SUICIDE BY BLOWS AGAINST THE HEAD. A MEDICO-LEGAL STUDY. BY ALLEN STAPLES, A.B., M.D. OF DUBUQUE, IOWA. Read before the Julien Medical and Surgical Association, Dubuque Reprinted from tke Journal of the American Medical Association, January I, 1887. CHICAGO: Printed at the Office of the American Medical Association. 1887. SUICIDE BY BLOWS AGAINST THE HEAD. A Medico-Legal Study. Although suicide, accomplished by blows against the head of such severity as to wound the contents of the cranium, is of very rare occurrence, it has been observed in a certain number of cases. Such self- murder requires more than ordinary energy, or in- sensibility to pain, for its execution, and these con- ditions chiefly obtain among the insane. There are recorded in medical literature a few instances in which the object was attained by blows on the head with a hammer or hatchet, or by driving within the skull a chisel or similar instrument. Certain of these cases, too, consist of persons who have tried to end their existence by other methods, less revolting, and have failed. Death from the self-inflicted wounds, or secondarily from the inflammation consequent upon them, as a rule, has been the final result. In the fol- lowing paper I purpose to give as complete a series as I can, of cases illustrative of the remarks above, and to narrate more in extenso the history of a pa- tient that came under my own observation. The first case to be related is that of Dr. L. Lan- ger.1 A poacher, 37 years old, attempted suicide by beating his head with a sharp angle of an ax. There were found on the forehead, between the frontal emi- nences and extending into the hair, three wounds filled with crushed and splintered bone. The middle one was about two inches long, and showed at its bottom a half-inch fissure in the bone. There was also a Y-shaped wound above and behind the right ear, extending to the bone, a similar one just above, and a large swelling just below the occipital protub- erance. The man recovered in two months. 1 Wiener Med. Wochenschrift, 1878, No. 37, p. 999.. 4 hammer. A large wound resulted. Patient became unconscious, tongue was deflected to the right. The next day there was return of consciousness, and in two months cicatrization of the wound. Fabrice9 reports the following case: A man who suffered much from headache dealt himself severe blows on the head with an ax, split his lower lip, wounded his throat, cut off a testicle, and on his re- covery could not tell what impelled him to the act. Zaggl10 reports the case of a patient in puerperio, who attempted to suicide with a meat ax. There was contusion of the scalp on the vertex, with a stel- late fracture and a bruised wound on the right pari- etal eminence. E. von Hofmann.11 A woman first stabbed herself in the liver, and as death did not ensue seized a hatchet and struck herself so many blows on the fore- head and vertex, that she fell back senseless. When she was brought into the hospital, consciousness had returned; linear cuts with contusions of the scalp were found. Much suppuration followed, and the patient died of pyaemia. The autopsy. revealed that the outer table of the vertex had been penetrated by the cutting edge of the hatchet. Krugelstein12 reports that a skeleton of a person who had run away from fear of punishment, was found in a wood. On the vertex was a wound evi- dently made by a hatchet that was lying near by. Casper Lima» :18 A laborer long afflicted with melancholia, struck himself such heavy blows on the head with a flax-beater, that he died of their effects in a few hours. Otto14 reports the case of a jealous butcher, who first struck his head violently against a wall, then 0 Ibid. 10 Ibid. nLehrbuch d. gericht. Med., p. 407. 12 Wiener Med. Wochenschrift, No. 15, p. 456. 13 Ibid. UIbid. 5 beat his head with an ax so long and heavily that he sank back senseless. Death from haemorrhage re- sulted.. The autopsy showed a hole in the frontal bone one inch long and two inches broad, with sev- eral depressions about it. Maschka :15 A woman 63 years old stabbed herself in the abdomen with a knife, then beat herself heavily on the head with an ax, and finally attempted to open the veins in the elbow. She died in six days from meningitis. The post-mortem examination showed a large fracture on the right side of the fron- tal bone. Riambault16 reports the following case: A man 53 years old, among whose relations were sixteen insane, and who suffered from severe headaches, was found hung in a barn. He had first cut his scalp with a pocket knife, then dealt himself heavy blows on the head with a hatchet, and finally hung himself. There were found, at the autopsy, a large fracture at the juncture of the parietal and frontal bones, and nine parallel incised wounds of the scalp. Kupfer17 reports the case of a man, 40 years of age, who was found drowned in the Spree. There was a history of overwork and anxiety, and a slight temporary mental aberration. There were found above and behind the right ear thirteen parallel wounds of the integument, some of which reached the bone. Over the left ear were many wounds with a large loss of substance, seventeen incisions being counted posteriorly, fourteen anteriorly. The bone was much splintered and fissured. Krugelstein18 records the following: On the head of a woman found hung were thirty parallel wounds, one-half inch long. These were situated on the forehead and vertex and had penetrated the outer table. There were in addition some small parallel 16 Ibid. 16 Ibid. U Ibid. 18 Ibid 6 incisions in the cardiac region that, as they were suppurating, must have been three or four days old. Von Haumeder19 gives the case of a hostler, ill of typhoid fever, who was found hung. At the centre of the vertex was a sharp-walled hole two inches long and half an inch broad, at the bottom of which the bone was laid bare. Both hands were stained with blood. A short distance from the body lay a heavy hatchet, on which were traces of blood, and yet further off was found, near a pool of blood, a large hammer. An examination showed that there were at least sixteen blows directed against the head, seven of which penetrated the skull. There was ty- phus abdominalis in the ulcerative stage. The expert opinion on the case was that it was one of suicide; this opinion was founded on the facts that the wounds were of comparative insignificance from such heavy instruments, that they were parallel in their course, that they were all near each other, that there was no evidence of resistance, and that typhoid fever was present. Howe20 reports the case of a man who, according to the statement of his wife, first dealt her blows on her head with a pistol, then fired two shots upon her. He next attempted to blow his brains out, but as the pistol missed fire, Tie struck himself very violently on the head. Death from shock followed. The autopsy showed the right malar region suffused and penetra- ted by an incised wound one inch in length, two in- cised wounds in the right temporal region, nine on the vertex close together, a lacerated wound over the right ear, and one on the vertex, and a triangular cut on the arm. The patient had previously showed signs of mental aberration. R. Frank's21 case : This remarkable case, together with the result of the judicial investigation into it, I 19 Wiener Med. Wochenschrift, 1882, No. 18. 20 Boston Med. and Surg. Journal, Nov. 8, 1883, p. 433. 21 Wiener, Med. Wochenschrift, Nos. 15, 16, 17, " Selbstmord durch Hiehe gegen den Kopf," von R. Frank. 7 will relate more fully, as the history is of much inter- est from a medico-legal point of view: In the Vienna Allgemeines Krankenhaus, Surgical Section, a woman 64 years old presented herself on the forenoon of September 28, 1884. Her statement was, that her wounds were self-inflicted and made by a hatchet. In consequence of her injuries she died on October 4. Except some mental hebetude, she did not show any cerebral symptoms. But because of her mental dulness, her ante-mortem on that her injuries were produced by her own hand was not deemed trustworthy, and a judicial investigation was ordered. It was elicited that the woman lived in easy circumstances, but was somewhat peculiar and secretive in habit. Her family energetically scouted the idea of suicide, and the wounds were explained by a fall from a chair or table while she was dusting pictures. An examination revealed the following injuries: Hair in the - anterior parietal and frontal regions abraded; a wound with ragged edges, four inches long, extending from between the eyebrows upwards and backwards, and forking above, was continued to the right an inch farther. This large wound had a stellate appearance, and at its widest portion was two inches across. On the left side of it were two smaller wounds, and on its right side were two oth- ers, incised and parallel, that penetrated the skull. Their walls were inflamed and purulent. Numerous smaller wounds were found on the right forearm, el- bow, knee, and on the left knee. The frontal bone showed a fissure two inches long, half an inch wide. In addition, there were seven punctures that had more or less completely penetrated the skull. Be- sides the above named lesions, on the inner surface of the calvarium were found blood clots with frag- ments of bone. The anterior portion of the right upper frontal convolution showed degeneration, and was dotted over with small haemorrhages. The rest 8 of the brain was anaemic and soft, the ventricles con- tained a turbid fluid; there were clots in the sinuses and purulent meningitis. The expert opinion of Prof. Hofmann in the above case was as follows: 1. J. N. died of purulent meningitis. 2. This was caused by violence through the above named injuries, especially by that reaching from the base of the nose directly backwards, forking poste- riorly, and producing the fissure on the frontal bone. 3. This fissure, as well as the neighboring elongated and sharply defined wounds of the scalp, coursing generally from before backwards, was caused by vig- orous blows with a sharp and heavy instrument, prob- ably with a hatchet, and the number of blows must have been nine or ten. The straight fissure of the frontal bone, and the incisions at the posterior end, from the fact that between the cleft walls, large pieces of bone are wanting, and the walls of integument bounding the wounds can be recognized, must have been caused by two or more blows. 4. Since these numerous wounds were compacted together upon a comparatively small surface, and easily accessible to the hand of the patient, and were in the same direction from before backwards and almost parallel, and since some of them scarcely break the skin, therefore the suspicion is very strong that these injuries were produced, not by a foreign hand, but by that of the patient herself, for the pur- pose of suicide. This suspicion is confirmed by the circumstance that on the inner surface of both fore- arms, on the flexor surface of the left wrist and under both knees are, huddled together, numerous parallel superficial wounds that doubtless arose from an at- tempt to open the veins, and were produced by the hand of the patient. A suicide caused by blows directed against the head is a rare event, yet one sometimes observed; and experience teaches that this extraordinary mode 9 of self-murder is chosen chiefly by the insane; it is therefore to be justifiably suspected that this patient, while she was insane, accomplished the deed. The last history of a case that I shall relate, is one that came under my own observation: On December 16, 1885, Dr. G. M. Staples was called to see J. A. M., a short, thick-set German, about 45 years of age, of florid appearance, and stone-cutter by trade. He saw M. about 10 a.m., and found him sitting up in a saloon that adjoined his shop. The patient was semi-conscious, and had the appearance of a man somewhat intoxicated. On inquiry, it was found that he had left the saloon about 9 a.m., after drinking several glasses of beer. The proprietor stated that he had appeared considerably depressed in spirits, but returned to his shop to work as customary. Twenty minutes thereafter two gen- tlemen attempted to enter his shop to consult him about work, but found the door, which was partially glass, locked. Looking through the door, they dis- covered M. walking towards them with a long chisel protruding from his forehead; he stooped down and attempted to unlock the door, but after trying some minutes and appearing unable to turn the key, those from the outside forced the lock and entered. M. then said to them, "Drive the chisels further into my head," and tfien, shortly after, "For God's sake pull them out." The patient was immediately taken to the saloon above spoken of, a distance of perhaps forty feet, and walked thence with but little aid. Dr. G. M. Staples was summoned at once, and found on his arrival the following condition: The head of a small stone chisel was found pro- truding about three lines from the scalp on the right side of the head, at a point about one and five-eighth inches above the meatus auditorius, and one inch in front of a line dropped from the vertex to the meatus. The point of the chisel had emerged on the left side, about one and one-quarter inches, at a point 10 one inch above, and half an inch in front of, a ver- tical line bisecting the meatus. The length of the chisel was eight and one quarter inches, the diameter of its head, three-eights of an inch, and it tapered to a flattened point. A similar chisel had been driven perpendicularly into the centre of the forehead, five- eighths of an inch above the plane of the upper margin of the superciliary ridges, and had pene- trated one and one-quarter inches. The pupils were dilated, the left irregularly; the pulse was slow and full. Forcible traction with strong forceps was necessary to extract the first men- tioned chisel, and an assistant pressing against the protruding point with a block of wood. The second chisel was bent to an angle of 20 degrees, five-eighths of an inch from its point, and was firmly imbedded on the frontal bone, requiring for its extraction, the greatest efforts with the forceps. Moderate haemor- rhage from the orifices made by the first chisel, fol- lowed. It is of interest to note, that a superficial punc- ture was discovered one eighth of an inch above, and to the left of, the point of entrance of the second chisel. Absorbent cotton was placed on the orifices, the head was bandaged, and the patient sent to his home half a mile distant. After the chisels were removed the patient became more comatose, and at noon he could be but slightly aroused. The pulse continued slow and respiration was somewhat laborious and stertorous; there were signs of restlessness and rhythmical flexion and extension of the lower extrem- ities. At 1 p.m. his restlessness became much more marked. He continually endeavored to arise in bed, and get upon the floor, requiring two powerful men to hold him down. His eyes were constantly closed, and the urine had been voided in bed. Morphia, % grain, was given hypodermically. At 4 p.m. Drs. G. M. Staples and Bready visited the patient together; he was then resting more quietly. The lower extremities exhibited rhythmical 11 movements as before. Respiration continued labored and there were ecchymosis and swelling about the eyes. Pulse was 80 and pupils contracted. Deglu- tition was slowly and very imperfectly performed. A rubber drainage tube was inserted, one and one- half inches into the right temporal orifice, and half an ounce of dark blood evacuated. The temporal wounds had been previously probed and bone, sup- posed to be the posterior clinoid processes, had been touched. After the tube had been inserted and the wound drained, the patient was visibly easier. The tube was padded with absorbent cotton and retained in the wound. The clothing and bed were saturated with the urine that had been involuntarily evacuated. At io p.m. the patient was seen by Dr. Bready and the writer; he was found very restless, continu- ally throwing himself about the bed. The pulse was 90 to 100. He indicated by motions a desire to urinate and passed water freely. Deglutition was quite impossible. He was given, hypodermically, morphia, Y> grain, and atropia, grain. The patient was seen by Drs. G. M. Staples and Bready at 8 a.m. on the following day; he had passed a comparatively quiet night, sleeping heavily. His respiration was 36, pulse 120, and fever, temperature 101. He could not swallow at all, fluids being re- tained in the mouth, and flowing out at the corners. Grumous blood, with some debris of cerebral tissue, kept slowly oozing from the drainage tube. Urine had been passed involuntarily during the night. Pa- tient seemed to be sinking, and a solution of spts. ammon. aromat. was made to trickle down his throat. At 3 p.m., he was again visited by Drs. Staples, Bready and Minges. He had died at 2:30 p.m. The dressings were removed, and a Nelaton probe with porcelain tip, was passed through the temporal wounds, from side to side, showing that the chisel had traversed brain tissue its entire length, after it had perforated the skull. 12 Although with our utmost persuasion, no autopsy was permitted, yet we were able to obtain very carefully made measurements. From these it was estimated that the first mentioned chisel must have penetrated the skull at the upper anterior angle of the squamous portion of the right temporal bone and lower margin of the right parietal traversing the base of his skull, in the region of the Sella Turcica, and emerging at nearly the centre of the squamous portion of the left temporal. The second chisel passed through the frontal bone, and must have entered the frontal lobe of the brain, at least half an inch. The mallet with which the chisels had been driven, was of wood, and weighed two and three eighth pounds. It was cov- ered with blood and presented about fifteen indenta- tions, that, from their peculiar situation and corre- spondence to the heads of the chisels, were supposed to indicate the number of blows needed to accomp- lish the deed described. Inquiry into the patient's family history, failed to reveal any hereditary ten- dency to insanity; it was discovered, however, that he had been greatly concerned about some business matters, that he was a hard drinker, and that he oc- casionally showed depression of spirits. In the absence of an autopsy, any statement as to the particular cerebral structures wounded, is at the best, mere conjecture; but after careful study and measurement, on the subject, I have arrived at cer- tain conclusions, and I give them to the reader for what they are worth. It is my belief that the first chisel penetrated the right tempero-sphenoidal globe, or entered the fissure of Sylvius, passed just below the Island of Reil, traversed the lenticular nucleus, internal capsule, and right optic thalamus. On the left side it must have passed a little lower through the substance of the tempero-sphenoidal lobe. That the region about the Island of Reil was not injured, I hold to be probable, by the fact that no aphasia existed. 13 The internal capsule being a part of the pyramidal tract, the course of nervous influence through it, from the cortical centres of motion, would be more or less modified and this, it may be, was the cause of the rhythmical motions exhibited by our patient. If, as was thought, the posterior clinoid processes were fractured, there probably resulted pressure on the pons; and if the patient had lived any time, the issue would perhaps have been similar to that of a case related by Belhomme. In this case an exostosis from these processes pressed upon the pons; the patient was subject to at- tacks of vertigo, and impairment of the motion of the legs, followed by forced movements from left to right. Towards the close of the case, convulsions and rotary motions from left to right ensued. From the lesions in the lenticulo-striate region, we would expect that the senses of vision and olfaction would be impaired, though this, in our case could not be ascertained. A wound in this locality accord- ing to Ferrier, would induce dilatation of the pupils, a phenomenon which we noted in the case of M. A wound in the tip of the frontal convolution would not be followed by any marked effect. Such wounds as those in our case belong to the punctured or perforating variety of wounds of the head; of this class there are but six reported in the large surgical volumes of the " Medical and Surgical History of the War of the Rebellion," and in no one of these was there absolutely complete perforation. Five of these patients were wounded by a bayonet, one by a sword, one survived, permanently disabled, five died with extravasation of blood in one case, cerebral hernia in one, encephalitis in one, and ab- cess of the brain in two cases. As to the treatment of our case there is little room for discussion. All surgeons will agree that the immediate removal of the foreign bodies was in- dicated. The best authorities, too, are in favor of 14 establishing and maintaining the most complete drainage possible. Dr. Harlow who treated the famous tamping iron case, says that it was due in great measure to the free outlets in the skull above and below, that the man Gage owed his life. In wounds of the head where the skull is perforated the mortality is always very high, no authority giving it as less than 80, and some giving it 100 per cent. " If death follows in twenty-four or thirty-six hours, it will be from shock and the extravasation of blood and serum, when the fatal result is longer delayed, encephalitis or abscess will ultimately prove fatal. When the projectile remains within the cranium, the danger is greater than when it passes through or per- forates, as in the former case there is one foreign body more in the cranium. The statistics of our late war show a difference of 5 per cent in favor of perforating over penetrating fractures, the mortality in the former being .80 per cent, and the latter 8tcc per cent."22 A study of the above cases shows that death often does not result from the immediate effect of the in- juries, more often the patient either gets well of them, dies from the resulting inflammation, or tries some other method of suicide. Another lesson to be drawn from these cases is, that even heavy blows against the head do not necessarily produce con- cussion of the brain. In a given case, the diagnosis between murder and suicide may be of great importance, and attention to the following points, wih be of use: 1. The situation of the wounds must be one readily accessible to the hand. The majority of these in- juries, as the cases given above attest, are situated on the frontal and parietal bones, more rarely on'the temples, very rarely indeed upon the occipital bone. 2. Usually more than one wound, frequently many, are found. It is easily comprehensible that the first 22 Agnew's Surgery, Vol. i, p. 290 . 15 blows are made somewhat cautiously, and being comparatively unimportant, do not render the suicide incapable of completing the act. 3. The injuries are, as a rule, huddled together in a comparatively small space, and take a parallel course. This is easily explained by the quick mo- tion that has been taken by the hand. This disposi- tion of the wounds almost characteristic, is one of the most constant and weighty signs to which our at- tention can be directed. 4. Heavy strong instruments are regularly used. If they are blunt, fewer wounds are to be looked for, as unconsciousness would be th** more quickly in- duced. 5. In many of these cases, other injuries made with suicidal intent, or traces of them, can be found in other portions of the body. 6. Signs of resistance or non-resistance, should in every doubtful case be looked for. Regularity of the wounds, and a grouping together of them, are not compatible with resistance. 8. The history of the patient, as concerns the mental state is always of importance. Most of these suicides had shown aberrations of intellect, perhaps of a transitory character, and hereditary taint came often into play. Delirium and cephalalgia were also the causes in one case each. It goes without saying, however, that to avoid an error of diagnosis, all the circumstances in a given case m,ust be carefully considered.