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Briggs very wisely operated first on the leg; and after five years the epileptic fits had not recurred, showing that their origin was not in the depressed fracture of the skull, which, prima facie, was the probable cause, but in the irritation of the disease of the leg. A very interesting case from the legal point of view is given by Hofmann.39 A man thirty-five years of age, who had always had good health, on January 1st, 1878, received a blow on the head, sinking unconscious to the ground. He remained unconscious till January 7th, when consciousness returned. He was called well on January 22d, but he had frequent headaches, associated with paleness; later there came intervals of staring and diminished sight. In December of that year he had an attack of mania, lasting five days. On October 26th, 1881, he was found in severe epileptic convulsions, repeated sixteen times in two days. On the 8th of November he had another attack, another on the 9th, and one every day until the 13th, when they were repeated with one hour intervals, and on the 14th of November he died in coma. The autopsy showed no sign of scar on the head, but intracranial lesions, with healed contusions of the cortex of the brain. The causal connection between the injury and the death was clear, and the assailant was convicted of manslaughter, although the death occurred five years after the injury.

233. Diabetes. Diabetes following trauma is also well authenticated. Brouardel40 collected thirty-three cases, in some of which the disease began immediately after the injury, and in others not until eleven months later. The acute cases beginning promptly after the injury usually ran a short, hopeful course, and were cured in two or three months. Those appearing later were generally fatal. Thomayer collected four cases where the diabetes was secondary to injury of the abdomen rather than the more common sequence of injury to the brain or spinal cord.

234. Sarcoma and epithelioma.— Possibly, also, still more remote are cases of sarcoma following traumatism; and in cases where the injury leads to an open wound that refuses to heal for a long time the possibility of epitheliomatous changes may be attributed to the injury.42

235. Traumatic neuroses.-But the most common, and, perhaps,

See Friedreich's Bl. f. Ger. Med. and 1882, p. 440. "Brouardel,

1888. XX., 401.

Thomayer,

1889, No. 34.

the development of malignant growths, see: Grasser, Wiener med. Annal. d'Hyg. Pub., Presse, 1893, No. 42; and Cremer, Würzburger Dissertation, 1885. CremWiener med. Presse, er describes one case of carcinoma of the kidney after a fall, and cites fifteen

For the relation between trauma other such cases.

the most elusive of the sequela of injuries are the traumatic neuroses, using the term in the broad sense to include the various functional disorders of the nervous system which follow injury, those due to injuries received in railroad collisions, local injury to the head and back, and to fright or anxiety, if this last group, without any bodily injury, may be included in the results of traumatism. There is an excellent chapter on this subject in the International Text-book of Surgery, by Dr. James J. Putnam, professor of nervous diseases at the Harvard Medical School, with citations of numerous medicolegal cases that have come under his care or have been recorded by others. He groups the symptoms as first, those of shock; then those due to the impaired innervation of organs which have not been injured, and then symptoms of a hysteroid nature. The outcome of such cases, especially where there is a legal complication, is very doubtful, "as the mere fact that a litigation is pending makes it difficult for the patients to avail themselves of the precious opportunity, in the early stage of their illness, for reasserting their self-control. If such persons could be assured that health would speedily return, provided they brought no suit, or if they could settle their claim at once for a moderate sum, they would often be glad to do so. But this assurance cannot be given, and so delay is advised. Meanwhile, the consciousness that a suit is pending makes it much harder for even the most conscientious person to adopt the mental attitude necessary for recovery so fully as to insure success; and very soon the invalid habits have tightened their grasp so strongly that no ordinary measures can relax them. In general it may be said that when a trial is concluded the patient ordinarily improves more rapidly; but this is not true of all symptoms.

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"Hysterical paralyses, which often count for so much in court, are far more likely to pass away quickly than the impairment of mental balance and nervous strength; and thus the lawyer and prejudiced physician unjustly count many patients as simulants because they soon leave off their crutches, when, in fact, they may still be far from well."

235a. Railway spine.- The one of the traumatic neuroses that has received the most attention, possibly, is "railway spine."43 Here there may be no, or very slight, evidences of injury immediately after the accident; but later there appear, and gradually increase in

For the more detailed accounts of these conditions, see Vibert, Précis de Médecine Légale, 4th ed., p. 311.

intensity, the symptoms due to the disturbance of the nerve supply to various organs,—insomnia, headache, psychic troubles, disturbances of memory, of emotions, of vision, often coming in crises brought on without any apparent cause. Disturbances of digestion. are very common. In many cases there develops a marked tenderness of the spine, which is very painful on pressure or on motion. The prognosis of these cases is bad in proportion to the slowness of development and the intensity of the symptoms. The severe cases may last indefinitely.

III. HOMICIDAL, SUICIDAL, AND ACCIDENTAL WOUNDS.

236. In general. To obtain a satisfactory solution of the question as to whether a wound found upon a dead body was of accidental, suicidal, or homicidal origin, much depends upon the evidence of the circumstances under which the wound was inflicted, and it is a legal rather than medical consideration. A few a priori considerations may not be out of place, however, before considering the results of the examination of the body. Hofmann** gives statistics of suicides in Germany, showing distinctly the prevalence of suicide during the active years of life, but with about 1 per cent after eighty years of age and about 5 per cent before twenty years of age (he cites one instance of suicide in a boy of seven years of age); and shows that about one fourth of suicides occur in women. As to the mode of suicide and the proportion of men to women in each mode, Vibert gives statistics45 from the French record from 1887 to 1891, showing, in general, the following percentages:

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Suicide in children is usually done by hanging, in the case of boys, and in the case of girls by drowning, or throwing themselves out of the window.

237. Situation of wound. The situation of the wound may point

"Hofmann, Ger. Med., 1903.

Vibert, Précis de Méd. Lég., 1900.

to its suicidal or homicidal origin. Suicidal wounds are inflicted upon those parts of the body most accessible to the hand: such as the head, neck, and anterior part of the trunk. They are usually either made by firearms or by cutting instruments. If by fire arms, most frequently in the head, or over the heart; if by cutting instruments, the throat is the most frequent site of the wound. If, therefore, a wound is found upon some part of the body which it is manifestly impossible for the suicide to reach, this circumstance, in connection with the direction of the wound, will make the intervention of another person or the occurrence of accident evident. Yet, as in the greater number of all wounds the situation is such that the wound could be self-inflicted, the locality of the wound alone affords merely, at most, a presumption as to the mode of origin. Moreover, it must be remembered that all suicidal wounds are not inflicted by means of the hand, but sometimes by violently striking the body against some solid substance by precipitation from a height, and by various other means, especially in persons of deranged intellect, who not infrequently contrive to mortally wound themselves in such a manner as would hardly be thought of by another. Dr. Pope reports a case of attempted suicide where the man, an inmate of a jail, drove a 3-inch wire nail into his head in the median line, 612 inches back of the nasal eminence. Mr. Tarleton reports an instance of an insane gentleman who was found lying insensible in his kitchen, with a cleaver by his side. Upwards of thirty wounds were found over the occipital bone; they were horizontal, many of them superficial, but one of them had removed a portion of the skull from the middle of the lambdoid suture, so that the brain had escaped. The man, who survived his injuries four days, admitted that he had inflicted them himself. Suspicion of criminal violence would, very naturally, be entertained in such cases as these, provided the body was accidentally discovered in a deserted place.

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238. Direction of wound.-The direction of the wound will more frequently serve to distinguish a homicidal or an accidental wound from one which has been self-inflicted. Thus, on the trial of Mrs. Mackin, in Edinburgh, in 1823, for murder, it was stated in the evidence that the deceased died from a stab. The prisoner alleged in her defense that she merely held the knife in her hand, sloping upwards, to deter the deceased from attacking her; but that he, being drunk, stumbled forwards upon it. This state

Pope, Journ. Amer. Med. Ass., Mar., "Tarleton, Taylor, Med. Jur., p. 191. 1904, p. 649.

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ment was disproved by the medical testimony, which showed that the direction of the stab was backwards, and very much downwards in the lungs, having penetrated the chest over the cartilage of the second rib.48 A similar instance is given by Elvert, in which the downward direction of the wound, and its having been made in the manner of the German butchers, viz., a second internal wound after a partial withdrawal of the instrument, not only disproved the accidental origin of the wound, but indicated also the occupation of the murderer. In England, a few years since, a murder was fixed upon a man from the fact that the wound in the neck of the deceased had been evidently made by a knife cutting from within outwards, as is done in slaughtering sheep. In cases of stab wounds, in which it is claimed that the dead person threw himself upon the weapon, such an assumption could not hold if the direction of the wound through the skin were oblique; nor could it hold if the wound penetrated deeply, unless it could be shown that the weapon had been held firmly in place.50

The direction of suicidal wounds is subject to too much variety to be relied upon as a criterion, for although in many cases we may obtain from it a presumption that the wound was voluntary, yet it is evident that a wound inflicted by a murderer may assume any direction which could possibly be given to a suicidal wound. Besides, the deceased may have been left-handed or ambidextrous,-a consideration of some importance in this relation. In short, but little information of value can be obtained from the direction of a wound, unless the circumstances under which it was received are known; hence, its chief importance is in corroboration of other evidence.

In any case in which a person is found lying dead or dying from wounds or other bodily injuries, an accurate inspection of the locality and of the position of the body in respect of surrounding objects is of the highest importance, and should be minutely noted before the body is removed.

239. Circumstantial evidence. That part of the circumstantial evidence which requires medical knowledge for its elucidation is often most curious and important, and as it has to deal with conditions incessantly varying, and is founded upon no familiar principles, nor any positive scientific basis, but rather upon loose and badly observed facts, must partake of the same nature, and often

Christison, Month. Journ., Nov., be drawn from the course taken by shot 1851, p. 401.

Kopp's Jahrb., I., p. 143. "The uncertainty of the inferences to

in the human body is discussed in Wh. Cr. Ev., § 771. See also § 215a, supra.

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