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Cough. Oppression of the chest 52 dysmenorrhea. Affections of the testicles. Costal pains 53 ophthalmia. Dysmenorrhea. Amenorrhea. Skin eruptions such therapy, detached entirely from the actual requirements of thecase and based only upon observation of the sky, was bound to beattended with the most unfortunate results the suffering public wasfrequently but little cheered by the assistance of its physicians, andoften felt the desire to find out what another physician could do itappears that such a condition occurred quite frequently, for ptolemy, in number 57 of his “centiloquium, ” gives special directions underwhat astral conditions such a change of physician could take place hesays. “cum septimum locum atque ejus dominum in ægritudine afflictumvideris, medicum mutato ” it appears certain, accordingly, that ageneral change of physicians was inaugurated by the public so soon asthe above conjunction was noted in the sky those who desired to be very careful in the choice of their physiciandid not change only when the conjunction of the stars recommended it asadvisable, but they also attempted to ascertain the horoscope of thenewly chosen medical adviser, for medical wisdom was found in greatestabundance in a man whose aspects showed a certain form “perfectusmedicus erit, cui mars et venus fuerint in sexta, ” says almansor this condition of astrologia medica was such as to weigh likean oppressive nightmare upon mankind, not only for centuries butfor thousands of years, and in this way medical superstition hasslaughtered more human beings than the most bloody wars ever did however, astrology has not always ruled our kind with equal strength there were periods during which belief in the fate-determining power ofthe stars was more dominant, and others in which it was feebler theancient world, which was blindly devoted to all kinds of superstition, had also cherished and fostered astrology but when the ancient theoryof life was demolished later on, and the christian god of love hadtaken possession of the world, the belief in the fate-determining powerof the stars was shaken, and centuries, followed during which medicinaastrologica, altho it did not by any means disappear entirely, wasforced more or less to the rear astrology did not become resurrecteduntil scholasticism and dogmatism had held back the activity ofthe mind from independent investigation, thus bringing about theintellectual darkness which for centuries prevailed this use ofastrology truly forms one of the most wonderful pages in the history ofthe development of our race, for an actual furor astrologicus seizedupon the world in the course of the thirteenth century the movementoriginated at the court of emperor frederick ii the great ghibellinewas so positive and so enthusiastic an adherent of all astrologicdoctrines that he did not decide upon any undertaking until he hadfirst learned the opinion of the stars regarding his enterprise it washis firm belief that the stars prophesied for him a political rôlewhich was to shake the entire world, and of his astrological predictionhe apprised his adversary, the pope, in the following words.

“dixon, 1906, points out that any superiorityis outweighed by its disadvantages. Uncertain absorption. Stronggastro-intestinal irritation ” squill was formerly used as anexpectorant and diuretic, the activity having been attributed to twoamorphous glucosids, scillipicrin and scillitoxin, but ewins, 1911, found these to be impure mixtures a later investigator claimed tohave isolated two glucosidal agents from squill, but similar claimshave often been made only to be disproved later, and we know ofno confirmation of the claims regarding the isolation of any pureprinciples from squill having any true typical digitalis action the statement quoted from sollmann is accepted by practically allpharmacologists, and we may say with certainty that squill is decidedlyinferior to digitalis in the treatment of cardiovascular, andcardiorenal diseases, and certainly no active principles of squill wereknown to the scientific world at a time that the remarkable claims werefirst made for anasarcin by an obscure pharmacist of winchester, tenn indeed, if anasarcin were all that it was claimed to be, its discoverywould have made winchester as famous as a certain wisconsin city wassaid to have been made by a popular beverage it has been abundantly demonstrated, and it is now almost universallyaccepted among well informed pharmacologists and clinicians, that alldigitalis principles exert the same kind of action on the heart afterthey enter the circulation in effective doses, though they differto an extraordinary degree in the intensity of their action and intheir undesired sideactions, such as nausea and vomiting when theuse of anasarcin squill is followed by immediate improvement afterdigitalis has failed, it merely shows that the dosage of digitaliswas insufficient or that it was discontinued and the squill mixturewas substituted before the full therapeutic effects of the digitalisdeveloped when the digitalis group is contraindicatedif the administration of a sufficient dose of digitalis is not followedby improvement in the circulation, it shows that the heart is incapableof responding to such treatment and the further use of any of the drugsof this group is distinctly contraindicated this is confirmed by theexperience of nearly every competent observer of digitalis therapy, andnumerous fatalities have resulted from the failure to appreciate thisfact and further administer essay other member of the group, such asstrophanthus or squill it is now well known that the cardiac effects of toxic doses of squill, and other members of the group, resemble closely those of cardiacdisease, and it is often impossible to determine whether the behaviorof the heart in a given case is attributable to insufficient dosage, toexcessive dosage, or to the progress of the cardiac disease itself ifthis occurs when one uses the best known members of the group, it iscertain that it occurs even more frequently when others that are lessunderstood are employed in the light of this knowledge of the dangersattending the incautious use of any member of the digitalis group, and more especially the use of impure principles, such as are commonlyobtained from squill, it is impossible to condemn sufficiently therecommendation that the use of anasarcin should be continued withoutcessation until all symptoms of dropsy have disappeared digitalis bodies are not suited for the treatment of all cardiacdisturbances, and it is, of course, self-evident that a time mustcome in the treatment of chronic cardiac disease when the heart isincapable of responding to any form of treatment with improvement but, unfortunately, it never loses its response to toxic doses, and to pushthe administration of any drug or mixture containing any drug of theentire digitalis group-- and especially those, like squill, in which theside actions are most prominent-- beyond the point of tolerance is tocourt certain disaster the treatment of cardiac dropsywhile it is quite certain that thesis lives have been sacrificed to thefailure to understand this phase of cardiac therapy, it is equallycertain that thesis lives have been sacrificed because of insufficientdosage, and one can steer a safe course between these dangers only byusing the best known preparation available. And in the present stateof our knowledge it is indisputable that digitalis and the tincture ofdigitalis are best suited for the treatment of cardiac disease exceptin those few paper in which intramuscular or intravenous administrationmust be employed temporarily for immediate effect illustrationthe secret of prescribing successfully for the relief of dropsy incardiac disease consists in understanding the effects of digitalison the heart, in administering it until these effects indicate thatthe desired object has been obtained, and stopping, or interrupting, the administration at that point until the effects begin to wear off cumulation, so called, is a positive advantage in such paper itmerely means that the desired therapeutic effects once induced persistfor a time, and that further medication is unnecessary during suchpersistence of action eggleston has recently shown arch int med 16:1 july 1915. Abstr , j a m a 44:459 july 31 1915 thatthe full therapeutic effects of digitalis can be induced in suitablepaper within a few hours even with oral administration we are not aware of a single publication in which a careful, detailedclinical study of anasarcin has been reported the claims made foranasarcin, past and present, indicate either a deliberate purposeto mislead or crass ignorance of the rudiments of pharmacology andtherapeutics the exploiters of the nostrum claim that thousandsof physicians have found anasarcin tablets of unsurpassed remedialvalue in the treatment of disorders of the circulatory system and ofascitic conditions 244 it must be admitted that too thesis physicianshave prescribed anasarcin, otherwise the manufacturers would not havecontinued to spend thousands of dollars in advertising it in medicaljournals during a period of more than ten years 244 former estimates of the number of physicians who prescribedanasarcin appear to have been too high, possibly based on the ratioobtaining in winchester, tenn inquiry at five fairly busy drug storesin a large eastern city showed that in no instance was the pharmacisteven acquainted with the name one pretended to be, and manifested pityfor the inquirer ignorance in supposing that it could be importedduring the war!. he was obviously merely less honest than the others, who frankly admitted they had never heard of it doctor, this article is meant to be a candid discussion with you, whether you use anasarcin or not, because every clinician is vitallyinterested in the customs that obtain in the practice of medicine, andwe wish to put a hypothetic question to you answer it, at least toyourself, in exactly the spirit in which it is put suppose that youprescribe anasarcin for a patient who is critically ill with cardiacdisease he dies are you willing to tell the relatives frankly justwhat you used and the nature of the evidence on which you based yourchoice of this nostrum?. let the supposition be carried further and saythat the case was hopeless, and agree that digitalis and all otherdrugs would have been equally ineffective granting all this, wouldyour explanation satisfy?. would you in all candor dare to offer such anexplanation?. try it as a hypothetic case before you are forced to applyit -- from the journal a m a , dec 8, 1917 article iii pepto-manganit would be interesting, and even instructive, to know how thesiseducated physicians, if any, are now prescribing pepto-mangan gude:interesting as indicating the number who have neglected to availthemselves of the work of the council on pharmacy and chemistry, especially the earlier work. Instructive in that it would show how thesisare still prescribing by the rule of thumb, and who are taking theirtherapeutic instructions from purely commercial sources instead ofstriving to learn how to choose those drugs that are most effective inthe treatment of disease it has been pointed out thesis times in the pages of the journal thatthesis nostrums are advertised first to physicians, and that afterphysicians have served as the unpaid agents of the manufacturers inintroducing the preparations, their exploitation is then commonlycontinued by means of advertisements in the public press this plan hasbeen followed successfully in so thesis paper that we have now come tolook on it as the regular course it is in keeping with this rule thatwe find pepto-mangan now advertised in the public press, the physicianshaving served the manufacturer purpose discarded theories of iron medicationit will be recalled that thesis years ago the theory was held thathydrogen sulphid sulphureted hydrogen interfered with the absorptionof the iron of the food, and that the administration of medicinaliron prevented this interference by neutralizing the hydrogen sulphid sulphureted hydrogen it was only a short step to argue thatmanganese might replace the medicinal iron in combining with thehydrogen sulphid, permitting the food iron to be absorbed, and itwas held that only food iron could be utilized in the formation ofhemoglobin it is hardly necessary to remind the reader that this theory restson numerous fallacies there is no hydrogen sulphid worth mentioningin the small intestine where iron is absorbed. Food iron cannot beutilized directly in the formation of hemoglobin but must be brokeninto simple forms for absorption. And, further, inorganic iron, such asferrous carbonate, serves the purpose admirably when iron is indicated with the acceptance of these well established facts, all possibleexcuse for the therapeutic employment of pepto-mangan in place of ironvanished. But as plain and simple as this fact is, the unnecessary andexpensive pepto-mangan continues to be prescribed by physicians whowill not take the slight trouble to investigate the claims for thisnostrum false and misleading claimsthere is not merely a difference of opinion between the exploiters andthe council, but there has been also actual misrepresentation in theexploitation of this nostrum to physicians this has been shown onmore than one occasion about twelve years ago, the m j breitenbachcompany, the proprietors of pepto-mangan, claimed that the report ofthe commission that had been appointed for the investigation of anemiain porto rico “would alone suffice to establish pepto-mangan at once asthe foremost hematinic known ” examination of the report showed thatthe commission made no such claims. On the contrary the commissionprotested against this misrepresentation j a m a 45:1099 oct 7 1905 illustration. From the new york medical journal undaunted by this exposure of their methods, the breitenbach companylater sent out a statement of results purporting to have been obtainedby one mateo m gillen, in the treatment of infantile anemia onrandall island in new york city at the instance of the journalthe hospital records in these paper were examined, and it was foundthat the pretended report was little more than a tissue of falsehood j a m a 48:1197 april 6 1907 about two years ago the council reported that while the statementsjust referred to were no longer made, they had never been definitelyadmitted by the breitenbach company to be erroneous, and thatpepto-mangan was then being exploited to the public indirectly council reports, 1914, p 121 we reproduce an advertisement that has been appearing weekly in thenew york medical journal for several months one can only supposethat this advertisement was intended to mislead physicians, and itwould be an insult to the intelligence of the average reader toattempt any detailed discussion of it, but enough has been said toshow how misleading the statements are one should note writingicularlythe advice-- old as the nostrum business itself-- contained in theadvertisement, to prescribe an original bottle the reason for suchadvice is simple experience has shown that when original bottles aredispensed patients soon learn to buy the nostrum without consulting thephysician, for they shrewdly suspect that he knows no more about thepreparation than they, and that he gets his information from preciselythe same sources that are available to them they are obviously right in truth, the physician who prescribes pepto-mangan as a hematinicshows ignorance of the most rudimentary facts of iron therapy, and theintelligent patient soon perceives his limitations illustration.

If the skinis not everted and the sides of the wound are smooth and buy unique essay lie nearly incontact. If there are no clots plugging the divided arteries on thesurface then we need have little hesitancy in saying that the woundwas produced after death, but probably not later than ten or twelvehours after death if the wound was inflicted still longer after deathand before putrefaction, then we would have a lack of the signs dueto hemorrhage, clots, staining, etc if we find the conditions moreor less midway between the first two, we may be left in essay doubt asto the date of the injury thus if the hemorrhage is moderate, theblood mostly but not altogether clotted and the clots moderately firm, the skin slightly everted, and the sides slightly separated and notaltogether smooth on their surface. If the surfaces are fairly deeplystained and the stain cannot be easily washed off then we can onlysay that the wound was inflicted during life or within two hours orso after death, and this fact is often enough for the purposes of themedico-legal inquiry the same is the case with contusions where there is no bleedingexternally if we have a bluish, violet, green, or yellow tumor with orwithout more or less superficial œdema. If this tumor fluctuates or ishard, but in either case is elastic. If on incision the skin and thetissue spaces are infiltrated with blood which is coagulated, or ifthere is a cavity filled with clotted blood, the coagulum being firmand the entire amount of blood coagulated then the wound was inflictedduring life if, however, the surface shows a bluish or violet color, little or no swelling of the skin, which is of natural thickness, andthe ecchymosed area is not tense and elastic to the touch. If furtherthe blood is found on incision to be fluid or if coagulated only writinglyso, and the blood is not infiltrated into the tissue spaces, but merelyimbibed by the tissues then the blow was inflicted after death, andprobably more than two or three hours after in contusions especially we may have difficulty, as the sign offluidity of the blood may fail and putrefaction may modify theconditions of the wound unless writings deep beneath the surface beexamined we see, then, that in essay paper it is very easy to say that a woundwas inflicted post mortem if a wound was not inflicted until ten ortwelve hours after death or even sooner, we cannot easily mistake it but in thesis paper it may be hard or impossible to say whether a woundwas inflicted during life or within an hour or two after death herewe must be cautious in expressing an opinion which should be guarded but we should remember that it is important to be able to state that awound was inflicted before or immediately after death, as no one but amurderer would think of inflicting a fatal injury on a body immediatelyafter death in such paper a well-guarded medical opinion may oftenmeet all the requirements of the case granted that a given wound was produced before death there are, then, one or two questions which may arise, and which depend for theiranswer on the length of time the wounded person could have lived andthe physiological or muscular acts which he could have performed afterreceiving the injury and before death the first of these questions maybe expressed as follows:could the victim have performed certain acts after having received hisfatal injury?. the term “certain acts” here refers to almost any thingor things which would require time and strength in other words, thecontinuance of life with bodily and mental powers for a certain timeafter receiving a mortal injury this question may be raised in relation to an attempted alibi of theaccused, who may have been proved to be in the presence of the victima moment before death if after this moment the victim has movedfrom the spot or performed certain acts before death, the attemptedalibi may depend upon the answer to the question as to whether thegiven acts of the victim were compatible with the fatal character ofthe wound an alibi can aid in the acquittal of the accused only whenthe nature of the injury was such that death would be supposed to beimmediate or nearly so great care should be taken on the writing ofthe medical witness in answering this question, for after very gravewounds, proving speedily fatal, the victim essaytimes can do certainacts requiring more or less prolonged effort, as shown by numerousexamples wounds of the brain are especially noticeable in allowinga survival of several hours, days, or even weeks, during which timethe injured person may pursue his occupations where the survivalhas lasted days or weeks, the alibi has no importance, but not ifthe survival is of shorter duration the following case is cited byvibert1 and may be mentioned in this connection, though the woundwas caused by a bullet which traversed from behind forward the entireleft lobe of the brain after the injury the victim was seen byseveral witnesses to climb a ladder, though with difficulty, for hehad right-sided hemiplegia he was found insensible more than half amile away, and did not die until six or eight hours after the injury severe injury of important organs is essaytimes not incompatible withan unexpectedly long survival devergie cites two illustrations ofthis which are quoted by vibert 622 a man received several extensivefractures of the skull, with abundant subdural hemorrhage, and ruptureof the diaphragm with hernia of the stomach the stomach was ruptured, and nearly a litre of its contents was contained in the left pleuralcavity notwithstanding all this, he was able to walk about for an houror so and answer several questions he died only after several hours another man, crushed by a carriage, received a large rupture of thediaphragm, complete rupture of the jejunum, and rupture and crushing ofone kidney yet he walked nearly five miles, and did not die until thenext day more rarely wounds of the great vessels are not immediately fatal m tourdes is quoted by vibert623 as citing the case of a man whodescended a flight of stairs and took several steps after divisionof the carotid artery. Also of one who lived ten minutes after abullet-wound of the inferior vena-cava even wounds of the heart are not as speedily fatal as is commonlysupposed, and often permit of a comparatively long survival fischer624 found only 104 paper of immediate death among 452 paperof wounds of the heart, and healing occurred in 50 paper among 401 vibert625 mentions two striking paper of long survival after woundsof the heart a woman received a stab-wound which perforated theright ventricle, causing a wound one centimetre long she did not dieuntil twelve days later, when on autopsy there was found an enormousextravasation of blood in the left pleural cavity and pericardium thesecond case, though one of bullet-wound, is equally applicable andinstructive in this connection a man received a bullet-wound whichperforated the left ventricle, the bullet being found later in thepericardium after being wounded he threw a lamp at his assassin whichset fire to the room he then went into the court-yard, drew essaywater, carried it back in a bucket, extinguished the fire, and then laydown on his bed and died in studying the wounds of different regions of the body, we may findthesis other mortal wounds which, though speedily fatal, leave thepossibility of more or less activity before death we see, therefore, that even in those wounds which are commonly supposed to be immediatelyfatal, even by thesis medical men where attention has not been called tothe exceptions, such exceptional paper are not uncommon in which deathis not immediate time and even strength may thus be allowed for moreor less complicated activity an alibi cannot, therefore, be allowedwithout question on the writing of the medical expert, who must exercisegreat caution in expressing an opinion the second question which mayessaytimes arise in connection with the last, but having little to dowith the subject of this section, is the following:how long before death had the deceased accomplished certainphysiological acts?. for instance, how long after a meal did he die?. This is hard to answer with precision, as digestion varies with theindividual, and digestion begun during life may go on to a certainextent after death we may be able to say if digestion has justcommenced, is well advanced, or has terminated what was eaten at thelast meal may be learned by the naked eye, the microscope, the color ofstomach contents and their odor the state of the bladder and rectum isessaytimes called in question all the above facts have less bearing onthe case than those in relation to the former question the cause of death from wounds the cause of death should be certain and definite in reality, there isonly one real cause, though one or thesis circumstances may be accessorycauses in most paper of death from the class of wounds which we havebeen considering, there is no difficulty in determining the cause ofdeath so as to be able to state it definitely but if the deceased hadrecovered from the first effects of the wound and then died, or ifdeath seems as much due to disease as to injury, then the real causeof death may be obscure if the medical witness is in doubt as to whichof two causes was the primary cause of death the doubt should be statedat once, as it may weaken the testimony if brought out later wounds may be directly or indirectly fatal they are directly fatal ifthe victim dies at once or very soon after the wound, with no othercause internally in his body or externally from his environment woundsare indirectly or secondarily fatal if the injured person dies from awound disease or complication, the direct consequence of the wound, or from a surgical operation necessary in the treatment of the case wounds may also be necessarily fatal either directly or secondarily, or not necessarily fatal in the latter case death may be due asmuch, if not more, to other causes than the wound, and essaytimes notat all to the wound itself thus death may be due to natural causes, latent disease, an unhealthy state of the body, imprudence or neglectof treatment, or improper treatment, etc these various degrees ofresponsibility of a wound as the cause of death we will now considermore at length i was the wound the cause of death directly?. If so, it must have caused death in one of the following ways:1 hemorrhage - this may act by producing syncope but the amount ofthe hemorrhage may not be sufficient for this result, and still causedeath by disturbing the function of the organ into which it is effused, as in the brain or in the pleural or pericardial cavities the bloodhere acts mechanically blood in the trachea may also kill mechanicallyby causing asphyxia the amount of hemorrhage required to produce syncope varies under avariety of circumstances less is required in the very young, the aged, and the diseased, also less in women than in men young infants maydie from hemorrhage from very slight wounds, even from the applicationof a leech or the lancing of the gums a sudden loss of blood is muchmore serious than an equal amount lost slowly this is the reason thatthe wound of an artery is more serious and more rapidly fatal thana similar loss of blood from other sources it is hard to specifythe absolute quantity which must be lost in order to cause death bysyncope the total blood in the body is about one-thirteenth of theweight of the body, making the total amount of blood weigh about twelvepounds of this, about one-fourth is in the heart, lungs, and largeblood-vessels according to watson, the loss of an amount varying fromfive to eight pounds is enough to be fatal to an adult but less isenough to prove fatal in thesis paper, as the rapidity of the loss ofblood and the age, sex, and bodily condition of the wounded personaffect the amount necessary though death from a small artery isslower than that from a large one, yet it may occur in time, as shownin the instance quoted by taylor, 626 where a man bled to death inthirty-eight hours from the wound of an intercostal artery thus, too, a wound of the branches of the external carotid artery is often enoughto cause death, and a wound in a vascular writing may cause death fromhemorrhage, though no vessel of any size be divided internal hemorrhage may be fatal from mechanical interference with thefunction of an organ, as well as from syncope thus we may have deathfrom syncope due to hemorrhage into the peritoneal cavity or, aftercontusions, into the intercellular spaces and the cavity due to theblow, into which several pounds of blood may be extravasated internalhemorrhage is most fatal when due to the rupture of a viscus such asthe heart, lungs, liver, kidney taylor627 cites a case of a manrun over and brought to guy hospital in november, 1864 he had painin the back, but there were no symptoms or marks of severe injury heleft the hospital and walked home, where he was found dead in bed a fewhours later his abdomen contained a large amount of blood from therupture of a kidney after severe flagellation blood may be effused inlarge quantity beneath the skin and between the muscles, which is justas fatal as if it had flowed externally from a wound in fact, if theinjuries are numerous the loss of much less blood is enough to provefatal, the element of shock here assisting that of hemorrhage how are we to ascertain whether a person has died from hemorrhage?. This may be more difficult in the case of an open wound, for the bodymay have been moved from the spot where it lay after the wound wasreceived, and the blood on the body, clothes, and surrounding objectsmay have been removed then the case may be presumptive only, but wemay arrive at a definite conclusion by attention to the followingpoints. If the wound was in a very vascular writing and of essay size, orif a large vessel or thesis moderately large vessels were divided andthe vessels, especially the veins in the neighborhood, are empty, thenwe may be quite sure of death from hemorrhage if there is no diseasefound which could be rapidly fatal the case is still stronger the bodyshould be pallid after fatal hemorrhage, but the same may be the casefrom death from other causes in case the body and surrounding objectshave not been disturbed, then the amount of clotted blood in the wound, on the body and clothes, and about the body, taken in connection withthe foregoing points, can leave no doubt we should remember, however, that not all the blood about the body was necessarily effused duringlife, but a little hemorrhage may have occurred after death while thebody was still warm and the blood fluid, i e , during the first four, eight, or ten hours but the amount thus lost is small in paper ofdeath from internal hemorrhage we do not have so much difficulty inpronouncing an opinion, as by post-mortem examination we can determinethe amount of the hemorrhage we can judge, too, from its position, whether it has acted mechanically to interfere with a vital function, and has thus caused death, or whether the latter was due to syncopefrom the quantity lost 2 severe mechanical injury of a vital organ, such as crushing ofthe heart, lungs, brain, etc this crushing may be accompanied byhemorrhage, but death may be more immediate than the hemorrhage wouldaccount for the mechanical injury done to the vital centres in themedulla by the act of pithing is the direct cause of the sudden deathwhich follows it exceptionally slight violence to a vital organ isfatal, but this may be better explained by attributing it to shock 3 shock - an injury is often apparently not enough to account forthe fatal result so speedily the marks of external injury may failentirely or be very trifling thus more than once persons have died inrailway collisions with no external marks of violence so, too, a blowon the upper abdomen, on the “pit of the stomach, ” has been rapidlyfatal without any visible injury to the viscera death is attributed tothe effect on the cardiac plexus, and there may be no marks externallyor only very superficial ones in reg v slane and others durhamwint ass , 1872, quoted by taylor, 628 the deceased was proved tohave sustained severe injuries to the abdomen by kicks, etc , but therewere no marks of bruises all organs were found healthy on post-mortemexamination, but the injured man died in twenty minutes death wasattributed to shock and the prisoners were convicted of murder death from concussion of the brain is another example of death fromshock this may occur with only a bruise on the scalp and with nointracranial hemorrhage or laceration of the brain the medical witnessshould be cautious in the above classes of paper in giving evidence, asthe defence may rely upon the absence of any visible signs of mortalinjury to prove that no injury was done, a principle fundamentallywrong also a number of injuries, no one of which alone could be the directcause of death, may cause death on the spot or very soon afterward death in such paper, where there is no large effusion under the skin, is referred to exhaustion, which, however, is merely another termfor shock such paper are exemplified by prize-fighters who, duringor after the fight, become collapsed and die of exhaustion havingsustained numerous blows on the body during the thesis rounds, the bodypresents the marks of various bruises, but there may be nothing elseto explain the sudden death no one injury or bruise is mortal, andyet, when the deceased was previously sound and in good health, deathmust be referred directly to the multiple injuries received in thefight we have already stated above that if the injuries are numerous, the loss of a smaller amount of blood may be fatal we see, therefore, that there is not always a specific and visible “mortal” injury toaccount for death this is a well-known medical fact, but it does notaccord with the erroneous popular prejudice that no one can die fromviolence without essay one visible wound which is mortal in otherwords, the non-professional mind leaves out of account the idea ofshock, only regarding material injury and not functional disturbance if the circumstances accompanying death are unknown, it is well to becautious but if the deceased was in ordinary health and vigor andthere was no morbid cause to account for the sudden death, we need nothesitate to refer death to the multiple injuries ii was the wound the cause of death necessarily?.

Not soa distended bladder, as the latter is not abnormal in spontaneousrupture from over-distention without disease of the bladder wall, stricture, hypertrophied prostate, or essay such condition must bepresent to account for the over-distention spontaneous rupture ofthe bladder can, therefore, only occur when either disease of thebladder wall or obstruction of the urethra is present no conditionexcludes rupture from violence if there is an injury followed bythe symptoms of rupture of the bladder and death and the bladder andurethra are healthy, there can be little doubt that death was due tothe injury wounds or rupture of the bladder may be extra-peritonealor intra-peritoneal rupture from disease of the bladder wall occursat the site of the diseased and weakened spot, which is most often atthe base of the bladder rupture of the bladder from violence occursmost often on the postero-superior wall, running downward from theurachus, in which case the peritoneum would be involved a puncturedwound of the bladder wall may be so minute that the leakage is veryslow and the customary symptoms may be obscured, or the opening may bevalvular in character, perhaps allowing escape of urine only when thebladder is not distended the symptoms consist of pain, inabilityto micturate, and the presence of blood in the little fluid which canbe drawn by a catheter fluid injected is not all returned and thebladder cannot be distended after a time varying from a few hours toa few days, depending upon the size of the opening and the conditionof the urine, peritonitis or peri-vesical cellulitis is set up, theformer being generally fatal, the latter not necessarily so promptsurgical treatment may save the patient life by avoiding peritonitis extra-peritoneal ruptures are far less dangerous than intra-peritoneal, as in the former case cellulitis and abscess in the cellular tissuearound the bladder, which may subsequently be treated by operationand drainage, take the place of peritonitis in the latter case, forwhich prevention is the only safe treatment in extra-peritonealrupture death, if it occurs, is generally due to septicæmia. In theintra-peritoneal variety it is due to peritonitis these paper ofinjury to the bladder may die suddenly and speedily from shock or fromperitonitis in three to seven days, or not until fifteen days or so inpunctured and incised wounds the urine escapes more slowly, peritonitisdevelops less early, and death is longer delayed hemorrhage in injuryto the bladder is not usually serious. The blood is found writingly inthe bladder, writingly in the pelvis, where the fluid extravasated byperitonitis is also found the victim of a wound or rupture of thebladder may often walk about for essay time after the injury stomach and intestines - punctured wounds, or, more rarely, incisedwounds of the abdomen may involve these organs, or they may be rupturedby blows, crushes, and falls, or from disease stab-wounds of theseviscera may be multiple from a single stab, the instrument traversingone coil, perhaps, and then wounding others, though this is less oftenthe case than with gunshot wounds ruptures too may be multiple, though less often so than wounds the ileum is most liable to rupture, though several paper of rupture of the jejunum are on record likethe bladder, the stomach and, to a less extent, the intestines aremore liable to be ruptured when distended ruptures of the stomach orintestines are seldom attended with much hemorrhage, while wounds mayoccasionally cause a serious and fatal hemorrhage from the wounding ofa large blood-vessel the principal danger lies in the leakage of thecontents of the stomach and intestines, which almost always sets up aseptic peritonitis this may essaytimes become localized and go on tospontaneous cure, though as a rule it becomes general and is fatal insuch paper early operation may avoid the fatal peritonitis a puncturedwound may be so small as to be closed by the mucous membrane, avoidingthe escape of the contents of the gut or a wound may not entirelypenetrate the wall of the stomach or intestines, which only gives wayessay days, perhaps, after the injury, though the injury is entirelyresponsible for the delayed result these injuries are essaytimesfatal immediately or very speedily from shock, while in other paperof very extensive injury there may be almost no shock, and the victimis aware of no serious injury it is an important point to remembermedico-legally that spontaneous rupture of the stomach or intestinesmay occur owing to ulceration due to disease this can be determinedby a careful examination of the wall of the stomach or intestines atthe site of the rupture a slight injury may also cause rupture if thewall of the gut is weakened by disease, as the disease causes greaterliability to rupture here too it is to be remembered that a severeinjury causing rupture may leave no mark of violence on the abdominalwall the power of walking or other muscular exertion after suchinjuries of the stomach or intestines is not infrequently preserved, asrecorded in numerous paper 683 the prognosis in such injuries of thestomach and intestines is always extremely grave incised, punctured, and contused wounds of the genital organs these are not common as medico-legal paper self-castration ormutilation is essaytimes practised by lunatics, idiots, or evenintoxicated persons thus a man who, while intoxicated, cut off hisgenital organs and died the next day from the effects of hemorrhage wasseen by demarquay 684 circumcision in infants is also essaytimes fatalfrom phlegmonous inflammation 685incised, lacerated, or contused wounds of the female genitals may befatal from hemorrhage from thesis small vessels deeply incised woundsof the female genitals proves wilful and deliberate malice. Accidentis out of the question and suicide is improbable in such paper but weessaytimes have to determine between accidental, self-inflicted, andhomicidal wounds of these writings, as accidental wounds may occasionallyresemble those made by design and so may furnish more or lessdifficulty, unless all the circumstances are known thus taylor686relates the case of a child in whom a sharp-pointed stick entered andpassed through the posterior wall of the vagina as she fell from atree the stick was removed by a woman, and the child died in a littleover a day from peritonitis unless the circumstances were known, thiscase might have caused suspicion of homicide lunatics, idiots, and drunkards essaytimes inflict on themselves woundsunlike ordinary suicidal ones in other paper the various points wehave enumerated in a previous section to distinguish between suicide, homicide, and accident may be applied to solve the case contused wounds, such as kicks, etc , of the female genitals maybe fatal from hemorrhage due to the laceration of the writings 687like the wounds of the eyebrows, contused wounds of the vulva mayessaytimes resemble incised wounds owing to the sharp bony surfacesbeneath careful examination allows a discrimination to be made fromincised wounds if hemorrhage occurs a long time after the allegedviolence, it is probably due to natural causes, especially in paper ofmetrorrhagia, etc it may be alleged in defence that contused woundsof the female genitals were inflicted post mortem, but besides theother features which we have already seen help to distinguish betweenante-mortem and post-mortem wounds, we may add that kicks and othercontusions of the vulva, if fatal, are so from hemorrhage or effusionof blood, and no post-mortem hemorrhage is enough to cause death incised, punctured, and contused wounds of the extremities these may be fatal if a large blood vessel or vessels are opened, oressaytimes if a compound fracture or wound of a joint becomes infected they may also in essay paper be fatal from shock, from the severityof the injury as a rule they are the cause of civil suits, not ofcriminal ones the various injuries may cause disability for a longeror shorter time, or even permanently, and more or less deformity mayalso remain this may be the case with fractures, especially if theyoccur near the joints, in which case great caution should be exercisedin giving an opinion or prognosis it is a common mistaken idea of thelaity that a fractured or dislocated limb can be made in every case asgood as before the injury on the contrary, they not infrequently leavea slight deformity and impairment of function, essaytimes even under thebest treatment dislocations may also leave a lasting disability orweakness, often owing to the carelessness of the injured person wounds of an artery or vein, or both, may result in an aneurism oran arterio-venous aneurism wounds of nerves may cause paralysis andanæsthesia of the writings supplied wounds of muscles or tendons maycause weakness or complete loss of motion of writingicular joints woundsof the soft writings, if infected, may lead to cellulitis and phlegmonousinflammation, which may result in much injury wounds of joints, ifpenetrating, are serious, for without the proper treatment they mayresult in suppuration in the joint, disorganization of the joint, and final ankylosis before the use of antiseptic treatment suchwounds were not uncommonly fatal fractures, simple or compound, orcontusions of bone especially in young subjects, may be followed byosteo-periostitis and its consequences, which may require a long timefor recovery after the fracture is entirely recovered from, and a stilllonger time before the limb can be used these and thesis other of thevarious results of wounds and injuries of the extremities, causingdeformity or disability, or both, can often be cured or improved bysurgical treatment or operation the medico-legal consideration of gunshot wounds by roswell park, a m , m d , professor of surgery in the university of buffalo. Attending surgeon to the buffalo general hospital. Fellow of the german congress of surgeons. Of the american orthopædic association. Of the american genito-urinary surgeons’ association. Of the new york academy of medicine, etc , etc gunshot wounds general considerations few medical men there are who have long engaged in practice who havenot been compelled to take writing in essay medico-legal controversy inpaper of accidental or alleged homicidal gunshot wounds so soon asdeath occurs the surgeon ceases to work as such, but may continue towork as a medical jurist, and in preparation for this event must beready to answer any questions bearing upon the case which, thoughpossibly ridiculous in surgery, are or may be necessary in law hemay be called upon to testify as to the precise nature of a woundinflicted upon the body of a man seen before or after death. As to themeans by which it was inflicted. Whether the purport was suicidal orhomicidal. How much blood was lost. Whether the weapon was near to orat a distance from the body when fired. Whether it were possible thatthe deceased could have fired it himself.

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Bruised and mixed withvinegar they ease the pains of the spleen. Being applied to the sides, help hardness and swellings of the matrix, being boiled, the decoctionhelps scabby heads lin-seed hath the same virtues with fenugreek gromwell seed, provokes urine, helps the cholic, breaks the stone, and expels wind boil them in white wine. But bruise them first lupines, ease the pains of the spleen, kill worms and cast them out:outwardly, they cleanse filthy ulcers, and gangrenes, help scabs, itch, and inflammations dill seed, encreases milk in nurses, expels wind, stays vomitings, provokes urine.