skull was free from fracture, and the linej of 
 fracture subsequently described in the skull-cap did not extend 
 as far down as the base. 
 
 The whole of the skull-cap was removed to Montreal and pre- 
 pared and mounted by Mr. J. Bailly, articulator. The location 
 of the lines of fracture will be understood from the following 
 description and from the accompanying 
 
6 
 
 (Fio. 1.) 
 
 The cranial bones were thicker and denser than in the case 
 of European skulls, though not unusually thick for an African. 
 The diploe was scanty and the tables relatively thick. The 
 measurements were : thickness in occipital region. 1 cm, of which 
 5 mm. was taken by the outer table, o mm. by greatly sclerosed 
 cancellous tissue, and 2 mm. by the inner table. In the parietal 
 region the total thickness was 7 mm., of which 2 mm. was occu- 
 pied by outer table, 1,5 mm. by the inner table, and 3.5 mm. 
 by the diploe. The length from glabella to occipital protuber- 
 ance was 19 cm. (7.5 inches) ; the diameter in mastoid region 
 was 13 cm. (5.3 inches) ; and in the anterior temporal region, 
 9 cm. (3.5 inches). The skull outline was somewhat unsym- 
 metrical and the thickness in particular spots varied considerably 
 from the means given, being at one point in the right temporal 
 region only 0-5 mm. (one-fiftieth of an inch). Both tables were 
 equally involved in the fracture, and nowhere was any splinter- 
 ing of the inner table observed. 
 
 The following lines of fracture were observed, eight in number, 
 including separation of the sutures : 
 
 No. 1 — A fracture extending forwards from a point in the 
 
 
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ooronal suture, half an inch to the right of the middle line and 
 running to the left external angular process of the frontal bone. 
 
 No. 2 — A fracture branching off from No. 1 at a point one 
 inch anterior to the coronal suture and extend'ng to the inner 
 third of the right supra-orbital ridge. 
 
 No. 3 — A separation of the anterior, 1^ inches, of the sagittal 
 suture. 
 
 No. 4 — A crooked line of fracture from the left frontal emi- 
 nence to the left parietal eminence. 
 
 No. 6 — A continuation of No. 4 from the left parietal emi- 
 nence to the posterior extremity of the sagittal suture in the 
 region of the Wormian bones. 
 
 No. 6 — A line of fracture extending from the posterior ex- 
 tremity of No. 'i an inch from the anterior extremity of the 
 sagittal suture and running to the left parietal eminence at the 
 junction of Nos. 4 and 5. 
 
 No. 7 — A curved line of fracture with the convexity upwards 
 extending from the right external angular process to the right 
 limb of the lambdoidal suture, passing through the parietal bone 
 just above the squamous suture. 
 
 No. 8 — A separation of the right half of the coronal suture 
 extending three inches from the coronal suture and then con- 
 tinuing as a fracture of the parietal bone and joining No. 7 at a 
 point half an inch posterior to the coronal suture. 
 
 On the inner surface of the cranium were seen eighteen small 
 round marks of lead on the bones ; these were scattered over 
 an area four inches in length by two inches laterally, and lay 
 along the vertex. Lead marks were also seen on the fractured 
 edges of the bones. None of the shot appeared to have pene- 
 trated the bones. 
 
 The thoracic and abdominal organs were examined and found 
 free from all traces of violence. The abdomen, on opening, 
 showed the peritoneum to be smooth and the position of the 
 viscera normal. The stomach was very small and looked con- 
 tracted. The level of the diaphragm corresponded to the third 
 space on the right side and the fourth rib on the left side. The 
 pleural cavities each contained about four ounces of clear reddish 
 

 8 
 
 serous flaid. The lungs were crepitant throughout ; the bases 
 felt sodden ; on section both organs were found to be oodematous. 
 Both lungs contained a fair amount of blood ; the bronchi weie 
 found free from foreign substance ; the bronchial mucosa was 
 pale. The heart was small and its ventricles contracted ; valves 
 normal. Spleen small in size, normal. Kidneys normal. Blad- 
 der contained about 4 ozs. of clear urine. Liver normal, con- 
 tained a fair amount of blood. Stomach small and nearly empty ; 
 contained about two ounces of fully digested food ; mucosa 
 normal. Intestines normal. 
 
 Microscopical examination of the blood stained substances 
 found on the plank across the creek showed them to contain 
 brain tissue, recognised in the form of granular detritus and 
 myelin drops. They also contained red-blood corpuscles aver- 
 aging seven to eight micromillimeters in diameter. 
 
 Summary, — The only injury found is a severe gunshot 
 wound of the left orbit, entering 'the skull in an obliquely up- 
 ward and backward direction, and lacerating the brain in the 
 area through which it traversed. The severity of the injury was 
 in itself sufficient to cause death. That death was probably not 
 quite instantaneous is probable from the oedema of the lungs, 
 but the absence of severe hemorrhage shows that it must have 
 very soon followed the injury. Loss of consciousness must have 
 been instantaneous from the severe shock. The oblique direction 
 of the wound makes it one which could not well have been in- 
 tentionally caused by a weapon in the hands of another person 
 than the victim, as it would be impossible to take aim so as to 
 produce this wound except under unusual circumstances, leading 
 to the victim being either several feet higher up than the assail- 
 ant or else lying down face uppermost. The wound is one which 
 could very well have been caused accidentally by the discbarge 
 of the gun while the muzzle was grasped by the hand of the 
 deceased. 
 
 The condition of the stomach agrees with the hour at which 
 the watch stopped, placing the hour of death and immersion 
 in the water at 6 p.m. on April 20th, the day of disap- 
 pearance. 
 
 "f.-ViJ.'SV 
 
 ^.'.'it,,;, 
 
 1; 
 
 W' 
 
 
A point of special interest was the totally different chtracter 
 of the cranial fracture in this case from the appearances mot 
 with in fractures produced hy direct violence from without, 
 such as results from blows or a fall on the head, etc. The 
 difference consists in the marked tendency to separation 
 of the sutures in the case of the gunshot injury of the cranial 
 vault from within, and the fact that the lines of fracture 
 do not tend to run across the base of the skull. This dis- 
 tinction can be readily explained on mechanical grounds when 
 the totally different relation of an arched cavity like the cranium 
 to external and internal shocks is borne in mind. An expansive 
 force acting from within would naturally tend to separate the 
 sutures, while a crushing force acting from without would have 
 no such tendency. An external force impinging on the roof of 
 tho cranial arch makes itself felt earliest and most severely at 
 the base, while an internal force directed upward expends itself 
 entirely upon the roof of the skull. 
 
 That this difference in the distribution of the lesions has not 
 previously been noted is perhaps due to the fact that the com- 
 monest form in which gunshot ur pistolshot wounds at short range 
 present themselves for examination is in the case of suicides, and 
 when the shot is fired through one of the natural orifices, the 
 mouth is that commonly chosen, in which case the bate of the 
 sphenoid bone lies directly in the line of fire, and is, naturally, 
 shattered. In cases where the entire skull is not shattered to 
 fragments, the scalp is perforated by the bullet in its exit. 
 
 In the present instance it was my fortune to meet with 
 a case where a most extensive fracture of tho skull accom- 
 panying a gunshot wound of the orbit, made at short range, was 
 not associated with any wound of exit or injury to the scalp. 
 
 Thinking that injuries of this nature arising from the careless 
 handling of firearms must be fairly frequent, I carefully searched 
 all the available sources of information in the shape of text-books 
 on medical jurisprudence and medico-legal literature, particularly 
 the files of the Vierteljahreasohrift fur gerichtliche Medidn^ 
 but was unable to find any case where a gunshot wound had 
 fractured the skull from within without producing a wound of 
 
10 
 
 exit. I was also disappointed in my expectation of finding 
 parallel cases reported among the forty thousand cases of gun- 
 shot wound of the head analysed and tabulated in the Medical 
 and Chirurgical History of the War of the Itebellion, or in any 
 special treatises on gunshot wounds and the museum catalogues 
 which I was able to consult. 
 
 In anticipation of a possible expression of opinion to the effect 
 that there is no inherent improbability of a fracture of the skull 
 from an injury such as is recorded here, being unaccompanied 
 by any evidences of injury to the scalp, I must state that the 
 experimental investigation on the production of fractures of this 
 nature was undertaken under conditions where the medical evi- 
 dence at a previous autopsy had led to the presumption thiit my 
 fracture of the skull had been produced after death by a sepa- 
 rate act of violence independent of the gunshot, and that it was 
 necessary to produce objective evidence sufficiently convincing 
 to change the views of a coroner's jury. 
 
 The medical evidence given at the first autopsy had led to the 
 presumption that the fracture of the skull was due to a separate 
 act of violence inflicted through blows from a blunt, smootli in- 
 strument, but my own examination convinced me that the gun- 
 shot wound was capable of having produced all the fractures 
 found in the skull. 
 
 Finding that there are no existing records of autopsies on in- 
 juries of this description, I obtained permission frcm the Attor- 
 ney-General for the Province of Quebec to make some experi- 
 ments in order to determine this point. In making these I re- 
 ceived valuable assistance from Mr. Bailly. 
 
 The following details were observed in my experiments : I 
 employed the gun used by the deceased, using a charge of 
 powder slightly less than 2 drs. to correspond with the amount 
 contained in the measuring cup of the powder flask found on his 
 body : the charge of shot used was three-cjuarters of an ounce, 
 as this amount corresponded with the amount found within the 
 within the skull. 
 
 It will be remembered that the whole eflects of the chariie 
 were concentrated within an area of an inch and three-quarters, 
 
11 
 
 as this was the size of the wound of the face. To prevent the 
 shot from scattering more widely than this, it was found, by 
 shooting at a plank at various distances, that the distance must 
 not exceed three feet. 
 
 Having procured a suitable anatomical subject, and taking a 
 somewhat smaller charge of powder corresponding with the 
 thinner skull of my subject, a charge was iired at a range of 
 two and a half feet into the left orbit, imitating as nearly as 
 possible the direction of the wound in the case of Clay. A 
 fracture of the skull (shown in Fig. 2) was produced, which 
 was practically identical with that found in Clay's skull, and 
 the scalp was also found to be practically uninjured, not being 
 perforated by the shot. 
 
 (Fui. 2.) 
 
 Setting aside the fact that the fracture of the experiment 
 happens to be somewhat more severe than that in Clay's case, 
 as might naturally be expected in dealing with a much thinner 
 skull, there is a wonderfully close resemblance in what I may 
 term the quality of the injury in both cases. Of the eight lines 
 of fracture described above in Clay's skull, no less than seven 
 found their counterparts in the fracture experimentally produced. 
 
12 
 
 I -i 
 
 A still more striking proof of the close relation between the ex- 
 perimental fracture and that of Claj's skull is that in both there 
 was extensive separation of the coronal and sagittal sutures. 
 In fractures of the skull fron the effects of blows or falls on the 
 head, this separation of the sutures appears to be most unusual, 
 if it ever occurs at all. 
 
 In the museum of McGill Medical College, amongst numerous 
 specimens of fracture of the skull there is only one which presents 
 this special feature, and this is a case of gunshot wound. The 
 reason ot this seems evident when the arched form of the cranial 
 roof is taken into account, as external pressure or violence would 
 tend to press the sutures more closely together, whereas pressure 
 or shock from within would tend to separate them. 
 
 That the charge did not penetrate the skullcap and scalp and 
 produce a wound of exit is apparently due partly to the thick- 
 ness of the skull and partly to the elastic resistance afforded by 
 the extremely thick scalp. In this connection the scattered 
 position of the shot over an area of eight square inches, as indi- 
 cated by the lead-marks on the inner table, must also be taken 
 into account. The distance of the muzzle of the gun from the 
 head also modifies the effect of the shot, and an increase of the 
 distance lessens the tendency to perforation. Thus I found in 
 another experiment, that with the same charge fired at a dis- 
 tance of one foot only, the shot passed (juite through skullcap 
 and scalp and buried themselves deeply in a plank placed behind. 
 That the fracture was in any measure caused by the expansion 
 of gas due to the explosion of the powder does not seem prob- 
 able. In a third experiment we placed the muzzle of the gun 
 directly against the left eye of a subject with a very thick skull, 
 and with the same charge of powder as in the last-named experi- 
 ment the whole of the top of the head was completely blown off 
 and the brain entirely disintegrated. In view of the fact that 
 at the intermediate range of one foot a circumscribed perforating 
 lesion was produced without any general, diffuse explosive effect, 
 it is improbable that the explosive force of the shot fired at two 
 and a half feet was the immediate cause of the fracture in Clay's 
 skull . 
 
18 
 
 Another point worthy oi . -iideration in this case is, that the 
 fractures did not run along the base either in the original case 
 or in the experimental fractures. Now it is well known that 
 the most delicate test of violence acting on the cranium from 
 without is the production of a fracture at the base, the force 
 being concentrated there by means of what we are in the habit of 
 calling contre coup. Fractures at the base uniformly occur as the 
 result of a Mow on the vertex too weak to fracture the bones of 
 the cranial vault, and I have never examined a case of extensive 
 fracture of the skull from external violence without having found 
 likewise fracture of the base. 
 
 In addition to the direct and indirect evidence in favour of 
 the violence acting from within rather than from without in the 
 case of Clay, I cannot conceive how such extensive injury of the 
 bones could have been brought about by external violence with- 
 out leaving traces of injury to the scalp. 
 
 The assumption that two separate acts of violence were needed 
 to produce the injuries found in Clay's body seems unneces- 
 sary. 
 
 As already stated, my reason for reporting the case at such 
 length was the absence of records of similar cases from medical 
 literature. Tho opinion given at the first autopsy that two 
 separate modes of injury had occurred, though to my mind quite 
 erroneous and " far-fetched," could best be controverted by 
 experimental evidence. 
 
 Anyone trusting to the information given in textbooks would 
 be completely at fault to find any precedent for assuming that 
 the gunshot had produced all the injuries. 
 
 I may also correct a misleading statement current in medico- 
 legal textbooks to the effect that fractures and lacerations un- 
 attended by hemorrhage have necessarily been produced post- 
 mortem. It was shown by Arnold Paltauf of Vienna, now three 
 years ago ( Wiener klin. Woehenschr., No. B7, 1889), that ex- 
 tensive fractures of the skull, ribs and other bones, and even 
 rupture of the liver, may be unaccompanied by any hemorrhage 
 even when the patients live for several hours after the injury. 
 
14 
 
 
 provided that the general blood -pressure is lowered to nearly 
 nil by either a profound condition of collapse from shock or a 
 copious hemorrhage from other parts. Blood cannot be extrava- 
 sated into the tissues unless the intra-vascular pressure at the 
 point of rupture exceed the resistance offered by the tissues. 
 
 I would point out in conclusion that my results, while correct- 
 ing and explaining in some respects those of the colleague who 
 performed the first autopsy, also established the accuracy of his 
 statement that the case was one of accidental death. 
 
 My thanks are especially due to Dr. F. J. Shepherd for hav- 
 ing furnished me with anatomical material and facilities for the 
 experiments, without which a successful result could not well 
 have been obtained in the short interval afforded by the adjourn- 
 ment of an inquest. 
 
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