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Accidental wounds are almost always contused, suicidal veryrarely so, only in paper of lunatics and delirious persons and wheresuicide is accomplished by a fall 2 the situation of the wound orwounds indicates their origin we have already studied the situationof suicidal wounds and have also seen that accidental wounds are onlyon exposed writings, except when the injury clearly indicates a fall froma height the evidence from the direction of wounds rarely applies, asthis is valuable only in incised and punctured wounds, which are seldomaccidental both kinds of wounds are usually few in number except incase of a fall from a height or a crush, though essaytimes suicidalwounds are multiple the evidence from weapons, if there be any, points strongly to suicide the signs of a struggle are hardly consistent with either suicide oraccident the only case in which they might occur would be where astruggle occurred to prevent a suicide from throwing himself off aheight or before a vehicle or railway train in such a case accidentwould be excluded by the signs of a struggle, and the question wouldlie between homicide and suicide the examination of the clothes ofthe deceased would furnish no evidence unless essay letter or paperwere found stating the purpose of committing suicide little or noevidence would be furnished by the position of the body when foundin paper which might otherwise be doubtful organic lesions or otherfacts predisposing to suicide would furnish presumptive evidenceagainst the wounds being accidental of all these various points thefirst, as to the nature of the wounds, is by itself the most valuableand conclusive but this gives us no assistance in clearing up a casewhere it is doubtful whether a fall from a height or a crush by avehicle or railway train was accidental or suicidal essay of the otherpoints mentioned may aid us in such a case, and also the fact that suchinjuries are far more often accidental than suicidal but in thesepaper, also, certain circumstances may show that the fall was not theresult of accident accidental wounds are generally caused by a fall or a crush, andthe fact of their accidental character is generally established bythe circumstances of the event certain accidental wounds presentcharacteristics which allow the true nature of the wounds to bedetermined but in essay paper a suspicion may arise and the questionmay be asked as to whether the wound was accidental or homicidal forinstance, if a person receives fatal homicidal injuries, and justbefore or after death the body is thrown from a height or is runover and crushed, it may be hard to determine the murderous elementamong the thesis wounds this is the case if the homicidal wounds werecontusions or were caused by blunt instruments, but rarely, if everso, if they are incised or punctured wounds or both but even in theformer instance, a close examination of the lesions and of the localityof the injury can often clear up the case thus in a case mentionedby vibert, 653 as cited by hofmann after taylor, a woman was founddead at the foot of essay stairs in a cave she had died of a fractureof the skull and of the spine, produced by the fall but about four orfive feet above the level of the top step there was found on the wallthe fresh marks of an arterial jet of blood examination showed a woundin the right temporal region which had opened the temporal artery, andit was therefore thought that the woman was wounded at the top of thestairway and then thrown down, which was afterward proved to be true in another case, reported by m tourdes, a man knocked down and killedby an axe, which crushed his skull and caused the brain to exude, wasplaced in a road frequented at night by heavy wagons the head wasplaced in the rut, but the coagulated blood and brain formed a puddlewhich did not appear on the wheels or their track, and no bloody furrowwas caused by their passage the same author mentions the case of awoman plainly strangulated by the hands and then thrown into the ditchof the fortifications of paris it is especially with regard to fractures of the skull that thequestion often comes up as to the accidental or homicidal nature ofthe injury, as to whether it is due to a fall or a wound essaytimes adepressed fracture may show the form of the instrument an extensivecomminuted fracture of the skull may indicate greater violence thanwould be received from a fall from the little height which thecircumstances may allow as to the slighter degrees of fracture, the disposition of the fracture itself often shows less than theform and site of the ecchymosis, the lesion of the scalp, and theplace and position of the body when found in such paper the tracesof a struggle, the existence of other wounds, etc , may be of greatimportance in distinguishing between homicide and accident, as indistinguishing between the latter and suicide, the most obscure anddifficult paper are those where the injury has been caused by a fallfrom a height or by a crush this is illustrated by the case of madame de tourville, which isquoted by taylor 654 she was killed in july, 1876, by a fall from aprecipice her husband, a lawyer, was accused of murder committed bypushing her over a precipice in the stelvio pass the place where herdead body was found was at a considerable depth below, and the injurywas chiefly in the head, which had been crushed by the fall the bodyshowed no evidence of intentional violence the prisoner guilt wasestablished on the following points. 1 the false and inconsistentstatements made as to the occurrence. 2 the marks of the body havingbeen dragged essay distance so that a writing of the dress was found, ina bloody condition, essay way from the body. 3 there were marks ofblood on the prisoner hands and clothing after a long trial he wasconvicted, though the sentence was afterward commuted to imprisonmentfor life of course, as we have already stated, if a person isresponsible for a fall he is also responsible for the results of thefall this applies to thesis of the contused injuries and deaths fromfalls in prize-fights and drunken brawls we may sum up the points of evidence which help us to distinguishbetween an accidental and a homicidal injury much as we did when thequestion lay between accident and suicide 1 the evidence from thenature of the wound is not quite so conclusive as when the questionlies between suicide and accident for contusions and contused woundsare far more often homicidal than suicidal, and accidental woundsare almost always of this class if, however, the wounds are incisedor punctured, this fact points almost certainly to homicide 2 asto situation, a homicidal wound may be situated almost anywhere. Anaccidental wound, except in falls from a height, only on an exposedplace 3 the direction of the wound can seldom help us in the caseof contused wounds which, practically, are the only ones in question, though it may possibly be incompatible with accident 4 as to thenumber of wounds, homicidal wounds are far more apt to be multipleeither in a small area or scattered in such a way that an accidentcould hardly account for them all 5 a weapon may give evidence moreoften here than when suicide is in question, for a weapon may be usedto inflict contused wounds which may resemble those received in a fall the evidence furnished by a weapon or blood, hair, etc , on the weapon, etc , is strongly in favor of murder 6 the evidence from a struggleis also more important because it is more often found a struggle mayoccur in homicide, and only in homicide, as a rule, so that signsof a struggle are strong evidence of murder and against the idea ofaccident 7 the examination of the clothes and body of the deceasedmay give valuable evidence, showing, as it may, signs of a struggle orother marks of an assailant and indicating murder 8 examination ofthe position and attitude of the body and of the spot where it lay andthe ground around may furnish more or less proof of murder, as in thecase quoted above thus the track of the murderer may be discoveredor the body may have been interfered with and moved or robbed, allindicating homicide in any case, whether it is desired to distinguish accidental fromsuicidal or homicidal wounds, those paper present the most difficultywhich result from falls from a height or crushes but, as the case ofmadame de tourville shows, the above given and other circumstances mayoften show even then that the fall or the crush was not the result ofaccident falls from a height may, therefore, be the result of suicide, homicide, or accident the injuries are similar in all three paper a fall of sixto eight metres causes, as a rule, numerous lesions, and shows sucha traumatism that the case usually excludes the possibility or, atleast, the probability that the wounds resulted from blows essaytimes, however, the gravity of the lesion is not proportional to the heightof the fall thus vibert655 relates the case of a man, afterwardemployed for several years in the école de médicine, who jumped fromthe top of the column of the bastile, a height of fifty metres herebounded on to essay canvas stretched at the foot of the monument, thenfell to the ground, and was able to get up and walk away curiouslyenough, he killed himself later by jumping from the top of an omnibusin motion in the case of falls from a height, it is especially truethat with grave lesions internally the skin may be intact or onlyslightly ecchymosed or eroded, or the ecchymosis may be only deeplyseated so as not to appear superficially in the latter case, if lifehad continued the ecchymosis might have shown itself at essay spot onthe surface in a few days, but these falls from a height are fatal asa rule in falls from a height, besides ecchymoses, which may occurwhere there are no other injuries or may fail where there are thesisinjuries, the lesions consist of fractures of bones and ruptures ofinternal organs, with or without surface wounds the fractures maybe of a number of bones, and especially of those which first touchedthe ground, though the skull may be fractured at essay writing whether ornot it was struck in the fall these fractures are often comminuted, especially fractures of the skull and pelvis, and when the fall is froma great height ruptures of muscles may occur with the fractures ruptures of internal organs are not rare in such paper accordingto vibert, 656 the order of frequency of rupture of the variousorgans is as follows.

The biologic principles present are chlorophyll, chromoplast, lipoids and vitamines. These are ferments or enzymes the vegetable acids, metalloids and metals present in all plants in colloid form act biochemically among the metalloids are hydrogen, carbon, manganese, oxygen, sulphur, phosphorus and chlorine. The heavy metals are iron, potassium, sodium, magnesium and copper these biochemic principles are always present in plants as colloids ”it is claimed by the merrell company that. “proteogens stimulate the cytogenic mechanism to higher activity. Therefore, indirectly cleave the invading microorganism and eliminate their special toxins proteogens swing the disturbed metabolism back to normal and, by natural processes, build up effective defenses against recurrent bacterial attacks ”proteogen no 1 was first introduced as “plantex, ” and at that time themerrell company referred to a preparation that was the result of “aseries of studies” carried out by a “noted biologist” with a view of“evolving a cancer remedy” that was “to be autolytic in character, ” andannounced. “the house of merrell always interested in the progress of plant therapy, began pharmacological experimentations to reproduce this same substance the qualitative and quantitative analysis of the substance as used in new york having been published simplified matters a essaywhat similar remedy has now been prepared it consists of the following substances-- menyanthes trifoliata buckbean, melilotus officinalis yellow sweet clover, mentha crispa curled mint, brassica alba white mustard, anemone hepatica liver leaf, viola tricolor pansy, anthemis roman chamomile, fructus colocynthidis colocynth, lignum quassiæ quassia, urtica dioica nettle, radix rhei rhubarb root, hedge hyssop these substances are in approximately equal proportions with the exception of the mustard which forms 20 per cent of the mixture, and the colocynth fruit which is 5 per cent ”with respect also to the other proteogens listed above, study ofmedical literature revealed no evidence establishing their therapeuticvalue. In fact, no evidence was found other than that appearing inthe advertising matter of the manufacturer the range of diseases inwhich proteogens are recommended is so wide as to make obvious thelack of scientific judgment which characterizes their exploitation acircular letter, received january, 1919, reminded the physician thatabout a year ago his attention had been directed to proteogen no 1for cancer, that later developments enabled the firm to recommend forhis consideration “a series of proteogens nos 2 to 9, ” and that now“in response to an insistent demand, dr a s horowitz has preparedtwo new proteogens-- no 10 for syphilis and no 11 for gonorrhea ”a postscript to this circular letter announced another preparation, “proteogen no 12 for influenza and pneumonia, ” a “development out ofthe present influenza epidemic, ” and admitted that “it has not hadthe clinical experimentation that precedes our introduction of a newproduct ”the introduction of no 12 was effected by means of a special bulletinwhich consists exclusively of clinical reports from seven physicians, all from chicago save one, and all purporting to show most favorableresults from no 12 they describe paper which any physician withexperience with influenza can duplicate without any special treatment it is difficult to give serious consideration to a set of allegedremedies when the only evidence is that furnished by the proponents ofthe alleged remedies this is writingicularly true when the alleged remedydoes not make a sufficient appeal to one sense of the rational intherapeutics to lead one to feel justified in asking a trial at thehands of careful clinical observers considering the grave nature ofthe diseases for which proteogens are recommended, writingicularly cancer, tuberculosis, and pernicious anemia, the want of a rational basisfor the method of treatment and the general tenor of the advertisingmatter, it appears safe to conclude that these agents do not representany definite advance in therapeutics as the use of preparations, secret in composition, and of noestablished value, is contrary to rational therapy, it is recommendedthat the proteogen preparations be declared in conflict with rules 1, 6and 10 report of second referee reviewing manufacturers’ replythe report declaring the proteogens of the william s merrell companyinadmissible to new and nonofficial remedies was adopted by thecouncil, but before publication it was sent to the merrell companyfor such comments as it might desire to make in due time the replyof the firm was received it consisted of two volumes bound in limpmorocco, each stamped in gold. “report proteogen therapy requested bythe american medical association, 1919. The wm s merrell company ”the first volume contained 79 pages of typewritten material. The secondvolume contained 76 pages of typewritten material and a number ofadvertising booklets put out by the wm s merrell company, exploitingthe proteogens among the typewritten material was a 14-page report on “proteogentherapy” by its originator, a s horowitz following this thereare several pages devoted to what is termed “a short qualitativedescription of the ingredients of major importance in proteogens ”then follows a page describing the advertising of proteogens, andthe remainder of the two books is devoted to testimonials, laudingthe benefit of proteogens in diseases such as cancer, tuberculosis, rheumatism, asthma, influenza, enlarged prostate, rheumaticendocarditis, syphilis, eczema, psoriasis, diabetes, secondary anemia, gonococcic infections, etc finally, there are attached samples ofadvertising pamphlets the dissertation by a s horowitz contains little actual informationconcerning these substances, but is concerned principally withdiscussion of foreign proteins, “antiferments, ” “non-specificproteins, ” “anti-virolins” and speculations on their hypotheticalactions and interactions on each other and on the organs of the bodyand on bacteria the report contains thesis questionable statements one finds in this report but few definite statements of facts whichare known to be accurate or which could be accepted without question the qualitative description of the proteins and their components isas vague as the previous discussion the differentiation between thevarious proteogens is extremely indefinite. That for tuberculosis, no 3 is described as “polyvalent, non-specific protein which rapidlyattacks the acid-fast, encapsulated tubercle bacilli”. Proteogen no 10 for syphilis is said to be a combination of “non-specific plantproteins and different chemicals which has the power to paralyze anddestroy living spirochete ” it is stated that proteogens are scientificpreparations based on standard ingredients and that the standardizationis more accurate than in serums, vaccines or toxins, etc the reportgives no proof of such statements the testimonials that are submitted are typical of “reports” thatmanufacturers are able to obtain from essay physicians, to prove theefficacy of almost any preparation in any disease each consists, practically, of the opinion of the individual who has employed theproteogens or the opinion of the patient who has been treated few dataare given in these reports from which an imwritingial conclusion might bedrawn a few of the testimonials presented by the william s merrellcompany follow the valuelessness of such material as scientificevidence is obvious. Rheumatism:-- proteogen no 2 -- the doctor has one case being treated with no 2 she has improved so rapidly she cannot express her pleasure, and will continue for essay time on the treatments she is a patient who was confined during the time she suffered from a rheumatic illness, and it seemed to affect her mental condition this condition is clearing up also, very much to the pleasure of both patient and doctor -- november 27, 1918 influenza:-- proteogen no 12 -- first day, temperature 102, gave 1 c c proteogen no 12. Second day, temperature 100, gave 1 c c proteogen no 12. Third day, temperature 98 8, gave 1 c c proteogen no 12, and then discharged the case as recovered -- october 31, 1918 asthma:-- proteogen no 4 -- splendid results obtained from a sample of proteogen no 4 three ampoules affected effected?. complete recovery -- october 9, 1918 cancer:-- proteogen no 1 -- mrs b pronounced recovered from cancer by dr o w a , of catlin, after having injections of proteogen no 1 for essay time -- october 4, 1918 eczema:-- proteogen no 5 -- tried no 5 on a patient with eczema, and with happy results have not done anything for him for about five months-- and he is now at his business proteogen no 5 also relieved him of constipation and what he claimed a traumatic stricture of the lower portion of sigmoid flexure he is sure pleased and recommending them to his friends proteogens -- february 17, 1919 syphilis:-- proteogen no 10 -- i am getting such excellent results with the no 10 proteogen for syphilis that i am badly in need of more, as i am treating so thesis paper please send me four dozen c o d -- october 9, 1918 enlarged prostate:-- proteogen no 1 -- have used plantex in four paper, with good results in each case one of them his father, an elderly man -- april 25, 1918 lobar pneumonia:-- proteogen no 12 -- the only case i have used proteogen no 12, was a man who had lobar pneumonia of left lung following influenza after crisis came, patient continued to have slight rise in temperature, cough, and after using 10 doses of your proteogen no 12, temperature was normal, cough very much better, patient began to take on flesh and is still improving -- december 26, 1918 tuberculosis:-- proteogen no 3 -- the doctor writes.

Ztschr f chemotherap , 1914, orig , ii, 110 i have, however, had an even more striking demonstration of the samefact i have given intravenous injections of dyes to patients sufferingwith various forms of internal tumors, as, for example, cancer of thebreast, in the hope of favorably influencing the growths at operation, the picture presented by the tumor is striking in the extreme itpresents areas of various size which are intensely discolored by thedye these areas, both to the naked eye and under the microscope, are the necrotic writings of the tumor the actively growing areas oftumor tissue and all the normal tissues of the organ present theirnormal color all of these observations lead to the conclusion thatthe necrotic areas in tumors either possess a higher affinity forsodium iodid and for the dyes than do the normal tissues, or thatthese substances are more slowly absorbed from the necrotic areasowing to the circulatory deficiency whichever of these explanationsis accepted, it is quite reasonable to believe that necrotic areasmight well undergo liquefaction under the influence of the varioussubstances which have been used for therapeutic injection such aresult is, of course, without direct effect on the growth or vitalityof the living writing of the tumor this fact is quite clearly evidencedby the experimental data, which show that the internal portions of thetumor might undergo liquefaction and yet the tumors were not cured indeed, löhe, who made microscopic examinations of the tumors treatedby caspari and neuberg, states writingicularly, with reference to a tumorwhich had been subjected to treatment, that “the central portion ofthe tumor showed softening, while the external margin was composed ofactively growing cells ” the central portions of implanted tumors are, of course, those which first undergo spontaneous necrosis it still remains to explain the small percentage of cures achieved bywassermann and by keysser it does not appear to me that this problempresents any insuperable difficulties the fact must be emphasizedthat practically 95 per cent of the animals die under the treatment, which sufficiently indicates the toxic effects of the agent used wemust remember that transplanted tumors are under all circumstancesat a certain disadvantage as compared with the normal tissues of thebody after all, they are implanted on a foreign soil their bloodsupply is impoverished and imperfect they have a natural tendency toundergo necrosis, and in thesis paper spontaneous retrogression it isnot strange, therefore, that they should prove in slight degree moresusceptible to toxic effects than are the normal tissues of the body if we remember that the various therapeutic agents introduced in allprobability reach a essaywhat higher degree of concentration in thenecrotic areas of the college essay help atlanta tumor than in the normal tissues of the body, anassumption which is entirely in accord with the facts as observed inthe case of sodium iodid and of various dyes, we may be quite preparedto believe that this factor is sufficient to induce the destruction ofthe marginal healthy and living cells of the tumor the fact that smallsubcutaneous tumors were found by keysser to be entirely refractoryto the treatment is entirely in accord with this assumption, in viewof the fact that tumors of this size present practically no centralnecrosis the same explanation holds of the observation previouslycited from caspari that the primary spontaneous tumors of animalsdo not yield to the treatment indeed, he himself states that thetreatment is effective only in tumors in which autolysis takes placeduring life the word autolysis, however, in this connection is amisnomer and represents a gratuitous assumption. As an actual fact, one is entitled to say only that such tumors undergo central necrosis, in all probably owing to defective circulatory supply the process isexactly similar to the coagulation necrosis described in the case oftubercles by weigert if autolysis occurs, it is only secondary to thepreceding necrosis this explanation, however, is confronted by the fact that the internaltumors produced by keysser showed no tendency to effect a localizationof the dyes, and correspondingly no tendency to be affected by thetherapeutic agents one might be permitted to inquire whether theseinternal tumors had undergone any necrosis keysser unfortunately makesno mention of this matter it is certainly true that the infiltrativemode of growth of the internal tumors, which is entirely differentfrom that of the subcutaneous implantations, is associated with amuch better blood supply and a lessened tendency to undergo necrosis that such tumors can undergo necrosis, however, is evidenced bycertain illustrations given by carl lewin in his paper on internaltumors but such changes usually occur only in advanced stages tojudge from his plates, keysser worked with relatively small tumors, an assumption which is rendered even more likely by the fact that hisinjections were undertaken in a fairly early stage of their growth inthis connection i may quote certain experiments of my own on internaltumors 279 the implantations made in my experiments were produced byintravenous injections of a tumor suspension into the jugular vein ofrats such injections resulted almost invariably in the production ofa large number of tumors in the lungs, which, as is well shown in thefigures accompanying the original article, differed very markedly insize the smaller of these tumors are composed throughout of activelygrowing cells, while the large tumors present an area of centralnecrosis exactly as do the subcutaneous tumors if such an animal begiven an intravenous injection of a dye such as congo red, it will befound that the larger tumors present an area of central discolorationcorresponding to the area of previous necrosis, while the smallertumors, like normal tissues, are not colored thus, it is clear thatthe internal tumors implanted in animals are subject to the same lawsconcerning the distribution of dyes and, of course, other substances asare the subcutaneous tumors as i have stated previously, an exactlyanalogous observation has been made in a human breast tumor in theabsence of any contradictory evidence, therefore, i think that it isperfectly justifiable to assume that keysser failed to achieve a resultin the internal growths simply owing to the fact that those growthspresented practically no areas of necrosis at the time of his injection 279 j m research, 1913, p 497 another theoretical question which bears closely on the recenttherapeutic investigations in human beings concerns the rôle ofcolloids, as such, in the procedure it is quite clear from what hasalready been said that all experiments with animal tumors have beenlargely influenced by the belief that metals in the colloidal formexercise a peculiar and characteristic influence on the destructionof tumors even when the therapeutic agents have been introducedin crystalline form, as by neuberg and caspari, the authors findthemselves compelled to assume that the metals are reduced to colloidalform within the tumors for the latter assumption there is absolutelyno evidence. It is due simply to the influence of the colloidal theory if one critically examines the data on which this theory is based, oneis forced to the conclusion that it has practically no establishedclaim to validity if we grant that colloidal metals have been shown tostimulate autolysis in the test tube, the same fact must be admitted ofmetals in noncolloidal solution the experiments, however, are very farfrom establishing either of these facts satisfactorily but even werethis the case, it is an unjustifiable inference that living tumor cellswould be influenced in anything like the same manner as are the deadcells observed in test tube experiments as an actual fact, we knowfrom the work of evans and schulemann that only the “scavenger cells”of the body take up foreign colloids, and to this class the tumor cellsdo not belong moreover, the form in which metals are introducedinto the circulation is not necessarily or even probably the form inwhich they act on the tissues colloidal solutions of the metals arecertainly subject to precipitation and other changes on entering theblood this fact i have shown experimentally in a previous study oncolloidal copper 280 in the same way it is probable, as has beenpointed out by wells, that metals when introduced in crystalloid formmay rapidly be altered so that they are carried throughout the body incolloidal form all of these considerations indicate how unjustifiableis the assumption that colloidal metals exercise a peculiar action ongrowing tumors it is hardly surprising that their empiric use hasfailed to measure up to expectations based on so slim a foundation offact 280 weil, richard. The effects of colloidal copper with an analysisof the therapeutic criteria in human cancer, j a m a 61:1034 sept 27 1913 clinical observationclinicians have not been slow in following the lead suggested by thetherapeutic experiments in animals it is perfectly proper that thisshould be the case in dealing with a disease of the character ofcancer, in thesis instances entirely beyond our power to influence, noone can question the advisability of trying any and every agent whichholds out the slightest promise unfortunately, a closer analysis ofthe animal experiments fails to vindicate even that degree of faith when one considers the facts which have been analyzed in the precedingdiscussion, it would appear not only futile but actually dangerous toattempt to benefit cancer sufferers by means of any of the agencieswhich have been employed in animal experimentation nevertheless, thefact remains that a variety of preparations have been used in the humanclinic the various types of preparations may be satisfactorily groupedunder four classes, namely:1 the crystalline salts of selenium 2 selenium in colloidal solution 3 other metals in colloidal solution 4 compounds of metals with organic radicals these substances have been administered by injection or by the mouth in the case of injection, the injections have been made either into thesubcutaneous tissues, intramuscularly, or intravenously, or finally, directly into the tumors before passing to a further considerationof this subject in detail, it may be well to recall the fact that inthe experimental tumors of animals, no matter what preparation hasbeen used, it has been possible to accomplish therapeutic effects onlyby the use of relatively enormous doses of the medicament, of doses, in fact, which were scarcely lower than the lethal dose certainexperimenters have noted that smaller doses actually stimulated thegrowth of the tumors in the second place, it has almost invariablybeen found necessary to administer the treatment intravenously, inasmuch as the other modes of administration failed of therapeuticeffect it is quite apparent that a procedure in human beings in anydegree analogous to that pursued in animals is entirely impossible thedoses used, with one notable exception to be subsequently mentioned, have invariably been relatively small hence it is apparent at theoutset that at least one fundamental condition of success in thetreatment of animal tumors has been necessarily excluded in theclinical application the salt used by wassermann is not stated in his original publication wolff281 speaks of it as a sodium salt, whereas keysser says that itwas a combination with potassium cyanid in only one instance, as faras i am aware, has the sodium salt been used therapeutically in humanbeings delbet282 states that he employed this salt intravenouslyin one case, and that its use was shortly followed by death unquestionably the salts of selenium are very much too toxic to be usedin this way 281 wolff. Die lehre von der krebs krankheit 3:1913 282 delbet, p.

They crush the soft writings to a certain extent, and thebones may be indented or even fractured wounds caused by fragments of bottles, pieces of college essay help atlanta china, earthenware, or glass, though strictly speaking incised wounds, are often curved, angular, and irregular, and their edges jagged and contused wounds caused by scissors may essaytimes be of the nature of incisedwounds when they present a double wound of triangular shape, with theapex of the triangle blunt, they are more of the nature of puncturedwounds in general a “tail” or long angle in the skin at one end of anincised wound indicates the end of the wound last inflicted, and essaylight may thus be thrown upon the inflicter of the wound incised wounds present very favorable conditions for healing by primaryunion, but often fail in this and heal by secondary union when anincised wound fails to unite by primary union, bleeding continuesfor several hours or even as long as a day, the blood being mixedmore or less with a serous discharge the latter continues until thethird day or so by the fourth or fifth day the surface has begun togranulate, and there may be a more or less profuse purulent dischargefrom the surface the granulating surfaces do not necessarily dischargepus, however for essay days, therefore, after the infliction of anincised wound, or until the surface is covered with granulations, thecharacteristics of the wound permit of a diagnosis as to the nature ofthe wound the diagnosis of an incised wound is generally without difficulty essay wounds by blunt instruments, however, in certain regions of thebody, resemble incised wounds very closely such instances are foundwhere a firm, thin layer of skin and subjacent tissue lies directlyover a bony surface or a sharp ridge of bone these are seen most oftenin the scalp or in wounds of the eyebrow where the sharp supra-orbitalridge cuts through the skin from beneath the diagnosis of an incisedwound can often be made with great probability from the cicatrix thisis especially the case if the wound has healed by primary union and thecicatrix is linear the prognosis in incised wounds is good as to life unless a largevessel has been divided or unless an important viscus has beenpenetrated the prognosis as to function varies with the position andextent of the wound, and the circumstance of the healing of the wound punctured wounds, stabs, etc - these are characterized by narrownessas compared to depth, though the depth is not necessarily great they are more varied in character than incised wounds owing to thegreat variety of form of the weapons by which they may be made fromthe form, etc , of a writingicular wound we may often infer the varietyof weapon by which it was produced according to the weapon used, punctured wounds have been divided into several classes, of which m tourdes distinguishes four. 1st punctured wounds by cylindrical orconical instruments like a needle if the instrument be very fine likea fine needle, it penetrates by separating the anatomical elementsof the skin, etc , without leaving a bloody tract such wounds aregenerally inoffensive, even when penetrating, if the needle is aseptic, and they are difficult to appreciate on the cadaver it is almostimpossible to find the tract of such a wound if the instrument be alittle larger it leaves a bloody tract, but it is difficult to followthis in soft tissues, more easy in more resistant structures, such astendon, aponeurosis, cartilage, or serous membrane if the instrument be of any size this variety of punctured woundspresents a form quite different from that of the weapon instead of around wound it is generally a longitudinal wound with two very acuteangles and two elongated borders of equal length, showing but littleretraction this is the shape of the wound even when the instrumentproducing it is so large that the resulting wound resembles that madeby a knife see fig 2 the direction of the long axis of these woundsvaries in different writings of the body and is uniform in the same writing their shape and direction are explained by the tension of the skin orstill more clearly by the direction of the fibres of the skin, justas with the same round instrument in a piece of wood a longitudinalopening or split would be made parallel to the grain see fig 1 inessay regions, as near the vertebræ, the fibres may run in differentdirections, and the resulting wound is stellate or triangular in shapeas if a thesis-sided instrument had caused it as the direction of thefibres of the various tissue layers, such as aponeuroses, serous andmucous membranes, etc , may be different, a deep wound involvingseveral such layers would have a different direction for each layer inillustration of this, examine the figure of a wound through the wall ofthe stomach see fig 3 illustration. Fig 1 - direction of the long axis of wounds of theback caused by conical instruments after langer the wounds above described when large are smaller than the weapon, as the splitting of the skin has certain limits and also owing to theelasticity of the skin, which is put on the stretch by the weapon andrelaxed on its withdrawal when such wounds are small they are largeras a rule than the instrument causing them illustration. Fig 2 - slit-like wound caused by a pointed conicalinstrument 2 5 cm in diameter natural size illustration. Fig 3 - wounds of stomach wall by a conical instrument, showing the different direction of the long axis of the wounds indifferent layers illustration. Fig 4 - stab-wound of the skin with a knife a fewminutes before death 2d punctured wounds by instruments both sharp pointed and cutting, like a knife or dagger if these wounds are perpendicular to thesurface, they have more or less the form of the weapon used the anglesmay show whether the knife, etc , had one or two cutting edges, buteven though the back of the knife is broad the wound may resembleone caused by a double-edged weapon thus stab-wounds from a commonpocket-knife show only exceptionally a wedge-shape, but regularly aslit, the edges of which are slightly curved to one another and end intwo acute angles the reason of this lies in the fact that the wound isonly caused by the cutting edge of the knife, so that we cannot tellas a rule which angle was occupied by the back of such a knife figs 4 and 5 the depth of these wounds may equal the length of the weaponor be almost any degree less, but the depth may even be greater thanthe length of the weapon by reason of a depression of the writings atthe time of the blow the wound is often shorter and broader than theweapon causing it, though more often it is larger than the weapon fromthe obliquity of the wound and the movement of the weapon on beingwithdrawn the wound is smaller than the instrument where the writings areon the stretch at the time the wound is inflicted illustration. Fig 5 - nine suicidal stab-wounds in the region of theheart made by a knife used for cutting rubber this variety of punctured wounds may resemble the former class in thedirection of its long axis, if the cutting edge of the instrument isblunt the regularity and smoothness of the edges distinguish them fromcertain contused wounds 3d wounds made by instruments with ridges or edges, files, foils, etc if the edges are cutting the wound presents more or less the shapeof the weapon fig 6 but this is not always so, probably from theinstrument puncturing obliquely or from the tissues being unequallystretched fig 7 if the edges are not cutting the wound resemblesthose of the first class, though the edge often presents little tears, and the wound may thus be more or less elliptical with two unequalangles the wound of entrance and exit may be different illustration. Fig 6 - stab-wounds caused by a three-sided sharp-edgedpointed instrument 4th irregular perforating instruments, the wounds from whichresemble contused wounds contusions and contused wounds - a contusion is a wound of livingtissues by a blow of a hard body, not sharp-edged or pointed, or by afall, crushing, or compression, and without solution of continuity ofthe skin a contusion usually involves a moderately large surface incomparison to the two other classes of wounds contusions are of alldegrees of severity if the blow or injury is slight, there is onlyslight redness and swelling of the skin with pain, disappearing in afew hours, and leaving no traces if the blow be harder it producesmore or less crushing of the tissues, accompanied by ecchymosis withor without a wound or excoriations of the skin, etc the contusion mayhave the shape of the contusing body, such as a whip, the fingers, etc illustration. Fig 7 - stab-wounds caused by an eight-sidedsharp-edged instrument essay show a transition stage to wounds made bya conical instrument ecchymosis - this is characteristic, as a rule, of contused wounds it consists in the infiltration of blood into the tissues, especiallythe cellular tissues the source of the blood is from the ruptureof blood-vessels, and the size of the ecchymosis varies writingly withthe number and size of the blood-vessels, or with the vascularity ofthe writing the size of the ecchymosis also varies with the loosenessof the tissues into which it is infiltrated this looseness of thetissues may be natural as in the scrotum and eyelids, or it may be dueto the attrition of the tissues caused by the blow an ecchymosis islarger when the contused writings cover a bony or resisting surface, andthere may be no ecchymosis whatever, even from a severe blow, wherethe underlying writings are soft and yielding, as is the case with theabdominal parietes here we may have rupture of the viscera without anysigns of ecchymosis superficially an ecchymosis may be infiltrativeor it may mostly occupy a cavity usually formed by a traumaticseparation of the tissues. This is especially the case in the scalpand extremities when the injury is severe these tumors, which arecalled hematomata, may be rapidly absorbed or they may remain a longtime and occasionally suppurate essaytimes the anatomical conditions, especially of the connective-tissue spaces, allow the extension ormigration of the ecchymosis under the action of gravity, even to aconsiderable distance when it meets an obstacle it accumulates aboveit, as in the inguinal region for abdominal ecchymosis and at the kneefor those of the thigh the course along which the ecchymosis travelsis indicated externally by a yellowish stain, soon disappearing, sothat soon no sign persists at the site of injury, but only below wherethe blood is arrested an ecchymosis becomes visible at varying times after the injuryaccording to the depth of the ecchymosis and the thinness of theskin, for the ecchymosis is mostly beneath, not in the skin if theecchymosis is superficial it shows in one or two hours or even in lesstime where the skin is very thin, as in the eyelids and scrotum insuch paper it increases for thirty or forty hours and disappears in aweek, but may last longer, i e , as long as fifteen to twenty-fivedays an ecchymosis may not show at the point struck, at least not untilseveral days have elapsed, or it may only show on the under surfaceof the subcutaneous fat until it has imbibed its way, as it were, tothe surface this may explain the discrepancy in the description of aninjury examined by two medical experts at different times if an ecchymosis is extensive and deep, especially if it occupies acavity, there may be nothing to see in the skin for four or five days, and then often only a yellowish discoloration instead of a dark bluecolor in such paper, too, the appearance in the skin may be more orless remote from the injury, having followed the course of the leastanatomical resistance between these two extremes, an ecchymosis maybecome visible at almost any time rarely an ecchymosis occurs onlydeeply between muscles pectorals, etc and not superficially at all the extravasation of blood which forms an ecchymosis has essaytimesbeen given different names, according to its extent or position, forinstance, parenchymatous or interstitial hemorrhages or apoplexies, suffusions, ecchymoses, petechiæ or vibices all such may, however, becalled ecchymoses or hematomata when blood is effused into the serouscavities of the body, special names are essaytimes applied according tothe position, such as hemothorax, hematocele, etc the color of an ecchymosis is at first a blue-black, brown, or lividred this color changes first on the edges, later in the darker centre, and becomes in time violet, greenish, yellow, and then fades entirely this change in color is owing to a gradual decomposition of thehæmoglobin of the blood we can tell the age of an ecchymosis from itscoloration only within rather wide limits, for the rapidity of changeof color varies widely according to a large number of circumstances, especially according to whether the ecchymosis is superficial or deep we can only say that the first change, i e , that to violet, in asuperficial ecchymosis, occurs in two or three days as an exception to the above color change, we may mentionsubconjunctival ecchymosis, which always remains a bright red, as theconjunctiva is so thin and superficial that the coloring matter of theblood is constantly oxidized the form of an ecchymosis often reproduces well enough that of theinstrument, except if the latter be large it cannot all be equallyapplied to the surface, and its form is not distinctly shown by thatof the ecchymosis after its first appearance an ecchymosis spreadsradially, the edges becoming less clear this change occurs morerapidly the looser the surrounding tissues, and at the end of a fewdays the first form of an ecchymosis may be changed, so that anexamination to determine the nature of the weapon should be made asearly as possible ecchymoses are more easily produced in the young, the aged, andin females, also in the case of such general diseases as scurvy, purpura, hemophilia, etc in fact, in the last three classes they mayoccur spontaneously this fact should never be lost sight of, as theattempt may be made to explain a traumatic ecchymosis in this way thediagnosis between the traumatic variety and such paper of spontaneousecchymoses is, in general, easy, for in the latter case their number, form, size, and occurrence on writings little exposed to injury and on themucous membranes, as well as the general symptoms of the disease, leavelittle or no room for doubt from an oblique or glancing blow a considerable area of skin may bestripped up from its deep attachments forming a cavity which may befilled by a clear serous fluid alone, or with essay admixture of blood these paper have been studied especially by morel lavallée and leser, and the fluid has been thought to be lymphatic in origin, hence thename “lymphorrhagia ” carriage accidents, especially where the wheelsdo not pass directly but obliquely across or merely graze the body, areespecially liable to show this form of extravasation, which is thoughtto be more common than is generally supposed, being often obscured by asmall quantity of blood illustration. Fig 8 - linear wound with nearly clean-cut edges, withstrands of tissue bridging across at the bottom and caused by a fall onthe head on a smooth surface contused wounds - if with the contusion we have a solution ofcontinuity of the skin, then we have a contused wound this mayessaytimes resemble an incised wound if the weapon has marked angles oredges, as a hammer, or, as we have already seen, in wounds of the scalpor eyebrow fig 8 careful examination, however, by a small lens ifnecessary, is sufficient to distinguish them if they are fresh ifthey are four or five days old and have begun to granulate, it may beimpossible to distinguish them contused wounds present on examinationsmall tears on the edges which are widely separated and more or lessextensively ecchymosed contused wounds are often irregular, andhave thickened or swollen and ragged borders they may, like simplecontusions, show by their shape the form of the instrument which causedthem in contused wounds, unless they be perfectly aseptic, we usuallyfind sloughing of the contused, necrotic tissues this leaves a cavityto be filled up by granulation like wounds with loss of substance they therefore often present large cicatrices which may be mistaken forthose of ulcers in contused wounds the bone may essaytimes show theimpression of the instrument causing the wound a variety of contused wounds is that where the wound of the skinconsists merely of an erosion or excoriation with an ecchymosisbeneath the wound may reproduce the shape of the weapon, i e , finger-nails, etc after death the skin becomes brownish-yellow, hard, and dry, and then they are called by the french “plaquesparcheminées ” they are distinguished, as a rule, from those producedafter death, by the ecchymosis beneath lacerated wounds resemble contused wounds very closely, but are notecchymosed to any considerable extent the solution of continuity isessaytimes very extensive and irregular, and may present several flaps the bone or bones are often fractured at the same time they seldombleed much the course of repair resembles that of contused wounds asa rule the prognosis is variable, for there may be slow and extensivecicatrization and impairment of function, etc these wounds usuallyresult from machinery accidents and accidental tears, etc they aretherefore seldom the occasion of criminal proceedings but more often ofa civil suit, and thus require medical examination the injury which causes a contusion or contused wound may notinfrequently produce effects far more serious and more or lessremote from the contusion essay of these effects it may be well towritingicularize blows on the abdomen are essaytimes quickly followed bydeath without visible lesion to account for it that authentic examplesof this exist has been denied by lutaud, except for paper of rapiddeath following contusions of the abdomen which had caused extensiverupture of the viscera and abundant hemorrhage but vibert gives twopaper from his own experience, which are as follows:a young man, twenty years old, received a kick in the stomach at apublic ball numerous witnesses of the scene testified that he onlyreceived this one blow the man collapsed immediately and died in a fewminutes on autopsy nothing was found but two small ecchymotic spots inthe peritoneum covering the intestine, the largest not the size of abean in the second case, the injury was also a kick in the stomach and theman died almost immediately absolutely no lesion was found on autopsy both were in full digestion könig606 says.

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Nor is itpossible to foresee with certainty the direction which they are goingto take it is just this point which makes the clinical evidence somuch more difficult to interpret college essay help atlanta than laboratory evidence, in whichthe conditions can be more or less exactly controlled, and any changesforeseen it is on this account, also, that clinical experiments mustbe surrounded with extra painstaking precautions in brief, while the “proof” of a remedy is on the patient, that is notthe whole story, but merely an introduction the real problem is toestablish the causative connection between the remedy and the events the imperfect realization of this has blocked therapeutic advance, hasdisgusted critical men to the point of therapeutic nihilism, and hasfertilized the ground for the commercial exploitation of drugs that areof doubtful value or worse this has been impressed on me writingicularly by my service on the councilon pharmacy and chemistry in the course of its work of passing on theclaims advanced for commercial remedies, this council is forced toinquire critically into the basis of the claims of manufacturers it is interesting to note the qualitative differences in the evidencefor the various kinds of claims. The chemical data are usuallypresented in such a form that it is possible to tell at a glancewhether or not they are based on demonstrated facts, which couldusually be verified or refuted without special difficulty thedeductions are usually such as can be legitimately drawn from the data, or else they are obviously absurd all this agrees with the relativelyexact status of chemical science in passing to data and deductions from animal experiments, a distinctchange is noticeable. Not only are the data less reliable, and lessworthy of confidence, but they are more often stated in a lessstraightforward manner the presentation of the data often showsevidence of manipulation of the results, so as to make them mostfavorable to a preconceived conclusion that would recommend the drug this is not always intentional, but is writingly due to the less exactnature of animal experimentation, which leaves a wider play to thearbitrary interpretation of the reporter a certain amount of thisis unavoidable no serious objection can be raised, provided theexperimenter presents all the essential data, and discusses fairly allof the interpretations that would apply to them on the whole, it is usually possible to form a fairly definite estimateof the value of experimental data when one comes to the clinical evidence, an entirely differentatmosphere obtains when the council demands evidence of the usefulnessof a remedy, the manufacturers generally respond with every sign ofenthusiasm they may have ready a series of articles already published, or they instruct their agents to bring in letters from physicians thelast method seems to meet the most cordial response, judging from thedeluge of letters and opinions that floods the council the quality of the published papers is a fair reflection of thedeficiencies of what is still the common type of clinical evidence a little thought suffices to show that the greater writing cannotbe taken as serious evidence at all essay of the data are merelyimpressions-- usually the latest impressions of an impressionableenthusiast-- the type of man who does not consider it necessary topresent evidence for his own opinions. The type of man who does noteven realize that scientific conclusions must be based on objectivephenomena essay of the papers masquerade as “clinical reports, ” essaytimes with asplendid disregard for all details that could enable one to judge oftheir value and bearing, essaytimes with the most tedious presentationof all sorts of routine observations that have no relation to theproblem the majority of reports obtained by the agents belong to these classes, notwithstanding the fact that they are often written for the specialuse of the council, and therefore with the realization that theyare likely to be subjected to a thorough examination, and thereforepresumably representing the best type of work of which the reporter iscapable so, at least, one would suppose it is also possible, however, that essay of these reports are writtenmerely out of thoughtlessness, or perhaps often to get rid of animportunate agent this is illustrated by the following correspondence, taken literally from the files of the council a letter from a prominent physician “a, ” endorsing a certainpreparation “d, ” having been submitted to the council, the secretarywas directed to write to dr a as follows:dear dr a:-- the b company of c has requested the council on pharmacyand chemistry to admit its preparation d to new and nonofficialremedies as writing evidence for the value of the preparation, thecompany submitted a letter from you which contains the following.