DEATH
AND
SUDDEN DEATH
BY
P. BROUARDEL
PROFESSOR OF MEDICAL JURISPRUDENCE, DEAN OF THE FACULTY OF MEDICINE,
PARIS, MEMBER OF THE INSTITUTE, AND OF THE ACADEMY OF
MEDICINE, ETC.
AND
F. LUCAS BENHAM, M.D., B.S. (Lond.), M.D. (Adelaide)
MEMBER OK THE ROYAL COLLEGE OF PHYSICIANS OF LONDON
SECOND -
EDITION
'Af^\
^
LONDON
BAILLIERE, TINDALL AND COX
8 HENRIETTA STREET, COVENT GARDEN
1902
[All rights reserved]
TRANSLATOR'S PREFACE
A WORK by Dr. Brouardel, whose name and position are
so well known in this country, does not stand in need of
much introduction or recommendation. However, a few
words may be said with regard to the motive for translation.
In the first place, as there is no such office in this country
as Dr. Brouardel holds as Director of the Morgue, it is not
an easy matter over here to obtain the amount of experience
of medico-legal cases that he possesses.
The book, which consists of part of a course of lectures
on Forensic Medicine, treats of a subject which is hardly
touched on in English medical literature.
The substance of the first part — on the phenomena of
death — is certainly dealt with more or less fully in all works
and lectures on medical jurisprudence ; but this somewhat
dry subject is here presented in a more attractive form than
is customary, and there are several novel and practical
features displayed in it.
The second part consists of what may, with some excuse,
be styled clinical lectures on the various forms of sudden
death, particularly in those aspects which have a legal or
vi TRANSLATOR'S PREFACE
practical bearing. This subject occupies an intermediate
place between Forensic and Systematic Medicine, and con-
sequently is usually ignored or slurred over by both. In
works on Forensic Medicine it is only alluded to in the
most general way; and in text-books on medicine it is
mentioned only briefly and incidentally. Yet the subject
is one of vast interest and importance, and there is dis-
tinctly room for a special treatise on the subject, especially
as it concerns every member of the medical profession.
But not the least charm of the book is its attractive,
lucid, and forcible style, which recalls in many ways
Trousseau's classical clinical lectures. It is interesting
as well as instructive. I venture to hope that by turning
it into plain English the spirit of the original may not be
altogether lost, and pains have been taken to render it as
accurate as possible.
The French original is accompanied by a very lengthy
appendix of illustrative cases, derived from many sources,
some of which are of considerable interest and value ; but
the records are not all equally complete, and consequently
they vary in merit. To have added them would have
swollen the book to a very great and inconvenient bulk ;
and it has been deemed expedient to omit this portion
altogether. There are, however, numerous striking and
vividly-described cases inserted in the lectures, which serve
to illustrate the text, and will deeply impress on the memory
the doctrines and facts that they are intended to exemplify.
A chapter on the laws of France dealing with the disposal
of the dead has been retained. Though these, of course,
TRANSLATOR'S PREFACE vii
differ from our own, and therefore have no direct practical
bearing for us, yet it may be of use to many to learn in some
detail what these laws are, both in theory and practice, that
we may contrast them with our own ; as it has been urged
by authorities, worthy to be listened to, that we should intro-
duce them, or some of them, on this side of the Channel.
F. L. B.
December^ 1896.
Digitized by the Internet Archive
in 2007 with funding from
Microsoft Corporation
http://www.archive.org/details/deathsuddendeathOObrouuoft
AUTHOR'S PREFACE
The danger of premature burial and the unforeseen nature
of sudden death have occupied public attention at all times.
I thought that I might advantageously exhibit to the
students of the Faculty of Medicine the actual state of
these questions, by utilizing the works of different authors
and the documents which the numerous medico-legal autop-
sies made by myself and my fellow- workers, MM. Descoust,
Vibert, and Socquet, during the last twenty years at the
Morgue, have furnished to us.
I have attempted to show that the uncertainties which
sometimes arise at the moment of death, and in the hours
which directly follow, may be removed by the physician ;
that his intervention is often necessary to establish the
reality of a person's death, and that this alone can remove
every apprehension that may be entertained of premature
burial.
Furthermore, the causes of sudden death are but ill
understood. They are very numerous ; they often cause
the suggestion of crime or of suicide to be raised, and give
rise to medico-legal inquiries.
No medical man can ignore them ; the expert ought to
know how to search for them, and how to avoid the
numerous errors that it is easy to make. Sudden death
AUTHOR'S PREFACE
is one of the most complex chapters of medical juris-
prudence.
The physician" is well acquainted with the pathogeny of
unforeseen death which may befall patients whose diseases
oblige them to take to bed or to enter the hospital. These
are accidents which are anticipated or dreaded — they can-
not take anyone by surprise ; but the physician knows much
less of the causes of that form of death which seizes a man
unawares, without any previous warning, even while he is
apparently enjoying perfect health.
I have shown that, in spite of an excellent outward
appearance, sudden death is the termination of very
different diseases, which develop secretly, quite unknown
to the patient and those around him : such are certain
affections of the kidneys, arterio-sclerosis, diabetes, etc.
In order to keep this volume from attaining extravagant
proportions, I have been obliged to limit myself to a brief
summary of the lesions which are studied in treatises of
pathology and pathological anatomy; on the other hand,
I have laid stress on the circumstances which demand the
intervention of justice.
These lectures were intended for the students of the
Faculty. Dr. Reuss considered that they might be profit-
ably consulted by doctors also. He has compiled them
with very great care, and has undertaken the material part
of this work. If the reader derive any profit from perusing
these pages, he will be indebted for it to my excellent
colleague. Dr. Reuss.
P. Brouardel.
Paris,
November 15, 1894.
CONTENTS
PART I
THE SIGNS OF DEATH
LECTURE PAGE
I. The Moment of Death. — Apparent Death - - i
Determination of the moment of death. — At what moment
does life cease ?- - - - - -2
Apparent death ...... g
II. The Uncertainty of the Signs of Death, and Prema-
ture Burial - - - - - - 19
Uncertainty of the signs of death - - - - 20
Predisposition to apparent death - - - - 33
Premature burial - - - - - - 40
III. The Signs of Death - - - - - 42
Insensibility - - - - - - 42
Motility ...-..- 45
Respiration - - - - - - - 49
Circulation ------- 50
Cadaveric sugillations - - - - "55
TempersLiure pos^-mor/e7n - - - - - 56
Parchment patches. — Burns - - - - 59
IV. Rigor Mortis - - - - - -63
V. Putrefaction - - - - - - - 75
General theory - - - - - - ' 75
Putrefaction in the open air . ... 78
Putrefaction in different media - - - - 82
Cadaveric alkaloids - - - - - 84
Putrefaction of different organs - - - - 90
Preservation of dead bodies - - - - 93
VI. Cremation.— Mummification - - - - 99
Cremation - - - - - - - 99
Embalming ------- 100
Mummification ------ loi
VII. Legislation.— Medico-Legal Applications - - no
xii CONTENTS
PART II
SUDDEN DEATH
LECTURE PAGE
I. Sudden Death - - - - - - 119
II. Sudden Death due to Lesions of the Circulatory
System - - - - - - - 125
I. Lesions of the heart - - - - - 125
A. Cardiac muscle - - - - - 125
1. Fatty overgrowth of the heart - - - 125
2. Fatty degeneration of the muscular tissue of the
heart - - - - - - 127
3. Fibroid degeneration of the heart - - - 128
4. Lesions of the coronary arteries - - - 129
5. Syphilitic affections of the heart - - - 130
6. Rupture of the heart - - - - 131
B. Pericardium - - - - - - 133
C. Aortic incompetence - - - - - 136
D. Mitral and tricuspid incompetence - - - 138
E. Endocarditis - - - - - - 141
F. Angina pectoris - - - - - i43
G. Neoplasms of the heart .... 147
II. Lesions of the arteries - . - - - 148
A. Congenital lesions - - - - - 148
B. Arterio-sclerosis - - - - - 150
C. Aneurysms - - - - - - 152
D. Spontaneous rupture of the aorta - - - 1 53
III. Lesions of the veins - - - - - I55
A. Rupture of veins - - - - - I55
B. Thrombosis and embolism - - - - 156
C. Air in the veins - - - - - 163
IV. Lesions of the capillaries - - - - 166
A. Miliary aneurysms - - - - - 166
B. Meningeal haemorrhages - - - - 169
C. Capillary embolisms - - - - - 170
D. Local disturbances of the circulation - - - 171
III. Sudden Death in Lesions of the Cerebro-Spinal
System and the Major Neuroses - - - i74
I. Meningitis - - - - - - I74
II. Abscess of the brain - - - - - i77
III. Cerebral tumours - - - - - - 180
IV. Lesions of the spinal cord - - - - 183
v. Lesions of the nerves - - - ■ - 184
VI. Epilepsy - - - - - - - 184
VII. Hysteria - - - - - - - 188
VIII. Inhibition.— Slight injuries - - - - 189
IX. Sudden death from emotion .... 201
CONTENTS xiii
LECTURE PAGE
IV. Sudden Death due to Lesions of the Respiratory
System - - - - - - - 206
I. Lesions of the larynx, trachea, and bronchi - - 206
A. Lesions of the larynx ... - - 206
B. Lesions of the trachea ----- 208
C. Lesions of the thyroid body . . - . 210
D. Lesions of the mediastinum . . - . 210
II. Lesions of the lungs - - - - - 212
A. Pulmonary congestion - - - - - 212
B. Pneumonia --.-.. 214
C. Capillary bronchitis - - - - - 216
D. Pulmonary phthisis . . . . - 219
E. Cancer of the lung _ . . . . 220
F. Emphysema of the lungs - - - - 221
G. Pleurisy - - - - - - - 221
H. Rupture of the diaphragm . . . - 226
I. Compression of the chest. — Tight-lacing - - 227
V. Modifications of Vascular Tension : Their Action
AS Auxiliary Causes, or as Efficient Causes
(when in Excess) - - - - - 229
I. Auxiliary causes : effort, cold, heat - - - 229.
II. Efficient causes : cold, heat - - - - 231
A. Heat 231
B. Cold 237
VI. Sudden Death due to Lesions of the Digestive
System - - - - - - - 242
I. Lesions of the pharynx ----- 242
II. Lesions of the oesophagus ----- 245
III. Lesions of the stomach ... - - 247
IV. Lesions of the intestines ----- 254
V. Lesions of the liver ------ 260
VI. Lesions of the spleen _ . - - - 264
VII. Lesions of the pancreas ----- 267
VIII. Lesions of the suprarenal capsules - - - - 269
IX. Corpulency ------- 270
VII. Sudden Death caused by Lesions of the Female
Genital Organs - - - - - 271
A. Vaginal examination - - - - - 271
B. Extra-uterine gestation ----- 273
C. Retro-uterine haematocele . - - - 274
D. Rupture of the uterus ----- 275
E. Vulvo- vaginal varices - - - - - 275
F. Syncope - - - - - " - 276
G. Chloroform - - - - - 277
CONTENTS
LECTURE
VIII. Sudden Death in Fevers - - - - - 279
IX. Sudden Death due to Hemophilia - - - 284
X. Sudden Death in Diabetes - - - - 287
XI. Sudden Death due to the Kidneys - - - 292
A. Uraemia — auto-intoxication . - . _ 292
B. Gout ....-.- 300
C. Dropsy — oedema of the glottis - - - - 303
XII. Sudden Death in Alcoholism - - - - 305
A. Drunkenness ------ 305
B. Delirium tremens - - - - -311
C. Chronic alcoholism - - - - - 311
D. Medico-legal intervention - - - - 312
XIII. Sudden Death in Children - - - - 319
A. Syncope - - - - - - - 3^9
B. Convulsions -.-... 32c
C. Asphyxia ...... 322
D. Pulmonary congestion ----- 327
E. Intestinal disorders ----- 329
DEATH AND SUDDEN DEATH
PART L
THE SIGNS OF DEATH.
LECTURE I.
THE MOMENT OF DEATH.— APPARENT DEATH.
Gentlemen, — To the medical jurist engaged in the study
of the causes of death, a knowledge of the phenomena which
precede this event, and the examination of the corpse, are
of great importance ; in more than half of the medico-legal
examinations that you will be called upon to make, whether
the question raised is one of suicide, murder, sudden death
or survivorship, it is with the study of the dead body thai
you will have to begin.
Activity does not entirely cease at the instant of death.
Vital phenomena are replaced by cadaveric phenomena : it
is requisite that you should become familiar with these last,
for inexperienced medical men have ascribed to poisoning
lesions which have been really produced after death by the
normal processes of decomposition.
In order that you may be able to pronounce an opinion as
to the cause, I am going to investigate with you the possi-
bility of determining the exact instant of death. I shall
then study apparent death (which will lead me to speak to
you of premature interment), the real signs of death and the
THE SIGNS OF DEATH
legal questions which have to do with the proof of death.
I shall finish this course with an inquiry into the causes of
sudden death.
DETERMINATION OF THE MOMENT OF DEATH.— AT
WHAT MOMENT DOES LIFE CEASE?
That is a question which looks very easy to answer. There
is not one of us, Gentlemen, who has not been present, at
least once, at this final scene of every human existence, who
has not seen a dying man draw his last breath. The stoppage
of respiration, or, to use the customary expression, drawing
the last breath, is, as a matter of fact, considered by the public
as the unequivocal sign of the disappearance of life. This
is a grave error. Gentlemen, for many persons who no longer
breathe have been recalled to life by means of care and skill.
The moment of death cannot therefore be assumed to be
identical with cessation of respiration.
It has been thought possible to find a more exact criterion
in the pulsation of the heart. The cor ultimum moriens has
been regarded as the rule since the time of Galen ; physio-
logists have agreed upon it. In their laboratories stoppage
of the heart is looked on as the finale of life : as soon as the
heart of an animal that is being experimented upon ceases
to beat, physiologists admit that the animal is dead.
Can we accept this criterion in forensic medicine ? I do
not think so. In certain medico-legal cases, the value of
the sign may be disputed ; the judge may ask you to say at
what precise moment death took place, and that for several
reasons. Here are some examples :
A man is murdered : several persons have been seen to
strike him ; these persons are arrested ; the judge may ask,
and will ask, the expert to determine which of the blows
inflicted has actually been the fatal one. Need I tell you of
the importance of this decision from the point of view of the
responsibility of each of the assailants ?
In a railway accident an entire family is killed and is
wiped out of existence in the course of a few seconds ; sup-
pose that the husband has his head separated from the
trunk, and that the body of the wife does not show the mark
THE MOMENT OF DEATH
of any injury. Which of these two expired first? This
question of survivorship, which will be put to you without
fail, is of extreme importance from the point of view of
inheritance.
When a case of murder has to be dealt with, the investi-
gation is usually entrusted to a single medico-legal expert.
When questions of survivorship and inheritance are raised,
there are at least three of them ; there is often a revisal of
the first decision ; sometimes the conclusions of the second
experts are at variance with those of the first. The Court
of Appeal sometimes orders a third report to be made.
This single example will suffice to show you what difficulties
you will have to combat.
We cannot admit, in forensic medicine, that stoppage of
the heart is a certain sign of death.
Recall to your mind the crime of the Rue Montaigne, the
case of Pranzini, which has been included among the causes
ceUhres of our time."^ Pranzini killed Marie Regnault, her
maid, and her little girl, who may have been the child of
either of these women, but who had at all events been
adopted by the former. Marie Regnault had her throat cut
and the carotids were severed, but the vertebral column was
intact ; she had fallen at the foot of the bed, but her hand
retained hold of the bell-rope ; she had doubtless been
attacked while in bed. The maid had heard her mistress's
bell ring, and had had time to put on a petticoat ; then she
had been struck in her turn : she fell with her neck deeply
cut, the vertebral column was opened behind, and the pos-
terior columns of the spinal cord were divided. Pranzini
lastly killed the child in her bed, no doubt because she
screamed out. The last victim was literally decapitated, the
vertebral column was completely divided, and the head was
only united to the trunk by a strip of skin along the front
of the neck.
The magistrate directed me to proceed with the autopsy
of the bodies, and to determine the circumstances of the
crime. The question of survivorship was necessarily raised ;
* Brouardel, ' Afifaire Pranzini : Triple Assassinat— Relation medico-
legale' {A7tn. (PHyg.^ 1887, tome xviii., p. 305).
I — 2
THE SIGNS OF DEATH
its elucidation was specially interesting, as the rights of
inheritance and succession depended upon its solution.
Evidently Marie Regnault was the first to be struck, then
the maid, and lastly the child ; but which of the three
victims was the last to die ? What criterion could be relied
upon to fix the exact moment of death in the case of each :
Marie Regnault, whose carotids were opened, died of
haemorrhage ; the maid had a lesion of the spinal cord ; the
little girl was beheaded ?
Some time before this, Drs. Regnard and Paul Loye had
been present at an execution at Troyes ; they even rode in
the van which carried the body from the scaffold. One
hour after the execution the heart still beat ; yet this man's
existence was over ; he had lost his personality, and yet his
heart was beating ! Well, to us and to every one a decapi-
tated person is a dead man, although his heart does continue
to contract ! *
My experiments in conjunction with Dr. Paul Loyet had
shown me that, when a dog is decapitated, movements of
the heart persist for fifteen, twenty, or twenty-five minutes
afterwards ; but they also demonstrated that it was quite
the same when the animal died of haemorrhage.
So when this question of survivorship was put to me in
the Pranzini case, I sought the opinion of our most eminent
physiologists : Brown-Sequard, Vulpian, MM. Franck and
Marey. Gentlemen, they declared themselves quite unable
to solve the problem ; moreover, that was my own view, and
I gave as my conclusion that I could not say which of the
three victims had been the last to die.
Allow me in connection with this matter to give you a
piece of advice. When you have not a scientific demonstra-
tion of the facts, always say, in giving your opinion, that you
do not know. Not only will you be speaking the truth, but
it is much better to say at the preliminary examination, ' I do
not know,' than to be forced at the trial to say, * I did not
know.' In these matters the law allows the magistrate to
* Vide also p. 28.
t P. Brouardel and P. Loye, ' Recherches experimentales sur la Mort
par Submersion brusque' {Archiv. de Physiologic, 1889).
THE MOMENT OF DEATH
apply simply the Articles of the Civil Code, which enable
him to settle the difficulty. That is, you will say, purely con-
ventional ; I admit that it is, but it is a legal convention,
and the arrest of the heart as a sign of death is also a con-
vention, but one belonging to physiology and disputable.
I am anxious to narrate another instance to you.
M. R and his wife went for a row in a boat. The boat
upset ; the rowers saw M. R rise several times, strug-
gling on the surface of the water ; no one saw Mme. R
again. They had each left a will bequeathing their respec-
tive fortunes to the survivor. The experts at Dijon (the
accident happened in the Cote-d'Or), admitted in their con-
clusions that M. R had died last, because he was seen
several times on the surface. On the other hand, the
experts of Marseilles, where one of the families lived, pro-
nounced the opinion that an individual who rises to the
surface will be drowned more surely and more rapidly than
another who sinks to the bottom and remains there in the
state of syncope ; according to them, Mme. R must
have survived her husband. A third expert opinion was
ordered, which was entrusted to me ; I declared that I could
give no reply to the question which was put to me, because
I did not know absolutely which of the two had survived the
other. This view was finally accepted, and the two families
shared the fortunes of both deceased. They might have
saved themselves the expense if they had only begun where
they concluded.
At present, then, gentlemen, we have no absolute criterion
at all to determine the precise moment of death, even when
we believe that the concomitant circumstances afford strong
grounds of probability. These proofs are no more than
merely probable.
Finally, sensitiveness varies very much, according to age and
sex and the states of surprise and sudden awaking from sleep.
As a result of strong emotions, certain persons may be
seized with syncope, others may pass into the contrary state
of excitement. Between these two extremes there are com-
plex cases in which the character of the emotion undergoes
great changes or variation.
THE SIGNS OF DEATH
Besides this, it is known in medical jurisprudence, though
it has only been learnt recently, that blows, even though
slight, which fall on certain parts of the body, may cause
instantaneous death. I will relate to you, in illustration of
this, a very typical example. A priest, whose conduct was
not as immaculate as it might be, was obliged to remove
his mistress from his vicarage. * The day had passed very
sadly,' said Abbe Delacollonge. * Everything was got ready
for her departure ; the sorrow had broken my heart, and I
said to her : " We should be happier if we were dead."
** Yes," said she, " if we could die together." I then said
to her jokingly, for I could find no other way of expressing
myself at the moment : " Could you bear me to cause you
much pain ?" " Try," she replied. We were both standing
up. I grasped her neck ; it was intended as a harmless
piece of pretence on my part, and she showed by a smile
that she regarded it as such. All at once she made a
gesture of pain and shook her hands, but without uttering
any cry. I relaxed the pressure, and she fell down. I
picked her up, but she was dead.'
The medico-legal experts neither accepted nor rejected
this hypothesis completely ; they spoke of asphyxia, syncope,
etc.
During the hearing of the case,* an ex-officer, M. Boure,
made the following deposition : * We were at Tarbes, stay-
ing in garrison. Among our number were Captains Lalande
and Surugues. In a moment of friendly mirth. Captain
Lalande seized Captain Surugues by the neck by way of a
joke. *' Now, old fellow," said he to him, " I am going to
put you out of the way !" (This was only said playfully.)
Captain Surugues, however, staggered and fell in a state of
unconsciousness. Owing to the skilful attention we bestowed
upon him, he soon returned to life,' etc.
The parts of the human body, contusion of which may
induce sudden death, are the laryngeal and epigastric
regions, the genital organs and the nostrils ; even irritation
of these parts sometimes suffices to provoke a catastrophe.i*
^ Assize Court of the Cote-d'Or, March i, 1836.
t ViWd zn/ra, p. 189: Inhibition: Slight Injuries.
THE MOMENT OF DEATH
During the reign of Louis Philippe, a Danish physician
professed to cure, or at least to check, attacks of asthma
by cauterizing the pharynx with ammonia. He had acquired
a considerable reputation, and the King's sister wished to
submit herself to his treatment. It happened, however, that
a maid of honour, who was asthmatic herself, died suddenly
at the moment the physician touched her pharynx with the
ammonia. From that time there was no more talk of the
Danish physician or of his wonderful cures.
It is consequently necessary in forensic medicine that we
should be aware that violence, or even irritation, of but
slight apparent intensity, applied to certain regions of the
body, may determine sudden death, even without our being
able to discover any visible traces of contusion, such as
ecchymoses. The fact is, that when a blow has ruptured
the capillaries, provided that the heart continues to beat,
the blood-stream will continue to reach the spot, and there
will be an extravasation ; but if, on the contrary, the heart's
action has ceased, there is no more onward movement of
the circulation ; the blood may escape so as to form a small
thin patch, but there is no effusion, no ecchymosis.
What is the explanation of these cases of sudden death ?
It used to be said that the individual died of syncope.
M. Brown-Sequard, who has thoroughly studied all these
matters, says * death is due to inhibition,' What is inhibi-
tion, gentlemen ? It is a term which you hear repeated
again and again in scientific discussions ; perhaps you do
not thoroughly understand its meaning and importance.
Your physiological studies have taught you that nearly all
vital acts are reflex nervous actions. A peripheral excita-
tion propagated through the system v^ill evoke reflex action
which will give rise to movements. Sneezing is the type
of reflex movements ; irritation of a very small point of the
nasal mucous membrane is transmitted to the corresponding
reflex centre ; this one transmits to other centres the excita-
tion it has just received; immediately, a certain number of
organs endowed with special functions react, and you have
then that inspiratory and expiratory perturbation, those
movements of the face, shoulders, arms and chest, that flow
THE SIGNS OF DEATH
of tears and of nasal mucus — in one word, all that group of
phenomena which constitutes sneezing.
Well, Gentlemen, suppose that under the influence of a
violent physical or moral excitation, instead of reflex move-
ments taking place, these are arrested ; suppose that the
excited centre paralyses the action of other centres which
are already in activity ; that paralysis is inhibition. When
the pneumogastric nerve is excited, the heart stops ; when
the cervico-dorsal region of the spinal cord is excited, the
activity of the stomach ceases ; the irritation of the bulb
caused by the pneumogastric inhibits the heart ; excitation
of a certain part of the spinal cord inhibits the stomach.
Reflex centres can therefore act upon one another either
so as to excite them or so as to inhibit them ; so that we
are now in a position to define inhibition as the arrest of
a function provoked by an excitation of a distant part of
the nervous system. If this excitation is violent enough,
the functions may cease, never to return, and if these
functions are necessary to life, death will of course be the
consequence of their cessation.
M. Brown-Sequard assigns to death by inhibition three
peculiar characteristics : (i) It takes place without a
struggle, without convulsions — in fact, as calmly as possible ;
(2) the venous blood remains red for a very long time with-
out turning black ; (3) finally, the temperature of the corpse
falls very rapidly.
The medico-legal expert, when called upon to make an
examination of a body, arrives too late to witness all these
phenomena ; therefore I do not want to discuss them be-
fore you to-day ; I shall only say this, that you ought
always to ask yourselves whether an individual in the
state of apparent death might not return to life, notwith-
standing the cessation of the movements of the heart and
of respiration ; whether the suspension of life is temporary
or absolute ; and I think that it will be possible in a
great many cases to save the individual and restore him
to Hfe, for the simple reason that, as a result of inhibition,
the blood retains its vital properties for a considerable time.
APPARENT DEATH
APPARENT DEATH.
Other difficulties also contribute to justify our reserve.
When an individual dies, there is no interruption in the
chemical changes which go on in his body. This continuity
of changes constitutes the chief difference between inorganic
substances on the one hand and animals and vegetables on
the other. There is in these latter a continual exchange of
used-up matters and assimilable matters ; inorganic bodies
are in a state of chemical repose.
These phenomena are continued energetically after death,
and even, in certain infective diseases such as small-pox or
rabies, with such a degree of energy that the temperature
of the body is raised from 2° to 4^° F., although the move-
ments of the heart and respiration are arrested. These
are chemical changes of a very active kind, but they obey
different laws from those which prevail during life.
This is not all : there is also the independence of the func-
tions and of the tissues. You know that in the lower animals
independence of the functions is carried to an extreme ; you
have seen that the heart may continue to beat in a man,
even after decapitation. Claude Bernard and Longet agree
in saying that the liver of a dead animal, placed on a table,
retains its glycogenic function for some hours. M. Bouchard
and I separately performed identical experiments on the
production of urea, and obtained the same result. Need I
remind you that muscular excitability persists for a certain \
time in an amputated limb ? The unity of the Hving being
is therefore only apparent, and we are therefore justified in
saying that an individual does not die in every part in a
single minute.
Another important point is the suspension of the organic \
functions during life. In hibernating animals the functions
of respiration and circulation are reduced to the minimum
during their winter sleep. Submit them while in this state
to a reduction of temperature of 9° to 18° F. ; the vital
phenomena, already nearly imperceptible, are absolutely
arrested, so that, if you were to cut one of the animal's
paws, you would have a little oozing of blood, but not a
lo THE SIGNS OF DEATH
Stream ; tap the heart with the end of your scalpel, and you
will not induce a contraction, and it will be equally impos-
sible to arouse muscular contractility.
Take these animals now; warm them gradually for an
hour up to an increased temperature of i8° F., and they will
resume their vital functions ; they were therefore in a state
of apparent death. Is there not room for reflexion, when
we see how closely these phenomena apply to the case of
human beings ?
Captain Ross, in his expedition to the North Pole, took
with him a box containing silkworms : he exposed them on
the deck of his ship to a temperature of —43*6° F. and froze
them ; these silkworms, while in this condition, resembled
little bits of dry wood, and could be broken into several
pieces with the greatest ease ; Captain Ross had these silk-
worms warmed again, and the greater number revived ; he
repeated the experiment three times, and after the third
time of freezing the last survivors still produced moths, the
appearance of which he has described, but they were imper-
fect ; he had formed monsters.
[Pictet* also records a number of interesting experiments
in the same direction. He found that silkworms' eggs may
be safely cooled to —40° F., and when hatched in spring
are more free from disease than usual. Even animals much
higher in the scale of organization can be frozen and yet
revive. He not only froze several species of pond-fish solid
in a block of ice, and gradually thawed them back to life,
but found that frogs and common snakes would return to
life after exposure to cold of — 13° F. Scolopendra and snails
would withstand an even greater degree of cold. Frogs^
spawn, if slowly cooled to —76° F., may survive and be
hatched.
The late Sir D. Lysons,t in speaking of the intense cold
of Canada, tells a somewhat remarkable story. He had
caught a number of trout in the lake, and these had become
frozen solid when lying on the ground. Presently they were
* ' Le Vie et le basses Temperatures' (Rev. Scieiitifiqiie, vol. Hi.,
November 4, 1893, p. 577).
t * Early Reminiscences,' Murray, London, 1896.
APPARENT DEATH n
removed to camp and thrown down near the fire, previously
to being cooked ; before long the frozen fish thawed and
returned to Hfe, with the exception, certainly, of some that
had broken in half owing to their brittleness.
Dr. Moore Russell Fletcher* says that the common pond
trout, when thrown into snow, will soon freeze, remain so
for days, and be as lively as ever when replaced in water.
Other sorts of fish may be kept alive for weeks in a frozen
condition. The same writer states that an adder, 2 feet
long, was sealed up in a glass jar and kept alive and well
therein for sixteen months.
It is well known that in some tropical countries, where
the beds of rivers and swamps become completely dried up
in the summer months, many reptiles will bury themselves
completely in the desiccated and hardened mud, and remain
thus until the rains return and liberate them. W. T.
Hornadayf found several small frogs, quite solidly en-
tombed, i8 inches deep in solid sandy earth, on the bank of
a dried-up stream. Their bodies were greatly distended
with large quantities of water, which they ejected on
Hberation. When extricated they became quite active.
They are buried voluntarily during the dry season, from
monsoon to monsoon.
There are also undoubted instances of toads living buried
in the earth, in stones, or in trees, for a considerable length
of time ; though the hypothesis of their having ever
remained in this condition for an unlimited time, which is
often put forward as an explanation of the facts, requires
more proof than has yet been offered. J Dr. W. F. Edwards
made the following experiment : He filled several paste-
board boxes with plaster and imbedded a live toad in each ;
one of the toads was found alive on the nineteenth day.
The rest of the boxes were left for six to ten weeks, and
when opened the toads contained in them were all dead
* ' On Suspended Animation,' quoted by Tebb and Vollum : ' Premature
Burial.'
t ' Two Years in the Jungle,' p. 277.
% An account of several such cases is given in Gosse's ' Romance of
Natural History/ second series.
12 THE SIGNS OF DEATH
and completely dried up. Of course the toad in the first
case was kept alive by the entrance of air through the
plaster, which is porous to a certain degree ; for when similar
boxes containing plaster, in each of which a toad was
imbedded, were immersed in water or mercury, the animals
died almost as quickly as if they had been simply drowned.*
In Professor Buckland's well-known experiments some toads,
sealed up in a block of limestone and buried in the earth,
lived for over a year.
A very curious instance of prolonged suspension of life
in a snail happened some fifty years ago;*!* it is perfectly
authentic. A specimen of Helix desertorum was brought
from Egypt, and, being supposed to be dead, was gummed
to a card and placed on a shelf in the British Museum, in
March, 1846 ; in March, 1850, signs of life were noticed in
it. The animal was removed and placed in water, when it
revived, ate, and lived for two years afterwards.
An almost precisely similar instance was reported by
Dr. MacBride, of Dublin,! of the revival of certain snails
which had been kept in the drawers of a collection for
fifteen years.
There are also stories, which appear to be well founded,
of bats living in a state of torpor for very long periods. The
occasional hibernation of swallows has long been a moot
point. There appear, however, to be some perfectly authen-
tic cases where these birds have been found in this condition,
and sometimes they have even made their winter retreat
under water.§]
It is possible, then, in certain animals to suspend life and
restore it ; those which enjoy this faculty have been called
* resuscitating animals ' ; certain vegetables possess similar
properties, such as the grains of wheat found in the coffins
of Egyptian mummies, which, when sown after thousands of
years, have germinated and fructified.
* ' On the Influence of Physical Agents on Life,' p. 13. London, 1832.
t For information regarding this case I am indebted to Mr. Edgar A.
Smith, of the British Museum, who vouches for its accuracy and
expresses his behef in the following case also.
% Graves' * Studies in Physiology and Medicine,' 1863, p. 213.
§ Edwards, op. cit., note, p. 468.
APPARENT DEATH
[M. Casimir de Candolle,* writing on the vitality of seeds,
says that he has raised perfect seedlings from seeds known
to have been kept for a hundred years. On clearing away
rubbish-heaps from a silver-mine in Greece, the ground
beneath soon became covered with a mass of plants, whose
seeds could not have been there for less than 1,500 years.
Many seeds survived a temperature of —40° F. for 118 days,
and afterwards produced perfectly normal seedlings. In the
experiments of Mr. Horace Brown, f seeds did not have their
power of germinating in any way impaired by being exposed
for no consecutive hours to the temperature of evaporation
of liquid air — z.e., — 370° to —378° F.
Those young warm-blooded animals | which produce least
heat, viz., mammalia born with closed eyes and birds with-
out feathers, are more readily cooled than adults of the same
kind, but support a considerable reduction of heat more
readily and recover from it. The hibernating mammalia
occupy the lowest ranks in the scale of heat-production
among adult warm-blooded animals. Bats cool the most
readily, and after them marmots ; other species, e.g., mice,
though not torpid in winter, have feeble power of producing
heat, and therefore find a shelter for themselves. In the
same way, young animals consume less air than adults, and
therefore withstand asphyxia better. A friend of mind in
Australia drowned three newly-born kittens by immersion
in water until they sank. They were then buried under-
ground and covered firmly with earth. In twelve hours he
heard a feeble mewing, and on digging in the spot he found
one of the kittens still alive. It was extricated and survived.
Is there any condition then. Gentlemen, in the range of
our pathology, in which we, as human beings, resemble these
hibernating animals ? Yes, there are certain — I do not say
all — hysterical states which present similar phenomena.
There are many malingerers among hysterical subjects;
but it is no less true that in certain patients of this class
nutrition and excretion are reduced to the minimum. They
* British Association for the Advancement of Science, 1896.
t Proceedings of the Royal Society, and Nature, December, 1897.
X Edwards, op. cit.
14 THE SIGNS OF DEATH
maintain their nutrition on two or three figs per diem, and
excrete less than half an ounce of urine and scarcely any faeces
at all. The observations of Empereur demonstrated also
that these hysterical patients did not excrete one-fifth part
of the normal amount of carbonic acid. The conclusion
may be drawn from these facts that there exists a group of
women in whom the nutritive changes are at the minimum ;
their life is almost latent.
[Dr. S. Weir Mitchell* describes and vouches for the truth
of the following extraordinary cases of hysterical fasting :
1. In a chronic case, which had lasted some years, the
bowels were opened only once a month, and this habit lasted
for years. For thirty-nine days an average of 3 ounces
of urine was passed daily ; after this the patient (a female)
went to the opposite extreme and passed 5 to 10 quarts
daily. Presently the former condition returned : she passed
6 to 10 ounces of urine daily, and drank, by teaspoon,
12 to 14 ounces of water. She took no food at all for
ten days, and then only a few teaspoonfuls of milk, which
always caused vomiting. Then she took no food at all for
twenty days, but had from fifty to eighty drops of laudanum
daily, which she retained. In one month and five days she
took no more than 24 ounces of milk, besides the water and
laudanum as above stated. The patient wasted greatly
meanwhile.
2. After gradually giving up food, the patient swallowed
neither liquid nor solid for a period of twenty-seven days.
She fell into such an extreme state of prostration that her
death was expected. However, at last the scene changed,
and other hysterical phenomena appeared instead.
3. Almost complete fast for forty-five days. During this
time all food was refused except a small piece (an inch or
two) of toast twice, and she drank water in small amounts,
but this almost instantly produced regurgitation.
Mr. Panachand Parakh,t writing on periods of long fast-
ing in India, states that it is common among the Jains to
* ' Lectures on Diseases of the Nervous System, especially in Women,'
second edition, 1885, p. 245.
t British Medical Journal, November 7, 1891, p. 1031.
APPARENT DEATH 15
fast for thirty or forty, or even for sixty, days. Some indi-
vidual or other among them performs once every year.
During the period he drinks warm water, but eats nothing.]
If this condition is pushed to a farther degree, these
women may remain for a time, which we can measure in
cases of lethargy and catalepsy, in a state of apparent death ;
their life is entirely latent.
We may, without being hysterical, be able to reduce or
arrest the movement of circulation. Donders and M. Chau-
veau have succeeded in doing so. M. Chauveau, whose
stature you know, managed, after preparing himself by taking
a deep inspiration which caused 600 to 730 cubic inches of
air to enter his chest, to stop his heart for a whole minute.
It was not merely by auscultation that this could be proved :
the sphygmograph applied to the radial artery gave a
perfectly straight line corresponding to this space of time.
Some persons, therefore, can arrest their circulation for an
instant.
An Englishman, Colonel Townshend, asserted that he
could arrest the movements of his heart for half an hour.
Cheyne relates that this Colonel, who had been ill a long
while, took it into his head one day to send for Drs. Cheyne
and Baynard, who were in attendance upon him, and for
Mr. Skrine, his apothecary, to beg them to witness a singular
experiment which he was anxious to repeat in their
presence ; it was to cause himself to die and to return to
life. The patient lay on his back ; Dr. Cheyne kept his
finger on the pulse. Dr. Baynard placed his hand over the
heart, Mr. Skrine held a mirror before the mouth. Shortly
after, no arterial pulsation or cardiac movement could be
felt, and the breath did not dim the glass. This spectacle
having lasted for more than half an hour, the spectators were
about to withdraw, persuaded that the patient had pushed
his experiment too far, when they perceived some movement,
then they felt the beats of the pulse and of the heart return
by degrees, and respiration recommenced ; in time the
patient began to speak, and left the spectators equally
astonished at his death and resurrection. When they had
gone away, the Colonel sent for his attorney, added a codicil
i6 THE SIGNS OF DEATH
to his will, and expired peacefully eight hours after the
experiment.*
[Dr. Weir Mitchell! also recounts the following :
* I saw, very many years ago, a handsome girl, 20 years
of age, from Cincinnati, who had spells of apparent death, if
I may use such a term. One of these I had the good fortune
to see, and, indeed, to cause. . . . The young lady happened
to be particularly sensitive to odours, and even discussion
about the subject would induce an attack. Hystero-epilepsy
in this case had given place to " Death-spells," as her friends
called them. She said to me, " I am going to have an
attack: feel my pulse. In a few minutes I shall be dead!"
The pulse, which just before was about 100, was now racing
and quite countless, while the irregularity and violence of
the heart's action seemed inconceivable. With the interest
of a hysterical woman in her own performances, she said to
me : " Now, watch it : you will be amazed." This certainly
was the case. Within a few minutes the pulse began to fall
in number, and, as well as I can recall it, in some 15 minutes
was beating only 40. Then a beat would drop out here and
there, the pulse meanwhile growing feebler, until I could no
longer feel it or hear the heart. In this state of seeming
death, white, still, without breathing or any perceptible
circulation, this girl lay from two to four days. In this time
there were spells of a few minutes during which the heart
beat again furiously and irregularly, as was also the case
when she revived.']
Certain special predispositions and certain peculiar cir-
cumstances must also be taken into account : blows in the
epigastrium gave rise to an inhibition ; this is especially true
while the process of digestion is going on. Experiments on
dogs are conclusive as to this. A Polish physiologist has
made some very curious observations on frogs by aid of
Marey's recording apparatus. He used a little hammer,
weighing 45 to 60 grains, with which he struck the frog's
stomach ; when the animal had been eating, the pulse
became slow and the apparatus registered scarcely two or
* Cheyne, ' The English Malady.'
t Op. cit., p. 189.
APPARENT DEATH ,7
three beats per minute : when the animal was fasting, the
pulsations underwent no change.
Finally, I ought not to leave you ignorant of certain
idiosyncrasies, which I entitle unfortunate ; such is the case
of certain women who may die suddenly after the introduc-
tion of a uterine sound.
When we have studied the phenomena of death, and when
I come to speak to you of putrefaction, you will see that the
decomposition of a body does not resemble in any way that
of any other substance. When an individual dies from an
accident and the body is entire, putrefaction goes on rapidly,
and gaseous infiltration may invade the whole body. On
the contrary, if the limbs are removed, they may be pre-
served for a tolerably long time in a fresh condition.
Butchers know this peculiarity well, and cut up their
animals as soon as they are slaughtered.
You should be familiar with the fact also, for it is of im-
portance in forensic medicine.
At the time of the crime of Lebiez and Barre, the first
experts who were called, on seeing the limbs separated from
the trunk, stated that the murder had been committed quite
recently, for the portions of the body which were shown to
them looked fresh. I stated, on the contrary, that the state
of preservation of these remains was not sufficient proof,
and that they might well belong to a woman who had been
killed a week before. I was right ; for, when the remainder
of the body was brought from Le Mans, the limbs accurately
fitted the trunk, which was decomposed.
You understand, then. Gentlemen, that it is sometimes ex-
tremely difficult to say whether such and such a person is or
is not dead. You will meet with insurmountable difficulties
when you have to fix the time that has elapsed between the
moment at which the fatal blow was received and that at
which life ceased. Suspension of the heart's action in par-
ticular is not sufficient proof. Nevertheless, in acute diseases,
the moment when the heart ceases is evidently, to within a
few minutes, the moment of death. But it has not been
shown scientifically that an individual whose heart no longer
beats cannot be recalled to life. On the contrary, it is
2
i8
THE SIGNS OF DEATH
certain that some conditions exist which may be styled
the state of apparent death. We might definitely choose some
sign as a distinction between life and death, and use it in a
conventional way ; but I am very much afraid that, how-
ever elastic this convention might be, whatever sign might
be proposed to denote the moment of death, this sign and
this convention will always remain useless in doubtful cases,
and we are obliged to acknowledge that we have no sign or
group of signs sufficient to determine the moment of death
with scientific certainty in all cases.
[The converse condition of apparent life in a dead body is
not without interest and importance. The late Sir B. W.
Richardson* enumerates such conditions as are likely to be
met with, and to give rise to doubt, as follows :
1. Local or partial change of colour of the surface of the
body to a bright red — e.g., in a case of supposed scarlet
fever. This is due to oxidation of the blood hy post-mortem
interchange of gases.
2. Retention of warmth, as a rule from arrest of circula-
tion in the cerebral centres, and which persists after rigor
mortis has set in.
3. Muscular movements, as in death from cholera. The
movements are most often displayed in the right leg or
hands, and may last for an hour.
4. Retention of a lifelike expression, most often observed
in children.
5. Prolonged preservation from decomposition. This is
sometimes postponed by large and frequent doses of alcohol
administered during the fatal illness.]
* 'Transactions of the Medical Society of London,' 1889, vol. xii.,
p. 100 e^ seq.
LECTURE II.
THE UNCERTAINTY OF THE SIGNS OF DEATH, AND
PREMATURE BURIAL.
Gentlemen, — All these matters have a very close bearing
on the question of premature interment. In speaking of this
subject, I shall purposely leave on one side everything that
is at all legendary. Stories of miracles and resurrections are
to be found at the origin of every religion. These are articles
of faith, w^hich it does not concern me to discuss here. Nor
shall I linger any more over the tales of the fakirs of India.
You know that these fakirs, by practising rapid rotation, or
by howling, get themselves into such a peculiar nervous con-
dition that they appear to be destitute of life, and success-
fully withstand a certain number of tests. One of these
performances, and by no means the least of them, is to
allow themselves to be buried for two or three weeks. At
the end of this time the fakir is disinterred, and returns to
life. I can neither affirm nor deny anything about them, as
I have not seen them myself* I shall not occupy myself
with them any longer. We have many other matters await-
ing consideration.
* The apparent death of the fakirs is the subject of an interesting
report presented by Dr. Kuhn to the Anthropological Society of Munich.
From his report we extract the following passages :
'■Fakir is an Arabic word signifying beggar. This term has been
applied later to Indian conjurers as well.
' Although one may be led to believe that the fakirs practise the
simulation of death on a large scale, the author of the report is none
the less of opinion, with a knowledge of the facts, that authentic cases
2 — 2
THE SIGNS OF DEATH
UNCERTAINTY OF THE SIGNS OF DEATH.
The uncertainty of the signs of death has occupied
universal attention for a very long time. Parrot* has set
forth the history of the question with many details.
are comparatively rare. He has had the opportunity during his extensive
travels of observing two undoubted cases. These were the cases of two
fakirs, one of whom had remained alive under the ground for six weeks,
the other for ten days. The reporter is convinced that the state of the
fakir, which he induces by artificial means, is in all respects identical
with that known as catalepsy.
' The cataleptic state may last for hours, days, or months.
' Catalepsy may constitute one of the phases of hypnotism. . . .
' In the fakirs we have nearly always to deal with this last form of
catalepsy, when we have to explain the phenomenon known as apparent
death.
* To attain to this condition, the fakirs, who are evidently confirmed
hysterical subjects, employ every means of exciting a condition of ecstasy,
mortification of the flesh by a special dietary, the internal use of different
vegetables known only to themselves, and a special posture of the body
maintained for many hours. (All the rules prescribed by religion to gain
the power of entering into communication with the Divinity are to be
found in the Indian book, "Hathayoga pradipika Sratmarimas," translated
by Dr. H. Walter.) When the fakir has had sufficient practice, he is put
into the ground, takes one of the doses prescribed by the sacred book,
and falls into a state of hypnotism by means of fixedly regarding the end
of his nose.
' The fakirs appear still to use hashish to lessen the energy of respira-
tion, and that hypnotic, combined with other vegetable drugs, and
employed in a particular fashion, compensates the want of air and
nourishment.
' At the beginning of hypnosis the fakir has hallucinations. He hears
sounds and sees angels, his face expressing a feeling of beatitude. But
little by little consciousness vanishes, and the body acquires a special
rigidity in proportion as "the spirit goes to join the soul of the world." '
Dr. Schrenk-Notring has replied to the narrator, adding that in the
picture drawn by Dr. Kuhn he has dealt simply with auto-hypnosis in
hysterical persons wrought up to a sufficient pitch of excitement. His
conclusions agree with those of Dr. Kuhn in considering that narcotics
play a large part in bringing about the state of hypnotism in fakirs.
' In studying the hypnotic state,' adds Dr. Notring, 'we frequently meet
with cases arid facts which afford an explanation of the Indian miracles'
{Zeitschrift Jiir Hypnotisrfius^ Berlin, 1894, and Ann. de Psych, et d'Hypn.^
May, 1894).
* J. Parrot, ' De la Mort apparente,' thesis for the Fellowship {agrega-
iion) of the Faculty of Medicine cf Paris, March 5, i860. Paris, i860.
:
THE UNCERTAINTY OF THE SIGNS OF DEATH
The first philosopher whose opinion on the subject has
come down to us is Democritus, who averred that there was
no certain sign of the cessation of life. Paul Zacchias and
many others coincided with this view. But it was not till
1742 that the public at large began to take an interest in
these discussions. Winslow had just declared that he had
actually been put into his coffin twice, and he has recorded,
in a memoir that has been celebrated ever since, the anguish
that he felt at the time. Bruhier, a physician living at
Poitiers, who commented on Winslow's work, gave his
support to the view that the signs of death are uncertain,
and based his arguments on a considerable number of cases.
His book made a great stir; but Bruhier had accumulated
all the descriptions and tales that he could get hold of, and
derived some fantastic statistics therefrom ; he reckoned, for
example, that fifty-two persons had been buried prematurely;
four had had their bodies opened during life, in the course
of autopsies made by over-hasty physicians ; 102 had re-
turned to life after a more or less prolonged period of
apparent death.*
Let us say at once that one fact is found to be almost con-
stantly present — viz., in the immense majority of cases the
persons died without having been seen during their illness
by a physician, and were buried without a physician having
having had the opportunity of verifying their death.
You know that each row of bodies in a cemetery is dug up
every five years to make room for fresh interments. The
corpses thus disinterred are all put together in a single
trench. It was und^r such circumstances that Tourette,
who was Professor of Medical Jurisprudence in this Univer-
sity, found in the charnel-house of the Innocents sundry
remains which occupied a different position in their coffins
from that in which they had been placed : the idea of prema-
ture burial naturally came into his mind.
■^ Two English works on Premature Burial have recently been published,
one by Dr. Franz Hartmann, the other by Messrs. Tebb and Vollum. In
both a large number of cases of supposed burial ahve are narrated, culled
from all manner of sources, but it cannot be said that the evidence thus
furnished is at all convincing. — Translator.
22 THE SIGNS OF DEATH
One thing is wanting in these accounts, viz., a history of
the patient, with notes of his illness. Some diseases that
we are well acquainted with — cholera among them — are
followed hy post-mortem contortions and convulsions which
may attain a considerable degree of force : displacement of
the limbs from this cause does not prove that a person has
survived burial. As to those stories of post-mortem examina-
tions having been practised by anatomists, when in too great
a hurry, on persons still alive, though in a state of apparent
death, I believe they are false, or invented for amusement.
I will cite two. One of them has for its hero the illustrious
Vesalius. Happening to be at the Court of Philip II., he
wished to perform an autopsy on the body of a gentleman,
who awoke under his scalpel. The affair was noised abroad ;
the Grand Inquisitor, it is said, arrested and imprisoned
Vesalius, who was finally condemned to go on a pilgrimage
to Jerusalem to expiate his offence.
When this story was again investigated some years ago
by a biographer of Vesalius, it was discovered to be false.
Vesalius was never thrown into the dungeons of the Inquisi-
tion, and he himself applied to Philip II. for leave to visit
the Holy Land.
The second case is that of Abbe Prevost, who fell down
dead in the woods of Clamart ; a medical man, who did not
employ sufficient delay, opened the abdomen to discover the
cause of this unexpected death, whereupon Abbe Prevost
awoke. He is said to have been cured, and to have lived
many years after.
Now, this Abbe had been tutor in the family of Firmin-
Didot ; M. Tourdes,* who is now the Honorary Dean of
the Faculty at Nancy, was closely connected with this
family ; he has interrogated the members of it at length, yet
no one was found who remembered that Abbe Prevost had
ever related this episode of his life, although it was so
unique that no one could help preserving the recollection
of it.
What has generally given rise to these legends is that the
persons who have been the chief actors in them have been
* Tourdes, ' Dictionnaire encyclop^dique des Sciences mddicales.'
THE UNCERTAINTY OF THE SIGNS OF DEATH 23
buried without any medical man having verified the fact
that life had actually ceased ; if a mistake has been made, it
is a popular blunder, not a medical one.
As a result of the outcry raised by Winslow^ and Bruhier,
whose opinions gained a great hold even outside France, the
so-called mortuary chambers were instituted in Germany.
What is a * mortuary chamber ' ? A person dies : he is
carried to an apartment called the * mortuary chamber,'
where he is surrounded with flowers, and a bell-rope is
placed in his hand ; moreover, an attendant visits the place
from time to time to inspect the corpse. Gentlemen, from
the time that mortuary chambers were instituted — and that
at Weimar dates from 1792 — neither at Weimar nor at
Munich (these are the mortuary chambers that I have
personally visited), nor anywhere else, I believe, has anybody
ever rung that bell. It may be, and has been, said in reply,
that the dead bodies brought to these places have always
been seen by medical men, and that the safeguard which has
been conferred upon them is superfluous ; we do not deny
the force of this objection, but we are perfectly justified in
concluding that cases of apparent death must be very rare
indeed.
The mortuary in Germany is a place whither corpses are
carried in order to make sure that death has really taken
place. In France mortuaries exist also, but with quite a
different purpose. There are two of them in Paris.* They
have been established in order that persons might be
removed there who, having only one room for themselves
and their family, die in the same apartment where the
members of the family will have to perform all their natural
duties by the side of the corpse, greatly to the detriment
of health and morality. I remember, as an instance of this,
the following occurrence : A man died of small-pox ; his
family and friends watched the body ; they ate and drank
* Decree of April 27, 1889, on the conditions applicable to the different
modes of burial. 'Art. 5. — It is lawful to establish funeral chambers
intended for the reception before burial of the bodies of persons whose
death has been caused by an infectious disease ; the funeral chambers
are to be established on the demand of the Municipal Council,' etc.
24 THE SIGNS OF DEATH
by its side, and when I came to see the man, of whose
death I had not been informed, there were bottles every-
where, even on the abdomen of the deceased. Do not take
this as an isolated case ; it is, on the other hand, very
frequent, and a cause of demoralization. It is the chief
reason which has urged us to demand the institution of
mortuaries ; they are necessary, as a matter of fact, to
insure proper respect towards death, and observance of the
precepts of hygiene.
Orfila, Fodere, and Michel Levy, all believed in the pos-
sibility of premature burial, and it is certain that it cannot
be denied absolutely. Against the partisans of the un-
certainty of the signs of death we may set some authors
who affirm that the signs of death are unmistakable. At
the head of them I will place Celsus, whose criticism of
Democritus I quote here : * If the apparent identity of certain
signs deceives an unskilful physician, an experienced and
inteUigent man cannot be mistaken ; and the case of
Asclepiades, who recognized, on meeting a funeral proces-
sion, that the person whom they were going to bury was
still alive, is a proof of this. The faults of an artist are not
defects of the art.' I will also cite Lancisi, and above all
Louis, who in a voluminous memoir concludes in the follow-
ing terms : * The opinion that the signs of death are not
certain is too dangerous to be true.' Notwithstanding all
the respect that I have for the memory of Louis, his con-
clusion seems to me a singular one, and as unscientific as
that of Celsus. It is much better to acknowledge one's
ignorance than to mask it by an aphorism of this sort.
Louis adds : ' I know of only one doubtful instance. It
was that of a woman who was delivered of a child at her
own home, and who was afterwards removed to the Hotel-
Dieu. There was no room for her there, so she was
directed to go on to the Salpetriere, which she did on foot.
On the way she fainted three times, and careful note was
taken of the places where these attacks of syncope occurred.
She reached the Salpetriere, and immediately died, or at any
rate was taken very ill for the fourth time. She was carried
to the dead-house. The house-physician under Louis
THE UNCERTAINTY OF THE SIGNS OF DEATH 25
entered the vault some time after to practise surgical opera-
tions, and found the woman half extricated from the cover-
ing that had been thrown over her, and struggling on the
slab whereon she was placed. He called out, and Louis
himself ran up and found that the unhappy woman had
one foot off the slab, and one arm out of the sheet. She
was still warm, but by this time she was quite dead.
Are there any cases in which medical men themselves
have failed to recognize a state of apparent death, and do
these cases, if any such exist, entitle us to demand a reform
in the law of burial, or may we rest satisfied with the
present arrangement of things ?
Here is a case to start with : Dr. Rigaudot, in practice
in the suburbs of Douai, and a thoroughly honourable man,
was summoned to a woman who was about to be confined.
On his arrival he was told that the woman had been dead
two hours. Thinking that it might be possible to save the
child, Dr. Rigaudot ruptured the membranes, and brought
into the world a child, which was raised to life with some
difficulty. It took him half an hour to accomplish this.
He asked to see the mother again, to whom no one was
paying any more attention, and who had been already laid
out ; he noticed that the body was warm, and then went
away. Some hours later, in the evening, that woman
returned to life ; but as a result of the accident she remained
deaf, nearly blind, and almost an idiot. This physician,
therefore, whose report may be believed, was confronted by
two cases of apparent death, viz., that of the mother and
that of the child.
In 1866 a petition was presented to the Senate with
reference to premature burials. Cardinal Dounet, in a
sermon which made a great impression, assured his hearers
that he himself had rescued two girls from the grave ; more-
over, he narrated the following history, which roused pro-
found emotion : ' In 1826 a young priest, while preaching
in a crowded cathedral, suddenly sank down in a swoon in
the pulpit. A physician pronounced that death had taken
place, and drew up the form for his burial the next day.
The Bishop of the cathedral where the occurrence happened
26 THE SIGNS OF DEATH ^Bl^^^B
had begun to recite the De Profundis at the foot of the
bier, and the body had been measured for a coffin. As
night approached, the agony of the young priest may be
imagined when his ear caught the sound of these prepara-
tions. At length he heard the voice of one of the friends
of his childhood ; this voice excited him to make a super-
human effort, and a marvellous result ensued. The next
day he was able to reappear in the pulpit. To-day he is in
your midst (sensation !) entreating you to demand of your
representatives, not only to take care that the provisions
of the law are complied with, but, furthermore, to enact
additional ones that shall prevent these misfortunes which
are too frequent and irreparable.'* In this case, had an
attack of syncope, or an inhibition caused by the violent
emotion of preaching in a cathedral, been mistaken for
apparent death ? I do not know, but the story must be
accepted as true.
Other cases have an equal title to be put on record.
Dr. Roger, of Plougonven (a suburb of Morlaix), relates
the following incident : In 1866, while cholera was raging in
the department of Morbihan, a young woman, aged 26, was
suddenly seized with pain in the head and various other
symptoms, and her condition rapidly became, serious. The
people around her believed that she had got cholera, and
before many hours had elapsed she died. She was laid out
and placed in a coffin, and sixteen hours after death her
burial took place. A noise was heard inside the coffin which
attracted attention. Dr. Roger was summoned ; he had
the coffin opened, and found that life remained ; he had the
woman removed into the church, as it was impossible to
carry her all the way home, on account of the distance ; he
was unsparing in his attentions, but she died in the course
of the night, and was buried in earnest the following day.
* This observation,' says M. Tourdes, ' seemed to us a
well-authenticated case of the burial of a living person. To
make quite sure, we communicated with Dr. Roger, the
witness of the incident, and received from him the following
reply, dated July 30, 1874 : "Yes, I was present at the ex-
* Moniteiir^ March i, 1866, p. 238.
THE UNCERTAINTY OF THE SIGNS OF DEATH 27
humation of a woman buried in a state of apparent death.
I did not hear the sounds of the heart distinctly, though on
auscultation I plainly perceived some faint rhythmical move-
ments in the praecordial region ; I am positive that the
woman was still alive when I examined her ; it is not a mere
probability. Here is a verbatim copy of the notes taken the
same evening : ' Plouigneau, Oct. i, 1867, midnight. — I
exhumed at 8 p.m. Philomele Jonetre, aged 24, buried at
5 p.m. in a grave 6 feet in depth. Several persons heard
her tap distinctly against the lid of the coffin ; these blows
appear to me to have left visible marks, but I did not hear
them myself. There was no smell, no evacuation, but
abundant evidence of respiration. Distinct rhythmical sound
in the region of the heart. No rigor mortis ; muscular con-
tractions of the arms present, as well as in the lower jaw ;
heat and colour of the skin normal ; no film on the cornea ;
tissues of the hand transparent to the light of the candle I
held. Ammonia was applied to the nose; alternate com-
pression and relaxation applied to the chest. She was not
dead, but like a candle the flame of which has been extin-
guished, though the wick continues to glow. No definite
sounds of the heart ; the eyelids moved in my presence. I
kept her unburied until the following day.' " It is out of
these notes that the account has been compiled ; it is an
authentic case of burial during life. Without doubt, if a
physician had seen her at the commencement of her illness,
if the supposed death had been properly verified, if the body
had not been placed in the coffin within an hour of the sup-
posed death, and if burial had not been proceeded with
within sixteen hours (though this was contrary to law), the
mistake would not have been made; but the same set of
circumstances may happen again, during an epidemic in the
provinces, where verification is not systematically carried
out, and it is useful to have it demonstrated, by a fresh case,
that the danger of being buried alive is not chimerical.'
Without being as confident as M. Tourdes, it cannot be
denied that the fact is within the range of possibility.
The case of General Ornano is well known. During the
retreat from Russia General Ornano had his head grazed by
28 THE SIGNS OF DEATH
a bullet while in the act of charging the enemy at the head
of his squadron ; he fell from his horse, and his orderly,
Captain Tacher, ran to his assistance, but found that he
showed no signs of life, and buried him under a heap of
snow, having no time to afford him a more becoming inter-
ment. The orderly then went to announce the death to
Napoleon. Two hours afterwards General Ornano came to
report himself to the Emperor ; he lived a long time after,
and was one of the pall-bearers of his old orderly Tacher,
who had in due course become a General.
The following case is probably one merely of syncope or
prolonged nervous commotion : In 1848, as Louis Philippe
was leaving the Tuileries to go into exile, the bodies of
three National Guards were lying at the gates of the garden,
near the Place de la Concorde ; wishing to spare the King
any fresh grief, some persons good-naturedly buried these
bodies under a heap of sand. When they were extricated,
some hours after, one of these men was still alive.
These cases have great probability, but perhaps they are
not altogether beyond dispute ; about two of them, gentle-
men, there can be no doubt at all, for they were under the
supervision of medical men. The first is related in Parrot's
thesis, of which I lately spoke to you ; here it is in full ; it
relates to an individual who was hanged at Boston in 1858,
and was observed by Drs. Clark, Ellis and Shaw :
* The executed man weighed 130 pounds, was 28 years of
age, and very robust. The hanging took place at 10 a.m.
It is stated that there was neither any struggling nor con-
vulsion. We must remark that, while admitting that the
spectators may have been too much affected to have been
able to study what took place with all necessary attention,
it must be allowed, at any rate, that death took place without
any very obvious convulsions, for if there had been such, no
degree of emotion could have prevented them from being
seen. Their absence is an interesting feature, which shows
that death was not brought about by rapid asphyxia, a con-
dition which is always attended by violent convulsions.
* In this man who was hanged at Boston, the lungs and
brain were found to be normal. How, then, did death take
THE UNCERTAINTY OF THE SIGNS OF DEATH 29
place ? Without the slightest doubt its primary cause was
sudden syncope from emotion or from excitation of the
brain produced by the drop (7 or 8 feet) at the moment of
hanging ; while the body was still hanging, seven minutes
from the commencement, the sounds of the heart could be
heard beating at the rate of 100 per minute. Two minutes
later the rate was 98, and three minutes after only 60, and
very feeble. In two minutes afterwards the sounds had
disappeared.
* At 10.25 ^•^^- the body was taken down. There was no
more sound or impulse of the heart ; the face was purple,
although a small space near the ear probably allowed the
passage of blood. The tongue and eyes did not protrude ;
the pupils were dilated. The rope had been applied just
above the thyroid cartilage. At 10.40 a.m. the rope was un-
tied, as well as the pinions which bound the arms to the
sides. This done, the face and body gradually became pale.
The vertebral column had not been broken. There was no
emission of semen — a fact in harmony with the absence of
asphyxia and of lesions of the spinal cord.
* At 11.30 a.m. a regular pulsation was noticed in the right
subclavian vein (artery ?). On putting the ear close to the
chest, one could make certain that this depended entirely on
the heart, and a single beat could be heard 80 times per
minute, regular and distinct, and accompanied by a slight
impulse. The thorax was then opened, a proceeding
which did not excite any pulsatile movements. The right
auricle was contracting and dilating with force and regu-
larity.
* At 12 m. the number of pulsations was 40 per minute ;
at 1.45 p.m. 5 per minute. The spontaneous movements
ceased at 2.45 p.m., and irritability persisted till 3.18 p.m.,
more than five hours after the hanging.'
Although Dr. Clark does not say so, it is infinitely prob-
able that the sound heard on auscultation before the thorax
was opened was due to movements of the right auricle, and
not of the ventricles.
That is the first case. I must point out, in passing, the
strange, cool manner in which these Boston physicians per-
30 THE SIGNS OF DEATH
formed their experiments on a living man. But it cannot
be denied that this man was hanged ; his death was wit-
nessed by medical men, and yet this man showed indis-
putable signs of the persistence of life.
The second case resembles the first ; it happened at
Pesth, and is reported by Hofmann ;* it also happened in a
criminal sentenced to be hanged ; he had round his neck
enlarged glands, which probably partly neutralized the con-
striction of the slip-knot which encircled it. However that
may have been, the body remained suspended for twenty
minutes, a medical man certified that death had occurred,
and the body of the executed man was transported in a van
at a rapid pace to the post-mortem room. There was some
distance to go, and when the van arrived, the physicians,
who were expecting a corpse, were greatly surprised to see
instead of a corpse an individual who raised himself up
before them, and looked at them with a scared expression :
the executed man had returned to life. A telegram was
sent to the Minister of Justice to ask for instructions, and
the Minister in reply told them to wait and see what
happened. It was not necessary to wait very long, for
three or four hours afterwards the man died of pulmonary
congestion, evidently a result of the hanging.
In both these cases the error was a medical one : it is
impossible to doubt that a blunder was made, precisely
because examination by a medical man had not been
omitted.
[Cheverst quotes a contemporary pamphlet which states
that at the dissection of Bellingham, who was hanged for
the murder of Mr. Perceval, in 1812, the heart continued to
perform its functions for four hours after the body had been
laid open. In contrast to the foregoing cases is an extra-
ordinary example of persistence of the heart's action for
twelve and a half hours after death, and six and a half
hours after the arteries had been injected with a solution of
arsenic. The case is reported by Mr. James MacNamara 4
* Hofmann, ' Nouveaux £ldments de M^decine Idgale,' avec introduc-
tion et commentaires par Brouardel. Paris, 1880.
t ' Medical Jurisprudence of India,' third edition, 1870, p. 647.
I Medical Times aitd Gazette^ March 30, 1861, p. 345.
THE UNCERTAINTY OF THE SIGNS OF DEATH 31
A male Hindoo, aged 24, died in Calcutta Police Hospital,
and was brought to the Medical College for dissection at
6 a.m., February i, 1861. At 7 a.m. the body was injected
with a solution of arsenic (i pound arsenic to 6 gallons of
water). At 11 a.m. Professor Partridge's prosector opened
the thorax and abdomen, in order to dissect the sympathetic
nerve. At 12 m. the writer was accidently passing by, and,
looking at the body, exclaimed: 'The heart is beating!'
There was a distinct, regular, rhythmical vermicular action
of the right auricle and ventricle. The pericardium was
open and the heart fully exposed and lying to the left of its
natural position. The heart's action, though regular, was
very weak and slow. The left auricle was also in action,
but the left ventricle was contracted and rigid, and appar-
ently motionless. The heart's spontaneous contractions
lasted till about 12.45 p.m. ; the right side, however, con-
tracted on the application of a stimulus, such as the point
of a scalpel, for three-quarters of an hour longer. The man
had died of cirrhosis of the liver and anasarca ; the viscera
were generally healthy. The exact time of death is not
mentioned ; but it is certain that the body was sent from
the hospital at 6 a.m., and no body is ever sent thence for
dissection till after an interval of several hours.]
There is yet a third series of cases of more or less apparent
death, concerning which I must say a few words to you.
Gentlemen, the child who is born into the world in a state
of apparent death is not always still-born ; you are well aware
that many of these * still-born ' infants may be recalled to
life. Depaul, who has left a minute and careful record of
such cases, succeeded in restoring new-born children by
means of pulmonary insufflation, an hour and a half, two
hours, or even three hours, after the heart had ceased to
beat.
It is necessary, therefore, to remind you that apparent
death is tolerably frequent at the moment of birth, and that,
with prolonged care by means of insufflation, and also of
rhythmical traction of the tongue, which has answered well
in the hands of M. Laborde, you can bring back to life
infants that are apparently dead.
32 THE SIGNS OF DEATH
To form a just judgment, Gentlemen, on so difficult a
question as that of apparent death, it is essential to eliminate
every source of error. The chief of these arises from the
persistence of muscular contractions after death, as in
cholera. One might even say that movement continues
after death. In the bodies of persons who have died from
this disease, we may actually meet with rhythmical contrac-
tions of the abdomen and of the muscles of the thigh, strong
enough to produce flexion of the limb, etc. These phenomena
have sometimes made people doubt the reality of death.
Gentlemen, when you happen to be alone by the side of
a corpse at night-time, observe it well ; you will notice a
singular persistence of movements in the muscles of the face
and of the hands. Abduct the thumb from the forefinger;
in the course of a few hours they will be approximated again;
but do not conclude from these facts that life remains. I
may say the same about contractions of the diaphragm ;
they may be energetic, causing an expulsion of gas, and
often of liquids (the watchers call this the ' emptying of the
body '), or abrupt, in which case they may evoke a hiccough,
or sometimes an inarticulate sound or cry.
The expulsion of semen has been considered to be a proof
of life. When cadaveric rigidity sets in, it appears to start
from the vesiculse seminales ; the semen, owing to this par-
ticular contraction, is discharged into the urethra, and may
perhaps escape externally, according to the position of the
penis. This escape is therefore no proof that life remains.
Identical stories are told of pregnant women being de-
livered on the tables of the mortuary. The observations
which have been made by Depaul and myself clearly demon-
strate that in women who have previously been confined,
and who die when again six or seven months advanced in
pregnancy, the development of gases in the intestines may
lead to the expulsion of the foetus, because the uterus
becomes inverted ; it is a mechanical phenomenon of putre-
faction.
[Instances of this occurrence are not extremely rare, and
are naturally more frequently met with in India and other
hot countries, where putrefaction is rapid, than with us.
THE UNCERTAINTY OF THE SIGNS OF DEATH 33
The uterus is often, but not always inverted in such cases.
The foetus expelled is in most cases immature, or seldom
of more than six or seven months development ; but one or
two cases are on record where the child was expelled at full
term ; the mother may have died undelivered, after a pro-
longed labour. In one extraordinary instance the body of
a woman was exhumed and a living child, which actually
survived and grew up, was rescued from the coffin.*]
Sometimes the outward appearances of life are preserved
in death. When the Opera-Comique was burnt down,
twenty-nine bodies were found near the refreshment bar
which showed no marks of burning or violence ; the dresses,
and even the finest lace, were intact ; these persons had
succumbed to asphyxia by carbonic oxide. When their faces
had been cleansed from the black and grimy coating which
the smoke had deposited, three of them were found to be
young girls. In the case of two of them, their relatives
could scarcely believe that they were dead when they saw
them ; for their complexions were rosy and the lips red,
because the carbonic oxide had preserved the scarlet colour
of the blood ; even when putrefaction had set in, a few days
afterwards, these girls still had a rosy look, because the
red blood was propelled towards the head and face.
Predisposition to Apparent Death. — Can we enumerate
and classify cases of apparent death? In by far the
majority of cases, the approach of death is known to those
who have to do with the patient. You have seen that
danger of apparent death is especially great in new-born
infants ; it has been said to be possible in the case of the
old; it is possible in the case of a large class of persons if
they are placed in special conditions.
First of all must be reckoned those hysterical persons
who live on the scantiest supplies of food, and who are prone
to fall into lethargy, and may remain in the state of apparent
death for a considerable time. I do not believe that a
physician would commonly be mistaken over them, for
auscultation of the heart would reveal the true state of
things ; but ordinary people might be deceived. Allow me
* Case quoted by Aveling, Lancet^ 1872, vol. ii., p. 473.
3
34 THE SIGNS OF DEATH
to insert a parenthesis here : In France, except in those
towns where there is a municipal organization for the
verification of death, entrusted to medical men, the registrar
of deaths is the sole person who is charged with proving the
reality of death. He does not, as a rule, perform this duty
in a thorough-going manner, and if he does take pains to
do so, he cannot perform it satisfactorily, since he is not a
medical man. There are, then, under these conditions, and
particularly in the country, many opportunities for making
mistakes.
[Cataleptic trance may also simulate death, and has been
mistaken for death by inexperienced people.]
I next call your attention to syncope, or inhibition. A
mass of literature, comprising more than a thousand volumes
or memoirs, has been founded on this subject, and the
immense number of cases embarrasses me not a little. One
reads therein of soldiers wounded in battle and dying of
haemorrhage, who have been restored to life after two, three,
four, or even twelve days !
I do not know how long life may be prolonged after a
fatal haemorrhage ; I know that it may be for an hour,
because I have seen instances of it. Am I entitled to deny
that it may be prolonged still further? Just remember,
then, that death by haemorrhage, by syncope, or by inhibi-
tion, may be a source of fallacy.
[The closest resemblance of syncope to death that I have
ever seen occurred in a young man suffering from scrofulous
disease in an advanced stage. He was extremely anaemic,
languid, and weak, and was confined to bed. One day he
went off into a swoon, with complete relaxation of all
muscles and insensibility; and no sign of circulation or
respiration could be detected. This condition lasted for
nearly half an hour, when he gradually recovered. A few
days afterwards this swoon was exactly repeated, but on this
occasion no endeavours were successful in restoring him to
life, and presently unmistakable signs of death supervened.]
Cases have also been related of individuals who have been
buried for two or three days, and yet have returned to life.
The fact may sometimes be explained; e.g., the layer of
THE UNCERTAINTY OF THE SIGNS OF DEATH 35
sand or of earth thrown over the body may be permeable
to air, so that a sufficient quantity for respiration and the
support of Hfe may be admitted.
As to submersion, we know that drowned persons are
resuscitated every day by means of diligent and well-con-
trived eiforts. But when we are asked to say how long these
persons may have been submerged, we cannot be too cautious
in expressing an opinion. It is a matter of estimating prob-
abilities. Some assert that resuscitation may be effected
after submersion for two, three, or five hours ; but people
who are present at the scene, and take part in the exertions
that are being made, have no idea of time. They will tell
you that they have been there an hour, although it may
really be only a quarter of an hour since they reached the place.
With regard to freezing, Gentlemen, there are certain
cases which I am bound to accept. A story is told of a
grenadier belonging to the Strasburg garrison, who was
found frozen in the river 111 ; he was taken to the hospital,
warmth was appHed, and he survived. At Strasburg, on
another occasion also, a hospital attendant was found frozen,
was resuscitated, and still continues his duties, which he
has now performed for many years.
The after-effects of lightning stroke have not received
sufficient attention. Out of seventy-seven instances related
by Sestier,* there are six or seven in which apparent death
lasted for five or six hours. Boudin quotes the case of a
sailor who was restored after having been apparently dead
for an hour and a half. I believe that the death-like state
may be ascribed in these cases to inhibition, caused by a
maximum degree of stimulus, a possibility which cannot be
gainsaid.
[Richardson t relates a case observed in 1869, by Dr.
Jackson, of Somerby : A man was struck by lightning while
driving ; he reached his home in a state of great prostration,
in which he lay for a long time, and then sank into such
complete catalepsy that he was pronounced to be dead, and
was laid out as a corpse. He actually heard the sound of
* Sestier, ' De la Foudre.' Paris, 1866.
t Loc. cit.
36 THE SIGNS OF DEATH
his own passing-bell, and by a desperate effort moved one
of his thumbs, thus attracting the attention of the women
around him. He recovered and lived for some time.]
Finally, Gentlemen, I come to concussion of the brain,
and I will at once cite to you two typical cases.
At the siege of Constantine, General Trezel, who com-
manded the division, was struck by a ball on the back of the
neck, and fell down. The troops continued their assault on
the town, which presently fell into the hands of the French.
Search was then made for the General's body. It was found,
and placed on a stretcher. While being carried on the
ambulance, the General returned to life and warmly thanked
the porters, but he did not recollect that he had been
wounded. How long did apparent death last in his case?
I do not know; but I can state positively that it lasted
during the time necessary to take the town, which must
have occupied some hours at least.
The second case came under my own eyes, and took place
while I was house-physician at La Pitie. At that time
the resident staff were not on good terms with the adminis-
tration. A little bricklayer, aged 13, was brought in one
day, who had fallen from the sixth story on to the pave-
ment. The accident happened in the Rue de la Tournelle.
The boy had been taken to a chemist, who pronounced him
to be dead, and sent him on to the hospital. The director
refused to admit him, as he was dead. Now, either by
intuition or else to bamboozle the director, I stated that
the lad was alive, although the sounds of the heart could
not be heard on auscultation. I had him put into a mustard
bath, and, to my delight, he came to. He had received no
wound or any definite injury, only he remembered nothing.
Gentlemen, I presume that an hour and a half had elapsed
between the time that he fell and that when he entered the
hospital. Just think that he had first been carried to the
chemist's, who had examined him : next, that a stretcher
had to be procured : and then there was a good deal of
parleying at the hospital door. That lad suffered from
cerebral concussion, whence he emerged suddenly without
any outward trouble. He might have been buried alive ; he
^P mi/
THE UNCERTAINTY OF THE SIGNS OF DEATH 37
might perhaps have returned to life beforehand. I hope he
would have done so, though I dare not feel sure.
Some authors have described poisoning by the fumes of
charcoal as being capable of inducing a state comparable to
that of apparent death. Dr. Harmand (of Nancy) relates
that he was called to a coachman, who gave no sign of life,
and that another medical man who had been called in before
had pronounced that the patient had succumbed to cerebral
congestion. Noticing the peculiar odour which pervaded
the room, Dr. Harmand had the windows opened, and
devoted his full attention to the restoration of the patient,
who returned to life and still survives. He attributes the
coachman's illness to poisoning by charcoal fumes.
Gentlemen, when a person is killed by charcoal fumes, he
is poisoned by carbonic oxide, not by carbonic acid. When
any one is placed in an atmosphere of carbonic acid, death
happens, not from poisoning, but because the atmosphere
has become irrespirable.
I can relate to you some curious experiments under this
head. A Commission in which I took part, with MM.
Schutzenberger, Du Mesnil, and others, was charged to give
an account of the poisonous nature of the gases contained
in the soil of cemeteries.* We caused graves to be dug
13 to 16J feet deep. In some of these graves we had corpses
buried ; others we left empty as control experiments. We
wanted to measure the amount of carbonic acid and other
gases liberated in these graves. In the soil of Paris, satur-
ated with animal matter, and still more with vegetable matter
in a state of decomposition, we detected as much carbonic
acid in the empty graves as in those which contained the
corpses. One grave, i6| feet deep, was full of carbonic acid
in five hours. Graduated candles burned in them for only
ten or fifteen minutes at the bottom ; at the upper part they
burned for two, three, four, or five hours. It is to this rapid
liberation of carbonic acid that the well-sinkers succumb who
pursue their trade in Paris and the suburbs.
* Brouardel, ' Projet de Creation d'un nouveau Cimeti^re a Boulogne-
sur-Seine' {Ann.iVHyg.^ 1866). Brouardel et du Mesnil, 'Conditions
d'Inhumation dans les Cimetieres, reforme du Ddcret de Prairial sur les
Sepultures' {Ann. d'Hyg., 1892, p. 27).
38 THE SIGNS OF DEATH
We likewise placed cages of birds and of guinea-
the graves. The birds in those cages which we let down tc
the bottom died ; those in the cages placed nearer the sur-
face were in a state of apparent death when they were drawn
up. When placed on their backs in the open hand, they
came to life suddenly and flew away.
There is, then, in these cases a state of anaesthesia which
is dissipated suddenly, without leaving any traces, and
which can be compared to that produced by nitrous oxide.
Dr. Harmand had to do with a case of this sort. The pheno-
mena which he describes could be produced by immersing
a person in an atmosphere saturated with carbonic acid, but
not with carbonic oxide.
Drunkenness may also produce a condition of apparent
death. M. Bourneville cites the case of an old woman found
in the street, who no longer breathed or gave any sign of
life. She was conveyed to the hospital. The rectal tem-
perature was yy° F. Energetic treatment restored her to life.
M. Laborde mentions an individual picked up in a lifeless
condition at the gate of the Bicetre. He was carried into
the hospital. His rectal temperature was 75° F. In some
little time he revived, and eventually recovered. In both
these cases the cause was drunkenness.
[Richardson* also mentions prolonged narcotism brought
about by other substances as causing a similar suspension of
vital action. He believes that this was induced by the
ancients by means of certain drugs administered to those
about to undergo torture or surgical operations. He states
that chloral, especially in large doses, will have this eifect,
and cites the case of a medical man who took 120 grains of
chloral. To all common observation he was dead. There
was no sound of respiration ; it was very difficult to detect
the sounds of the heart ; there was no pulse at the wrist,
and the temperature was 97° F. He had been like this for
some hours, yet he was revived by raising the temperature
of the room to 84° F., and injecting warm milk and water
into the stomach, and he made a perfect recovery.]
Ancssthesia, and especially chloroform or ether anaesthesia,
* Loc. cit., p. 105.
THE UNCERTAINTY OF THE SIGNS OF DEATH 39
may cause a state of apparent death. This state gives way
when appropriate treatment is quickly administered. But
this is a question which rather concerns surgery ; I shall
not go farther into it, except to say that in fatal cases of
chloroform anaesthesia the palpebral reflex is the last to
disappear (Boudin).
In some years' time, Gentlemen, it will be possible to
make a more complete and more scientific classification
than in the outline I have just sketched to you; for I can
only make a rapid review, a somewhat dry nomenclature, at
the present moment. But what has now been known for
some years about the toxic principles which are formed in
the human body — you may call them toxines, ptomaines,
or leucomaines — entitles us to divide them into two groups,
according to their physiological properties; we are able
now to distinguish them either as convtdsives, analogous in
their action to strychnine, or as ancesthetics, reminding us of
chloroform. The experiments which I performed in 1878
with Boutmy showed that ptomaines extracted from the
bodies of those drowned, and injected into frogs, produced
phenomena of both classes.*
It is impossible to deny that in individuals whose pro-
cesses of nutrition are slackened, as they are in hysterical
patients, or whose nutrition is profoundly altered, as it is in
alcoholic subjects, toxic substances may be produced, giving
analogous results. But in the present state of our know-
ledge it is not possible to affirm anything more.
It has been insisted strongly, in reference to this matter,
that in certain acute diseases, such as cholera, plague, or
typhoid fever, there may be prolonged attacks of syncope,
which are easy to confound with apparent death ; M. Dieu-
lafoy's thesis was devoted to this subject. It seems to me
that there need be no fear of confounding these attacks
of syncope with apparent death. In these cases the myo-
cardium is altered ; the heart stops because its muscle is
* Brouardel et Boutmy, ' Ddveloppement des Alcaloides cadavdriques,
Ptomaines ' {Ann. d'Hy^., 1880). ' Des Ptomaines, Reactif propre a las
distinguer des Alcaloides v^gdtaux' {A7in. d'Hyg., 1880). * Conditions du
Developpement des Alcaloides' {Ann. d^Hyg., 1881).
40 THE SIGNS OF DEATH
affected and has yielded : it seems to me difficult to admit
that any state can be met with in those diseases that might
be mistaken for apparent death.
As to syncopal attacks from which persons may and do
revive, they are not usually of sufficient duration to stand
the chance of being mistaken for apparent death.
PREMATURE BURIAL.
There is, then, such a thing as apparent death ; that is to
say, certain conditions may simulate real death. It is im-
possible to say how long such a condition may last, and we
can affirm that it is possible, in a certain number of cases, to
restore to Hfe persons who have been believed to be quite
dead.
Having said so much, I add that in the immense majority
of cases we die after a struggle, by suffocation, by bronchial
over-secretion, but after a more or less long and painful
scene. In these cases, death does not raise any doubt.
Allied to this question of apparent death, which has
excited men's minds ever since Winslow raised it, there is
another which is grafted upon it, and which has always
occupied public attention. Petitions have been presented
to Parliament, elaborate reports have twice been issued,
and I myself am intrusted at the present time with the
preparation of a third. The question is this : Can an indi-
vidual, after being buried while in a state of apparent death,
come to life again in the grave ? Except Dr. Roger's case,
which I have narrated already, none of the cases reported
as such are very conclusive. The newspapers describe them ;
but no medical man has been a witness. When I read of
such a case in the newspaper, I make an inquiry — as
Bouchut, M. Tourdes, and M. Armaingaud used to do ; I
write to the mayor or to the medical officer of health {offlcier
de sante), and ask him if the facts are genuine. The reply I
am wont to receive is that the story is quite unknown in
that part of the country whence it is supposed to have come,
or that the person mentioned is not dead and has not been
placed in a coffin.
Nevertheless, I should not like to affirm that a person
PREMATURE BURIAL 41
might not be buried while in the state of apparent death.
If he were to return to himself, how long could life be main-
tained in the coffin ? In an ordinary coffin, with a glass lid,
a dog lived for five or six hours ; but a dog occupies much
less space than a man ; the latter, after being once shut up
in his coffin, has scarcely 3 J cubic feet of air; he might
therefore be able to breathe for twenty minutes. I do not
wish any one to pass such a dreadful twenty minutes.
This calculation is based on the average respiratory
activity ; in persons whose nutrition is conducted more
slowly than in others, such as the hysterical subjects of
whom we have spoken, survival might be much longer.
LECTURE III.
THE SIGNS OF DEATH.
Gentlemen, — We come now to the study of the signs of
death, those signs which will enable us to avoid the errors
which I have pointed out to you as possible. How can they
be determined, and whose duty is it to prove their existence?
I shall divide these signs into two classes : those which
show themselves immediately after death, and those which
do not appear for some hours afterwards, such as rigor
mortis and putrefaction.
Gentlemen, every author who has taken up the question
has endeavoured to bring to light a pathognomonic sign
which shall enable us to certify death in the earliest moment
after life has departed. There is no more any patho-
gnomonic sign to determine the moment of death than there
is to estabHsh the diagnosis of typhoid fever. Just as in the
latter it is a combination of symptoms observed (headache,
epistaxis, fever, diarrhoea, rose spots, etc.) which make the
diagnosis sure, so in the case of death it is a collection of
signs which gives the physician absolute certainty, and he
alone can estimate their value. Let us see what the different
signs are, so that we may examine them seriatim. In the
first hours we have only negative signs, we notice the abolition
of the bodily functions ; intelligence is abolished after death,
but so it is in syncope.
INSENSIBILITY.
This is general and complete, but certain hysterical sub-
jects, or persons in whom there is general anaesthesia, pre-
sent the same phenomenon. Here, then, is one cause of error,
INSENSIBILITY 43
which is all the greater inasmuch as Charcot has shown that
these anaesthetic individuals may be pricked with pins with^
out a drop of blood escaping, unless a large vein be pierced.
Josat invented a pair of forceps with claws, with which he
proposed to pinch the nipples of persons whose death has
to be ascertained. Josat obtained the first prize of the
Academy, but Briquet, repeating the same tests on the
hysterical subjects under his care, proved that they did not
react under Josat's forceps any more than the dead.
Analogous experiments have been made on all the senses.
Hearing. — It has been the custom for women to be placed
around the dead man's bed, to cry and howl, with the object
of waking the dead if he were so only in appearance. This
custom, which dates from the remotest antiquity, is still
practised in some of the departments of the South of France.
Smell. — By passing beneath the nose of the body the
strongest and most offensive perfumes. (In this respect
allow me to remind you that a small drop of ether, thrown
high enough up into the nostrils, rouses a person from
tolerably profound syncope.)
The reactions of the eye have been closely studied. Even
quite recently a learned man discoursed at the Institute
about a certain sign of death, viz., the immediate lessening
of tension of the globe of the eye at the moment of death,
due to the cessation of circulation and emptying of the
vessels. It proves that the heart is not beating, but not
that the person is dead. The iris undergoes modifications.
During the death-struggle, and at the moment of death, the
pupil dilates, even so as almost to disappear completely,
then it gradually returns to its normal midway position ; and
as the eye loses more and more of its tension, the iris is
thrown into folds. Bouchut, who has taken great interest
in these questions,* has observed that atropine and eserine
have no effect after death. Too much importance must not
be attached to these signs ; if the ocular tension persist, it
is not necessarily because life remains. For in the drowned,
owing to the imbibition and absorption of water, tension is
■^ Bouchut, ' Les Signes de la Mort et les Moyens de prdvenir les
Inhumations prematurees.' 3rd edition. Paris, 1883.
44 THE SIGNS OF DEATH
often increased, the eyeball being harder than in the normal
condition.
A method of recognizing death has been borrowed from
the saleswomen at the markets. When these women buy a
fowl or a fish, they look at its eye ; it shows a speck on the
sclerotic which gives the eye the appearance of parchment,
and this is all the more plainly visible the longer the time
that has elapsed since death. A man dies with his eyes
half shut, and an attendant closes them completely. If the
lids had remained open, you would see that the conjunctiva
and sclerotic presented a very characteristic brown hue.
M. Larcher,* of Passy, has insisted strongly on this sign.
Allow me to say a word or two about a plan that was
urged on a particular occasion, and which made some stir
in forensic medicine. It was affirmed that in persons
dying suddenly, the eye preserved the impression of objects
which were in front of it. Photographs of the retina of a
person supposed to have been murdered were shown to the
Society of Legal Medicine. It is said that these photo-
graphs reproduced the figures of a man and a dog in the act
of springing and making the attack to which the individual
had succumbed.*!* These images, which were said to be so
clear, were really extraordinarily vague, and yet in his
report, M. Vernois was quite positive about them. Kuhne
of Heidelberg has repeated the experiment. I have seen
some of his photographs, and some of them are very distinct.
He placed a grating in front of a rabbit, then killed the
animal rapidly and removed its eye, exposed the retina and
photographed it. In the print the transverse and vertical
bars of the grating may be recognized. He has endeavoured
also to reproduce a fence and a chair ; but even when set in
the full sunshine these objects gave only very indistinct images.
Many obstacles besides stand in the way of these experi-
mental results ever having a practical use in forensic medi-
cine ; the animal must as a matter of fact be killed rapidly,
* Larcher, ' De la Rigidit^ cadavdrique et d'un nouveau Signe de le
Mort (Tache scldroticale) ' {Ann. cPHyg.^ 1869, tome xxxi., p. 468).
t Vernois, 'Application de la Photographie k la M^decine legale:
Rapport sur une communication de M. le Dr. Bourion' {Attn. d'Hyg. et
de Medecine legale., 1870, tome xxxiii., p. 239).
MOTILITY 45
and the retina must be photographed immediately after death.
These conditions are hardly to be realized in forensic medi-
cine ; and though these results in animals may have some
little weight, we cannot admit that we should find, twenty-
four or forty-eight hours after death, any copy on the retina
of a murdered man of the last scene of the fatal drama.
MOTILITY.
The immobility of death has been considered a classi-
cal sign ; and the same importance has been attributed
to the falling of the lower jaw, which immediately follows
the moment of death, and the occurrence of which is pre-
vented before rigor mortis sets in by the application of a
bandage round the head. This sign is not constant ; death
may take place with the mouth closed in tetanus, poisoning
by strychnine and hysteria.
[This point of verisimilitude is frequently overlooked by
actors on the stage. In a performance of 'Julius Caesar'
at Her Majesty's Theatre, a few years ago, Caesar's body,
after he was stabbed and supposed to be dead, lay supine,
and with the mouth closely shut. It was difficult to believe
that he was not shamming.]
A young man called one day at a chemist's, whose identity,
happily for him, has never been traced, to ask for some
strychnine to kill his cat. The chemist supplied him with
the strychnine ; but the young man changed his mind when
he reached home, and no longer wished to kill the cat ! Before
shutting up the strychnine which the chemist had given him
in a drawer, he thought he would like to see what the powder
tasted like ; so he wetted his finger, dipped it in the powder,
and licked it ; he died in the midst of horrible convulsions,
with the jaws closed and the biceps and psoas muscles
globular and contracted.
[Not only may rigidity come on immediately after death
from strychnine poisoning, but it may also persist for an
unusually long time. At the trial of Walter Horsford for
the murder by strychnine poisoning of Annie Holmes, on
January 7, 1898, Dr. Stevenson stated that he found the
fingers and legs rigid at the exhumation of the body on
46 THE SIGNS OF DEATH
January 26, nineteen days after death, and that he had met
with a similar condition in the case of Matilda Clover, who
was poisoned by strychnine (by * Dr.' Neil Cream) a few years
before.]
Gentlemen, when a person dies he usually falls flat on the
ground, though not invariably ; the exceptions have nearly all
been observed on the field of battle. When the cervical
part of the spinal cord is injured a little below the bulb, the
individual struck may preserve his attitude, so as to be, as it
were, transformed into a statue, if, at the moment of being
struck, he is in equilibrium. I can give you as an example
the case of an English Colonel charging at Inkermann at the
head of his regiment, sword in hand. His head was carried
away by a cannon-ball ; nevertheless he continued the act of
charging, firmly seated on his horse, which bore him into
camp with the rest of the regiment. The fact was published
at the time, but some doubts were raised as to its authen-
ticity, whereupon one of the military surgeons who was
present at the battle of the Alma produced the photograph
of a Turk who was killed when he was in the act of saying
his prayers, and who had been found on his knees with his
hands joined together, fixed in the position in which he was
struck.
[An almost exactly similar instance was narrated to me
by an old pensioner who had fought in the battle of Chillian-
wallah in 1849. A dragoon a few files off had his head shot
away, and * he remained sitting on his horse till he was
pulled off.']
During the American War of Secession, a trooper from
the Potomac was surprised at the moment of mounting his
horse ; he was hit by a ball, which injured the spinal cord
in the neck ; he remained upright and motionless in the
position in which he was struck,- with one foot in the
stirrup and his hand on the mane of his horse, which had
not stirred. He was photographed in this attitude.
A French soldier was found, during the war of 1870,
sitting on the edge of a stream drinking out of his can.
This soldier had been beheaded by a cannon-ball ; the lower
jaw was disarticulated and hung down on his neck.
MOTILITY 47
Wounds of the cervical cord may therefore induce com-
plete rigidity of the corpse, and stability in the position
which the wounded man occupied at the moment of his
death.
The same fact happened at Bazeilles, but from a different
lesion. A Prussian foot-soldier was photographed while
about to shoot, his gun being supported on an iron bar.
This soldier had a large wound in his belly, but the spinal
cord was untouched. He had doubtless died by inhibition ;
it is the only instance of the kind that I know.
[Several instances of this phenomenon have been met with
after sudden death from violence in civil life. It appears
usually, if not always, that in such cases the limbs or muscles
remaining rigid after death had been in a state of active
contraction or tension at the time of death, and that death
had been instantaneous. The retention of a weapon in a
suicide's hand is of course well known.]
We ought to collect all these cases, for they may have
their application in forensic medicine.
It is stated by some old authors that an individual
sometimes dies wearing on his face the expression of the
sentiments he felt at the moment of death. Fodere has
gone much farther. He has attempted to distinguish between
suicide and murder by means of this test. I have often
wished to verify the fact. Gentlemen, but I have never been
able to find the slightest proof of such a thing. There
probably are psychical phenomena in these cases, but they
are on the part of the medical man, not of the victim.
This is especially true v^hen an execution takes place.
Owing to the circumstances of the case, the local sur-
roundings, the displacement of property, the blood spilt,
and the attitude of the victim, a singular sensation is aroused
which impresses the event on the mind of the physician.
[Frank Wilkeson,* who fought in the army of the Potomac
in the United States Civil War, observed several such cases,
and reflected on what he saw ; he says (p. i6o) : ' A man a
few files to my left dropped dead, shot just above the right
■^ ' The Soldier in Battle/ London, 1896, which contains a chapter on
' How Men die in Battle.'
48 THE SIGNS OF DEATH
eye. He did not groan or sigh, or make the slightest
physical movement, except that his chest heaved a few
times. The life went out of his face instantly, leaving it
without a particle of expression. It was plastic, and, as the
facial muscles contracted, it took many shapes. When this
man's body became cold, and his face hardened, it was
horribly distorted, as if he had suffered intensely. Any
person who had not seen him killed would have said that he
had endured supreme agony before death released him. . . .
I have seen dead soldiers' faces wreathed in smiles, and
heard their comrades say that they had died happy. I do
not believe that the face of a dead soldier, lying on a battle-
field, ever truthfully indicates the mental or physical
anguish or peacefulness of mind which he suffered or en-
joyed before his death. The face is plastic after death, and
as the facial muscles cool and contract they draw the face
into many shapes. Sometimes the dead smile, again they
stare with glassy eyes and lolling tongues and dreadfully
distorted visages at you. It goes for nothing. One death
was as painless as the other.']
I have spoken to you of the Pranzini case {vide p. 3). When
I saw the victims, it seemed to me that the countenance of
Marie Regnault had an expression of indescribable horror ;
she simply had her eyes open, and their fixity was most
impressive. It is necessary to warn you. Gentlemen, against
relying too much on this first impression when you are
summoned to make a medico-legal examination. In such
circumstances have a photograph taken of the victim, for
by photography only will you be able to get the magistrate
and jurymen to share your opinion, and it will enable you
to review your first ideas coolly. Photography has now
become a very commonplace art. Get a photographer to
accompany you in your proceedings whenever you can. A
photograph gives the exact appearance of a wound better
than all technical descriptions.
Muscular immobility is attended with relaxation of the
sphincters. Muscular contractility lasts for some time yet ;
then it disappears, and cannot be aroused again even by
means of electricity. When Ruhmkorff invented his coil, it
MOTILITY 49
was thought that this might perhaps serve to furnish a
certain sign of death ; the Senate was flooded with petitions
that experiments should be instituted ; people even went so
far as to demand that the priests might keep a Ruhmkorff's
coil in every church, and test the muscular contractility of
every corpse before proceeding with the funeral ceremonies.
These experiments would have serious inconveniences, the
least of which would be the ignorance of the priests charged
to carry them out, and I do not want to insist on the
childish and uncertain character of the test.
[Sir B. W. Richardson* attached comparatively great
importance to the absence of muscular contraction under
electric stimulus ; but it must be remembered that electric
excitability lasts for some time after death — usually for a
few hours — until rigor mortis sets in. However, if there is
a reaction, the evidence is presumptive of life; if there is
not, the evidence is strongly, but not absolutely, affirmative
of death.]
Dr. Collongues-|- attaches great importance to * dynamos-
copy '; he affirms that, when you put into your ear the finger
of a living person, two noises can be heard distinctly, two
shght rolling sounds produced by the muscular system.
When these sounds disappear, the individual is dead.
Gentlemen, leaving aside the fact that it is not very
pleasant to introduce a dead person's finger into one's
auditory passage, there are two sources of error : (i) When
you put a living finger into your ear, you can hear a number
of sounds which I would compare to the humming or
buzzing which is produced by holding a shell to the auditory
meatus ; (2) when the finger is dead, these noises may be
almost the same if the finger is not placed in the right
position.
RESPIRATION.
Abolition of respiration is the most untrustworthy of all
the signs which have been invoked. You know the test of
placing a mirror before the lips of the corpse ; perhaps you
* Loc. cit.
t Collongues, 'Traite de Dynamoscopie.' Paris, 1862.
4
50 THE SIGNS OF DEATH
do not know that of the glass of water, full to the brim,
placed on the hollow of the epigastrium, which was extolled
by Winslow. He held that if the water ran over, the indi-
vidual was not dead.
Winslow either forgot or did not know that rhythmical
contractions of the diaphragm persist after death ; these
may provoke evacuation of gases, and even hiccough, as a
result of which the mirror becomes soiled and the glass
upset.
[On the other hand, life may persist for a time though
the respiratory movements are completely in abeyance —
e.g.y in catalepsy, shock or deep narcotism.]
CIRCULATION.
I come now. Gentlemen, to the two signs or the
pair of signs which are of chief importance, i.e., the
cessation of circulation and the temperature phenomena
which ensue upon death. In former times one used to fee]
the pulse of the dying man, and when the beat of the radial
artery could no longer be felt, it used to be said, * It is all
over ; the patient is dead.' Bouchut,* who has studied all
these questions with great care, has rightly said that one
must not be satisfied with feeling the pulse, but must gc
higher, and consult the heart also. In a memoir published
by him, and submitted to the Academy of Science, he states
that an interruption of the action of the heart lasting foi
two minutes was sufficient to render the diagnosis of death
certain. Andral, who was appointed to report on Bouchut's
memoir, believed that this interruption should be prolonged
for five minutes. Later on he was obliged to acknowledge
that even this length of time was inadequate, since in the
interval he had met with a woman who returned to life some
hours after the action of the heart had ceased to be per-
ceptible ; it is true that a few contractions could be perceived
from time to time, but they vanished, to reappear later.
Bouchut thinks the heart should be listened to for half ar
hour. There are at least two sources of error there. Gentle-
* Bouchut, ' Les Signes de la Mort et les Moyens de pr^venir lej
Inhumations prdmatur^es.' 3rd edition. Paris, 1883.
CIRCULATION 51
men ; you cannot listen to a heart for half an hour con-
tinuously. Try to do so ; in five or six minutes you will
hear buzzings and murmurs of all sorts, and at last you will
hear the beating of your own heart. A second source of
error is as follows : When an animal is dying, and you
practise auscultation, you hear very plainly the two sounds
of the heart, then only one sound, which presently dis-
appears also. If the animal is opened, the heart is found
still beating. Therefore it is essential that the heart
should beat with a certain degree of energy in order that
its beats should be heard. And lastly, without suspecting
the talents of my fellow-practitioners, it is evident that
certain physicians will be able to perceive the beats of the
heart after others can no longer do so. Acuteness of hear-
ing is not the same in everybody ; and when auscultation
is in question, the education of the ear is a very important
factor. It is certain that all of us require to repeat our
apprenticeship in auscultation when we have not been en-
gaged in practice for a time — when we return from a holiday,
for instance. It is a question of the force of daily habit. I
am sure that none of us has an auditory nerve as delicate
and susceptible as that of any clinical professor at Paris.
We must not pay much heed to those experiments, which
may be all very well as tests in the laboratory or in the
hospital, but are not always feasible in the course of practice.
Moreover, the principle itself is merely an assumption ; for
we know that an individual whose heart no longer beats
may survive (vide supra : the two men hanged at Boston and
at Buda-Pesth). The absence of the beats of the heart may
be considered as a sign of apparent death, but not of real
death.
You know the following experiment as it is performed in
the laboratory or in the course of lectures; M. Middeldorf
has ventured to extol it as a certain sign of death. A needle
with a small flag at one end is thrust into an animal's heart ;
this flag waves as long as the heart beats. M. Middeldorf
v/ished to introduce this experiment into practice, and
called it the * akidopeirastic ' method, and he devised for
employment in this way needles 4 inches long, which the
52 THE SIGNS OF DEATH
physician was to thrust into the heart of the person whose
death he had to verify. This method seems to me to be
scarcely applicable in family practice ; objections would be
raised and resistance offered which seem to me to be very
natural.
While still making use of the stoppage of circulation,
other authors have proposed section of the temporal artery.
If the heart were beating, this section would be followed by
a flow of blood ; there would be none in the contrary case.
I think it would be useless to repeat before you the dis-
cussion already set forth on the subject of the movements of
the heart.
Phlebotomy was formerly considered the classical procedure
to determine the reality of death ; the family, and sometimes
the deceased himself, have expressed a wish to have a vein
opened, in order to make sure that no blood would flow.
Gentlemen, venesection of a person just dead yields no
blood. But if, after opening the vein, you do not take the
precaution of fastening a firm bandage over the wound, the
vein will yield some blood in the course of a few hours.
[Sir B. W. Richardson says* that if the blood be found
firmly coagulated in two or three veins, and if a long cord
of coagulum can be drawn out of a vein, the evidence is con-
clusive that death is absolute. He also relates a rather
exceptional case. A lady died suddenly in the country ; he
was called in and opened a vein ; blood flowed as freely as
after an ordinary venesection, though there was no elevation
of the stream, and the blood remained quite fluid for many
hours, and never coagulated firmly. Rigor mortis also was
absent. The same phenomena were repeated five days after
death. Monteverdi's ammonia test is another experiment
on the arterial circulation. If lo minims of liq. ammoniae
(sp. gr. 1090) be injected under the skin, there will be a
reaction in the form of a wine-red erythematous blotch with
raised spots as long as the circulation is going on. If this
has ceased, there will only be a blotch of dirty skin-colour.
Redness of transparent tissues under a strong light is
another, but subordinate, test of the presence of circulation.]
■^ Loc. cit.
CIRCULATION 53
The explanation of this apparently abnormal fact is very
simple. When the individual dies, chemical processes con-
tinue ; fermentation develops gases in the intestines, which,
if the temperature is high, may acquire in twenty-four hours
a tension in the abdomen of an atmosphere and a half.
Under the influence of this tension the diaphragm is pushed
up as far as the third rib, and the blood in the heart, great
vessels, and lungs is driven towards the periphery in the
veins. It is an actual posthumous circulation. At the
moment of death the skin is white. Putrefaction begins ;
the outline of the veins may be seen in blue under the skin,
and if venesection is performed blood escapes, sometimes in
abundance, though it will not coagulate. That is a very
important fact, and in the Middle Ages a singular interpreta-
tion was drawn from it.
[Immediately after death, the lungs contain very little
blood, but by the time that an autopsy is usually made,
several hours afterwards, blood has begun to accumulate
therein, and continues to increase for some time. This fact
has, as far as I know, escaped observation until pointed out
by Dr. C. Daniels of Georgetown, British Guiana.* After
having examined a large number of bodies, excluding cases
of gross pulmonary disease, which would affect the result,
he finds that the average weight of the two lungs in male
adults is as follows :
Under 3 hours after death - . - - 17*6 oz.
3 to 4 „ „ „ .... 25-6 „
4 „ 6 „ „ „ ... - 277 „
7 » 12 „ „ „ .... 29-1 „
13 » 18 „ „ „ . - - - 34-8 „
Over 18 „ „ „ ... - 44-1 „
This result is very striking. The increased weight is of
course due to the presence of excess of fluid in the lungs,
which the writer assigns to loss of elasticity in the pul-
monary tissues.]
You know what was called 'the judgment of God'?
When a corpse was found near a village, and it was im-
possible to detect the murderer, the inhabitants were made
* Lance f, October 7, 1899, p. 961.
54 THE SIGNS OF DEATH
to file before the corpse ; if blood and gas escaped from the
wounds, the person who stood before the body at that
moment was arrested ; that man, it was said, was the
assassin, because the corpse revolted at the sight of him.
This custom prevailed until the reign of Charles V., who
instituted the first medical jurists.
Other difficulties also crop up with respect to phlebotomy.
If bleeding is performed on any one who has just died, the
blood ought not to coagulate, it is said. When blood flows
from a wound made on a person who has just expired, it
may coagulate, but the clot thus obtained resembles currant-
jelly ; it will be treacly, and flow as a liquid on the scalpel.
Between a clot like this and a firm, well-cupped coagulum
obtained from a case of pneumonia, there is an infinity of
degrees, according to the greater or less consistence of the
meshes formed by the network of fibrin. When you perform
phlebotomy thus at the request of the family or of the
deceased himself, who thought that he would in this way
elude the danger of being buried alive, always place a tight
bandage on the arm after opening the vein, so that the blood
expelled by putrefaction may not escape afterwards.
Ligature of the finger has been considered by some to
furnish a certain sign of death. If the individual is alive,
the finger becomes blue ; if he is dead, it does not alter its
colour. This sign indicates whether circulation persists or
not.
[Or a similar test may be applied by compressing the
veins on the back of the hand, to see if they refill. It is one
of the best and readiest tests.]
The same applies to cupping and leeches as to bleeding.
Leeches may suck blood when the posthumous circulation,
of which I have just been speaking, is established. Here
is an example : M. Tourdes pronounced that a certain person
was dead ; however, leeches were applied ; the leeches took,
and the next day, when M. Tourdes returned, three leeches
still held and had drawn a little blood.
These are delicate tests, subject to many fallacies ; pre-
cisely for this reason I do not think they deserve the
semeiotic value which has been attributed to them.
CADAVERIC SUGILLATIONS 55
Decoloration of the Retina, due to the absence of circula-
tion, is a very difficult sign to get evidence of in private
practice.
CADAVERIC SUGILLATIONS.
These are a consequence of the abolition of circulation ;
I do not hesitate to attach great importance to them, with-
out, however, going so far as to say that they constitute an
infallible sign. When we examine a body, we find in the
dependent parts that the skin is covered with violet patches:
which have been called cadaveric sugillations or lividity.
To what can these patches be attributed ? When they
are cut through, it is seen that the little capillary vessels of
the skin are gorged with livid blood ; if, at the end of four
or five hours, a fresh section is made, it will be evident, not
only that the veins contain blood, but also that the colour-
ing matter of the blood has exuded into the tissues around.
Could these blotches be confounded with any other lesions ?
When there is merely venous congestion, it is very difficult
to mistake it for an ecchymosis. Ecchymosis is due, is fact,
to an extravasation of blood ; but even when in a sugillation
there is some effusion of colouring matter of the blood, you
must be but very little acquainted with these phenomena to
mistake it for an ecchymosis. When blood has escaped,
the serum, stained by the colouring matter which has left
the corpuscles, is absorbed by and colours the neighbouring
tissues.
In the instants which immediately follow death, these
sugillations have a great value ; when they are recent, they
may be displaced by turning the body over. The distri-
bution of these patches of lividity indicates the position the
body has occupied for some hours. But if we turn the body
over, the sugillations alter their situation ; they always show
themselves in dependent parts. If death is not recent, and
the tissues are stained by the colouring matter of the blood,
the sugillations no longer shift their place.
Sugillations are constant. In an interesting work pub-
lished by Dr. Mollaud, an inspector of verification of death
56 THE SIGNS OF DEATH
in Paris, he has summarized 15,146 cases observed by him ;
sugillations were not absent once.
Nevertheless, difficulties present themselves here also ; in
the first place, it is not always easy to determine the exist-
ence of lividity ; when there has been abundant haemorrhage
there may be none. M. Mollaud affirms that he has seen
them in women who have died of post-partum haemorrhage,
but in these cases they were not well marked. M. Devergie
is of the same opinion. It is therefore a matter requiring
skill to estimate.
The patches of lividity do not always appear at the same
moment; in persons who have died of haemorrhage they
appear late, and are only slight ; they show themselves five
or six hours after death, when the debatable point is already
settled, and the proof of death is no longer wanting.
On the other hand, they may appear before death in
cholera, uraemia, and asphyxia. In persons attacked with
cholera, for example, the peripheral circulation has ceased.
Magendie was unable to withdraw a single drop of blood
from the radial artery of a cholera patient who lived for
several hours longer. Lividity which appears before death
is due to stasis of blood, i.e., to gravitation, not to an altera-
tion of the corpuscles.
In spite of these reservations, the presence of sugillations
is an important sign.
TEMPERATURE POST-MORTEM.
I come now to the phenomena of heat which ensue after
death. The evidence afforded by the temperature is a sign
of great importance and value. It has been much studied
both in France and abroad, and has been taken up again
within the last few years by M. Bourneville, who has already
written much on the subject.
As everyone knows, when a person dies his body becomes
cold. Nevertheless, De Haen had already remarked that
in the moment of death there was sometimes a rise of
temperature. In certain infective diseases, such as small-
pox and cholera, the rectal temperature may rise from
TEMPERATURE 'POST-MORTEM' 57
3^° to 7° F. This rise of temperature proves that chemical
activity lasts after life has departed ; then, as a sequel to
the rise, there is a lowering of temperature. I do not in-
sist on the chemical theories which have been formulated
to explain these phenomena ; they are of no consequence.
Taylor and Wilks, in England, have tried to find by obser-
vation of the laws of cooling some certain sign of death.*
They noticed that six or eight hours after death the tem-
perature varies from 60° to 80° F., and that twelve hours
after, it varies from 56° to 79° F.
Gentlemen, when a man dies, he may do so under one of
two conditions : either he dies at home or he dies in the
hospital. If he dies in his bed, as soon as he has breathed
his last the bed-coverings are drawn over him, candles are
lighted by the side of his bed, and a fire is kept up for the
sake of ventilation. He remains in the bed wherein he
died ; the mattress, pillows and coverings preserve the heat
for a longer or shorter period of time, and the cooling of
the body is reduced to a minimum.
At the hospital, on the contrary, the dead man is removed
at the end of an hour ; he is enveloped in a shroud, and his
body is laid on an iron table or marble slab in the dead-
house : the rapidity of cooling is at its maximum. Between
these two sets of conditions there is complete opposition.
It is necessary also to take into account a large number of
circumstances which Taylor and Wilks have examined.
ist. The external temperature; the higher this is, the
slower is the cooling, which thus becomes extremely
variable.
2nd. The disease which caused death ; if it has been of
long duration, cooling is slow ; if death was due to haemor-
rhage, cooling will be rapid; if it was from an infective
disease (cholera, tetanus, small-pox), there will be an initial
rise of temperature.
When Alvarengaf published his thermometric observa-
tions, he drew a curve — a somewhat diagrammatic one — of
* Taylor and Wilks, ' Guy's Hospital Reports,' 3rd series, pp. 180-183.
t Alvarenga, ' Precis de la Thermomdtrie gdndrale,' 1871, p. 129.
58 THE SIGNS OF DEATH
these variations. Wunderlich* attributed the post-mortem
rise of temperature in zymotic diseases to rigor mortis ; he
thinks that there are produced at this time thermo-chemical
phenomena identical with those which accompany muscular
contraction. It is useless to discuss this question now.
In 1872 M. Bournevillet found in a person who was picked
up in the street one evening, and carried to the hospital, a
temperature of 8i|° F. It was 11 o'clock at night. The
man was kept warm, and at i a,m, the rectal temperature
was 83° F. He died at 8 a.m. ; five minutes after death the
thermometer rose suddenly to 99° F. This man was not in
a state of drunkenness.
Thus, there are persons who, from drunkenness or from
some other cause, have their peripheral circulation impeded
or abolished : when these persons die, the spasm which
hindered their circulation gives way, and the temperature
rises again. This fact distinctly depreciates the value of
the sign.
In 1878 Dr. GuillemotJ made a study of the same facts in
an excellent thesis which has not as yet had very practical
results. He proved that the axillary and rectal tempera-
tures did not take the same course : the axillary tempera-
ture, which may be regarded as an index of the external or
surface temperature, falls, while the rectal or central
temperature remains the same, or, at any rate, falls but
slowly ; at the end of some hours there is a tendency to
equalization, and Guillemot has found that it was nearly
complete at the end of thirty hours.
We are all familiar with Marey's paradox. A person
placed between two others gives one of his hands to each,
who may disagree about the temperature of the hands they
hold. One of these two persons finds the hand very warm ;
the other one finds it cold. Which is the one who feels it
cold ? It is the warm hand which is chilled, and the cold
one is warmed. After death the periphery of the body
becomes cool, and the cooling is most perceptible in the
* Wunderlich, ArcJiiv der Heilkwide, tome ii., p. 547.
f Bourneville, Gazette des Hopitaux^ 1872, p. 32.
% Guillemot, 'These de 1878.'
1
TEMPERATURE 'POST-MORTEM' 59
axilla. When, therefore, owing to the tension of the gas
which forms in the abdomen, the blood is driven towards
the periphery, this part gets a little warmer ; as I have just
told you, Guillemot assures us that in thirty hours equili-
brium is established between the temperature of the rectum
and that of the periphery ; I do not, of course, speak here of
the case of corpses exposed to the air out of doors.
On October 28, 1893, M. Bourneville stated, and published
with a series of illustrative cases, that the rectal temperature
was lower than that of the surface at the end of twelve or
fourteen hours. These are hospital observations, extremely
interesting and necessary, but which require, in order to
obtain their full value, to be compared with observations
made elsewhere than in the hospitals. It would be neces-
sary to take another series of persons who die in their own
beds ; if this second series gave the same results as the first,
a certain sign of death would be invented. I am well aware
that there are in practice certain material difficulties which
would have to be overcome, the nature of which you can
readily guess. But I add that this sign must be placed in
the front rank ; it is only capable of application in the hands
of a medical man, and it ought to be resorted to in doubtful
cases. Only it will be necessary to take the temperature
twice, at an interval of some hours.
Necrometers or thanatometers have been constructed on
this principle. They are graduated instruments which indi-
cate certain death, probable death, etc., according as the
column of mercury rises or falls to points fixed beforehand.
These instruments cannot be managed by non-medical
persons ; it is the same in using them as in taking the
temperature of patients ; you all know how difficult it is in
practice to take a patient's temperature, and how untrust-
worthy are the figures when it has been taken by the patient
himself or by one of his friends.
PARCHMENT PATCHES.— BURNS.
I wish also to say a few words on the search for parchment
patches. When the epidermis is removed from a greater or
less extent of the skin of a dead body, the exposed cutis
6o THE SIGNS OF DEATH
becomes like parchment in about eight hours, and yields a
sharp sound when tapped with a scalpel. This is not an
easy sign to obtain except in a hospital, and consequently is
not of much practical value.
I shall say as much with regard to hums. Stress has
often been laid on the difference between burns made during
life and those made after death. During life a burn pro-
duces a blister surrounded by a reddish areola, and contain-
ing an albuminous liquid. When the blister breaks, there is
seen beneath it a network of small dilated vessels. Are
these phenomena constant during life ? Is there always
albumen in the serum ? No. When an individual dies at
the moment he is burnt, blisters are produced, but no con-
gestion. When the explosion occurred in the Rue Beranger,
in Paris, Mme. Mathieu perished in an atmosphere the tem-
perature of which exceeded for a moment 3,600° F. The
body was blistered all over, but it was impossible to recog-
nise any reddish areola or congestion of the skin, or any
albumen in the blisters.* That means, in plain terms, that
the individual must have lived longer for these phenomena
to be produced.
In the dead body a burn may cause a blister, but it will
not form an areola. Let a drop of melted sealing-wax fall
on to a limb that has just been amputated, and you will
succeed in producing a blister.
The test of burning is therefore a doubtful sign, and one
against which I would put you on your guard. Consent is
readily given to its employment by the public, and burns
are made — often very severe ones — by applying heated flat-
irons to the heels of dead persons of whose death it is
desired to obtain assurance. On the other hand, revulsives
sometimes take no effect, even while the individual is still
alive. Do not the attendants on a patient say, ' Oh, he is
dead ; the mustard-plasters and blisters do not take any
longer' ? A sign quite as uncertain is that of M. Marteno
of Cordova ; he advises us to apply the flame of a candle at
the distance of half an inch from the extremity of the fingers
* Brouardel, ' Etude medico-legale sur la Combustion du Corps humain '
{Ann. d'Hyg.^ 1878, 2^ sdrie, tome I., p. 509).
PARCHMENT PATCHES.— BURNS 6i
or toes ; if death is real, the epidermis of that part of the
finger exposed to the flame dries up and separates from the
cutis ; it forms an air-bhster, which bursts suddenly with a
disengagement of gas which is sometimes strong enough to
blow the candle out. This is an elegant experiment to per-
form in a course of lectures, but it is scarcely conclusive.
The explosive blister may also be produced during the last
moments of life.
I prefer to use * Mayor's hammer.' It is an ordinary
hammer, which has to be wetted with boiling water, and is
then applied, after being dried, to the hollow of the epigas-
trium. It is an excellent means of reviving a person who
has fallen in a state of syncope. The worst that can happen
is that it m^ay form a bulla on the place where the hammer
touched. This plan may be always tried ; but I should not
like to popularize Marteno's explosive blister.
What conclusions may be drawn from this exposition ?
There exist many excellent signs which enable a medical
man to say : ' This man is actually dead.' However little
doubt a physician may have, still, he ought to make use of
the various tests that have been passed under review, and,
if need be, to wait and not pronounce an opinion until abso-
lute certainty can be obtained.
But when there is no medical man to verify death, it may
happen that persons only apparently dead may be taken to
be really dead. It is therefore necessary, on all grounds, to
entrust the duty of deciding whether a person is dead or not
to a medical man ; for he alone is capable of estimating the
value of the signs, and to make an exact diagnosis, as he
would in the case of a disease.
The conclusion to be drawn from all these facts that we
have estabHshed, Gentlemen, is that the combination of
signs of death gives us almost complete certainty of death,
if we are physicians, if we have thought the question out,
and if we make a diagnosis such as we are not accustomed
to make unless we have learnt to do so in the hospitals.
But I believe that it is right to remain in a state of philo-
sophic doubt ; we know that apparent death may last for a
longer or shorter time, and that in three cases at least (viz..
62 THE SIGNS OF DEATH
the men who were hanged at Boston and Buda-Pesth, and
the woman who was buried, as described by Dr. Roger)
persons considered to be dead have been recalled to life. In
the German mortuary chambers, some of which have been
in existence for more than a century, where every precaution
is taken, where every corpse has a bell-rope placed in its
hand, only once has the bell been rung — the hand of the
corpse shook the cord of the bell at the moment when rigor
mortis passed off, so that the arm fell down.
The verification of death should therefore always be
entrusted to a physician, who alone is competent to esti-
mate the value of the different signs that we have just been
examining together ; I believe that accidents will then be, if
not impossible, at any rate infinitely rare, and I am obliged
to add that though there is a great improbability of a living
person being buried alive under those conditions in which
verification of death is, or, rather, is not, performed, still, it
is impossible to assert that that direful contingency might
not happen.
We thus at last arrive at the same conclusions that were
formulated by the Academy of Medicine with regard to the
competition instituted by the Marquis d'Ourches in 1874.*
In short, said the Academy, the signs of death are certain
enough to render all mistakes impossible, provided that
verification of death by a medical man is made universal
throughout the communes of France, and if the medical
man has skill enough to make the diagnosis. But we are
compelled to acknowledge (i) that in 25,000 out of 36,000
communes (two-thirds of the population) this verification
is not performed at all; (2) that this portion of science
is too much neglected, and that the attention of medical
men is not called with sufficient insistence towards this
branch of diagnosis. Dr. Armaingaudf adopts the same
conclusions.
* Devergie, Ann. d^Hyg.^ 2® s^rie, tome xxvii., p. 293.
t ' (Euvre de rEnseignement ^Idmentaire/ April, 1893.
LECTURE IV.
EIGOR MORTIS.
Gentlemen, — -We have to study two other signs of death,
rigidity and putref action ^ which appear at a later period.
These two signs are almost incontrovertible.
When we meet with putrefaction, there can no longer be
any doubt at all as to the reality of death.
With regard to rigor mortis we shall have to make some
reserve, just as we did for the cessation of circulation and
the fall of temperature. When a person is dead, not much
time should be wasted before covering the body with the
burial garments. Rigor mortis^ as all nurses know, would
soon make it impossible to put them on.
Is rigor mortis a constant sign of death ? Louis, who
would have thought it a dishonour to medicine to be unable
to determine the reality of death, states in one of his
memoirs that he found rigor mortis in every one of five
hundred bodies that he had examined. And yet a great
many authors have disputed its constancy.
Haller, who watched by the body of his daughter for
forty-eight hours, declared that he could not discover rigor
mortis in her at any moment. Those who maintain the
constancy of the phenomenon have replied as an objection
that Haller was not really in a proper mood for observing.
Other authors have shown that in still-born children and in
the foetus rigor mortis is often wanting. The partisans of
its constancy have not failed to give as an explanation of
this that rigidity had existed while in the uterus, and that
the foetus had only been expelled when rigidity had passed
away.
64 THE SIGNS OF DEATH
Bichat, who was a first-class observer, stated that rigidity
did not occur in persons suffocated by charcoal. He must
have met with cases in which it was really absent, or in
which it was so slightly marked as to escape detection. In
all the cases of asphyxia by carbonic oxide, or by the fumes
of charcoal, as it is commonly called, on which I have been
called to pronounce an opinion, I have always found very
marked rigor mortis.
Bichat had expressed the same opinion about individuals
struck dead by lightning. M. Tourdes, who has happened
to meet with three cases of death by lightning, has testified
to the presence of rigidity in all of them. We may say, then,
that rigor mortis is a nearly constant phenomenon in adults,
but it may be so slightly marked in certain cases as to escape
the notice of the most painstaking observer.
When rigidity is complete, the corpse may be moved like
a plank ; the body takes a characteristic position : the lower
limbs are extended, the upper limbs semi-flexed, the hands
clenched ; this is the attitude which Devergie has called
*the attitude of combat.'
Rigor mortis is often of extreme intensity ; it is sometimes
impossible to flex the thigh on the pelvis, or to separate the
jaws.
Two interesting points must be noted. The rigidity and
muscular contraction may be so great that, even without
making extension, the muscular fibres are ruptured here and
there ; it is a tearing of isolated bundles of fibres. When,
on the contrary, the limb of a frozen body is forcibly
stretched out, ruptures of the muscular tissue are produced
likewise, but these are ruptures of larger masses of muscle,
of irregular shape. M. Tourdes, in order to measure the
intensity of rigidity, introduced discs of stearine between
the jaws of persons just dead. When rigor mortis became
established, the teeth dented the two surfaces of these discs,
and often left marks one-eighth to one-fifth of an inch deep.
This experiment shows that there is a violent contraction
during the production of rigidity.
Murderers sometimes try to take advantage of cadaveric
rigidity. They place a knife or a revolver in the hand of the
RIGOR MORTIS 65
victim, which is about to close. The mag^istrate who has to
take the first evidence has great difficulty in withdrawing the
weapon from the hand stiffened in death ; the presumption
of suicide appears natural. This is a species of simulation
of which it may be useful to forewarn you.
When it is important to know whether the stiffness of a
body is due to rigor mortis, or to any other cause, the best
plan is to attempt to extend the limbs. If rigidity has but
recently set in, the extended arm contracts again, and
returns to its former position. If rigidity is passing away,
the arm remains straight, and contracts no more. This
secondary contraction does not occur in frozen muscles.
At what moment does rigor mortis appear ? That is an
important question for the medical jurist. How many times
have I not read with regret this phrase in medico-legal
reports : * Death must have happened within the last
five or six hours, because rigor mortis has not yet appeared.'
Or this other phrase : * X must have been dead
at least twelve or fourteen hours, since rigor mortis is
present'
Gentlemen, when we have to do with a corpse, uninvaded
as yet by rigor mortis, all we can say is that death happened
not long ago ; it is impossible to fix the time that has elapsed
with exactitude.
Nysten asserted that rigidity appeared as soon as the
bodily heat had disappeared. This is not correct ; it
appears much sooner. Niederkorn found that in 103
corpses observed by him it appeared :
From
2
hours after death
in
2 cases.
2 to 4
45 .»
4 ,, 6
24 »,
6„ 8
18 „
8 „ 10
II M
0 „ 13
3 M
Total 103
In a general way, therefore, it is from the third to the
sixth hour that rigor mortis first appears.
Other authors have made interesting remarks. Brown-
S^quard, for example, in 1848, met with rigidity affecting
5
66 THE SIGNS OF DEATH
the jaw in a patient suffering from typhoid fever a quarter of
an hour before he died. Immediately afterwards it spread
over the whole body ; but it disappeared at the end of thirty
minutes, and did not return.
Gentlemen, when one is performing the experiments of
injecting guinea-pigs and rabbits with septic substances,
capable of setting up fermentation, rigor mortis may be found
setting in a quarter of an hour or longer before death. This
fact should be borne in mind.
Remember, also, what I told you about persons dying
suddenly from injury of the cervical spinal cord ; they pre-
serve in their rigidity the attitude they were in at the
moment they were struck. I did not give you any explana-
tion of this fact, and will not attempt to do so to-day, either.
Lastly, as my own experience has shown, after poisoning by
a large dose of strychnine, rigor mortis follows immediately
upon the phenomena of contracture which existed at the
time the patient died.
[The same condition may be met with after death in a
severe fit of epilepsy.]
With regard to the duration of rigidity, we are also
obliged to make allowance for different influences. It lasts
on an average twenty-four to forty-eight hours. It may,
however, last for a few hours only ; at other times it persists
for five, six, or seven days. Our data with reference to this
subject are very scanty. We know that in exhausted indi-
viduals, such as those dying, of cancer or phthisis, rigor
mortis appears early, but does not last long ; on the con-
trary, in an individual dying while in good health, it appears
late, and is of long duration. These facts are of importance
in forensic medicine. Cadaveric rigidity appears first in the
muscles of the lower jaw, then in those of the neck and eye-
lids, then the lower limbs, and lastly the upper limbs. Too
great importance must not be attached to this particular
order. The only thing needful to remember is this : that
the duration of rigor mortis is nearly the same in each of the
members invaded ; also that the part which was invaded last
will keep it last. Experience has taught us that the muscles
of the fingers, as a matter of fact, preserve their rigidity
RIGOR MORTIS 67
latest. It is possible to infer from these facts an indication,
but no positive evidence, of the moment of death. The
muscles of vegetative life are affected like the rest. Rigidity
of the muscles of the skin, w^hich is, however, of short dura-
tion, gives to this structure the appearance of cutis anserina.
Rigidity of the dartos is very plain. I do not know what
made Casper assert that retraction of the dartos took place
only in those who have been drowned ; nothing is further
from the truth.
The muscles of the intestinal walls may present a certain
degree of rigidity. That of the vesiculcB seminales is constant
and early. Half an hour after the execution of the anarchist
Henry, the two vesicles were as hard as small chestnuts.
Their contraction induces the expulsion of the spermatic
fluid which they contain. When the individual has died
in good health, the spermatozoa contained in the ex-
pelled semen may retain their movements for twenty-four
hours.
[Rigor mortis is well displayed in the spleen. The capa-
city of this organ for rapid enlargement and contraction is
pretty well known. Some observations illustrative of these
points are recorded by Mr. J. Bland Sutton.* He says : * A
wandering spleen, when lying in the belly, extended from the
floor of the pelvis to a point midway between the umbilicus
and the ensiform cartilage. When removed from the body,
it contracted so rapidly that in fifteen minutes its greatest
length was 6 inches, and it weighed little over i pound. It
was left for six hours in a vessel of cold water, and when rigor
mortis was well pronounced the spleen scarcely exceeded its
normal size. This remarkable contractility of the spleen I
was able to study closely in a girl during a splenectomy.
The spleen reached from the diaphragm to the uterus, and
when exposed through an incision in the belly wall looked
a very formidable object. It was withdrawn carefully, and,
unwilling to sacrifice such a large quantity of blood, I had
the spleen gently supported by an assistant for a few minutes.
Exposure to the air acted as a powerful stimulant, and the
* ' Transactions of the Medical Society of London,' vol. xx., p. 96 :
* Remarks on Wandering Spleens.'
5-2
6^ THE SIGNS OF DEATH
contraction was so obvious that, while we watched, the
enormous spleen shrank one-third of its original bulk.' In
this latter case, the contraction was, of course, ante-mortem,
and not due to rigor viortis.^
The muscle of the heart does not escape rigidity. Gentle-
men, all the treatises on medical jurisprudence contain
regrettable errors on this subject. The results of experi-
ments conducted in the laboratory have been falsely applied
to the results of medico-legal autopsies. It has been
attempted to compare the facts of experience with the
results of ingenious experiments.
In a laboratory an animal is killed by means of some toxic
substance or other, the body is immediately opened, and it
is found that the heart is either in systole or diastole.
In a singularly inconsequent way, medical jurists have
attempted to make this same procedure apply to the human
corpse, and have claimed that they can determine, accord-
ing as the heart is in systole or diastole, whether there has
been poisoning by any given substance. But an autopsy is
never performed immediately after death, especially in
medico-legal cases. When there is a question of poisoning,
the time which elapses between the decease and the post-
mortem examination far exceeds twenty-four or forty-eight
hours. A suspicious death gives rise, as a matter of fact, to
rumours that are more or less definite. The attention of
the public prosecutor is drawn to the matter, but he cannot
intervene at once ; he has to obtain evidence before putting
the law in motion. The autopsy does not take place, in
nine cases out of ten, for three weeks, or sometimes a year
or more, after death occurred. When the medical jurist
endeavours, therefore, to draw decided conclusions from
laboratory experiments, he makes a mistake.
When an individual dies, the heart is sometimes in a state
of rigidity. That of the anarchist Henry was in a state of
absolute rigidity half an hour after his execution. It is then
in systole. When the rigidity has passed away, it is in
diastole. In an autopsy which I performed, in conjunction
with M. Vibert, eight hours after death, the heart was in
complete rigidity. When rigidity seizes the cardiac muscle.
RIGOR MORTIS 6g
this contracts, and expels the blood which is within its
cavities. As soon as the rigidity is gone, it is filled afresh,
because it has become distensible.
[The illustrious Harvey had already observed this fact.
He says :* * I have several times opened the breast and
pericardium of a man hanged within two hours after his
execution by hanging, and before the colour had totally left
his face, and in presence of many witnesses, and have
demonstrated the right auricle of the heart and the lungs
distended with blood ; the auricle in particular of the size
of a large man's fist, and so full of blood that it looked as if
it would burst. This great distension, however, had dis-
appeared next day, the body having stiffened and become
cold, and the blood had made its escape through various
channels.']
Refer to the trial of La Pommerais.f Physiologists and
physicians were called to give evidence at the Assize Court.
The president put this question to them : ' When a person
dies from poisoning by digitalis, what appearances does the
heart present ?' Claude Bernard, Vulpian, H. Bouley, and
others did not agree. None of them made any allusion to
the normal rigidity of the heart muscle. You know the facts
of that notorious case. Mme. de Paw was ill. One evening
Dr. Blachez returned home ; his hall-porter and the porter
from a neighbouring house told him that a woman was
dying in the house opposite, and begged him to go and
attend to her. Dr. Blachez, after some hesitation, decided
to go upstairs to see the patient. He saw her, came down-
stairs again, and went to find a police officer, to whom he
communicated his opinion that this woman was dying from
poisoning by digitalis. It is possible that he took into
account, in making his diagnosis, certain information that
was supplied to him by those in attendance on the patient.
Thus, a formal deposition had been made before a magis-
trate, which is very rare. It was known, besides, that
* Second disquisition.
t Tardieu, ' Relation mddico-legale de I'Aflfaire Couty de la Pommerais,
empoisonnement par la Digitaline ' {A?zn. d'Hyg. et de la Mddecine legale,
1864, tome xxii., p. 80).
70 THE SIGNS OF DEATH
Mme. de Paw was the mistress of a medical man, La Pom-
merais, who had effected an insurance on her Hfe some
months before. The law took up the case then with excep-
tional rapidity. A post-mortem was made twenty hours
after death, and the heart was found contracted rigidly in
systole.
Many animals die with the heart in systole, even without
having been poisoned by digitalis. It is the same with
animals into which suspected products obtained from
corpses have been injected. In the discussion which fol-
lowed, M. Hebert, head dispenser of the Hotel-Dieu, made
the remark that frogs and rabbits into which a maceration
of scrapings of the floor had been injected, died with the
heart in systole likewise. This experiment of M. Hebert is
not understood yet. Gentlemen, it contains the germ of the
recent researches on ptomaines. La Pommerais was found
guilty. I am convinced that he was so ; but the scientific
discussions which took place during his trial prove once
again with what reserve we ought to make our affirmations
before the magistrate. The heart behaves after death like
an ordinary muscle ; it undergoes rigor mortis. This rigidity
ceases after a certain time ; but it is quite impossible for us
to assert what its duration is.
It often happens that the magistrate will ask you how
long it is since death occurred. This is a very important
question, for it may serve to assign responsibility. Never
say in your reports, as I have seen done, alas ! too often :
^ Rigor mortis is complete, therefore death took place five
hours ago.' You can say, if rigidity is complete, that death
is recent, but it is difficult to say any more ; and in support
of your assertion you can refer to Niederkorn's table. The
conditions have been studied which affect the development
of rigor mortis. When it is cold, it is said rigidity appears
late, and is prolonged ; with heat it is, on the contrary, early
and brief. Such is the formula which you will find in books
and treatises ; it is properly contradicted by Brown- Sequard.
Claude Bernard, who was not satisfied with words, placed
rabbits in chambers heated to 77° F. Rigidity appeared
slowly, and was prolonged for more than forty-eight hours.
RIGOR MORTIS 71
Claude Bernard's experiments* are thus in apparent con-
tradiction to everyday experience. We shall find the ex-
planation when we come to study sunstroke and heat-
stroke.
Practical experience shows us that in the post-mortem
theatre, with a warm and moist atmosphere, rigidity is
early and short. I admit the truth of this general state-
ment, but I do not dispute Claude Bernard's experiments.
When a dog dies in consequence of sunstroke, it is already
in a state of rigidity, even while it still breathes. It dies
when the heart stops, and this organ becomes rigid imme-
diately. M. Vallinf relates that when he was in Algeria he
opened the bodies of dogs dying from this cause, and that
their hearts yielded a sound when cut like that of a piece of
wood. When people die from sunstroke in India, or even
in Europe — for example, in the case of troops who retire
into a wood to rest, where the air is hot and close — rigidity
appears very late.
In the face of these contradictory results, we must con-
clude that other factors are concerned, which we already
suspect, and which I will indicate to you directly. Devergie
had a formula concerning the duration of rigor mortis which
I must repeat to you. He said : * Winter and summer alike
the figure remains the same ; only in winter it stands for
days, in summer for hours.' Remember this formula, but
do not apply it too rigorously.
Rigor mortis may be produced experimentally in a muscle
by loading it with a weight. Take a dog that has just been
killed, and hang a weight to one of its paws : rigidity will
appear sooner in that paw than in the others.
When animals are fatigued, rigidity appears with rapidity.
It is often noticed in hunting, and in cock-fights where the
animal is exhausted, that rigidity follows immediately upon
death. Some sportsmen maintain that the driven animal
stops stiffened in death. Thus, in overwork rigidity is pre-
cocious and brief, and it may be added that putrefaction
follows quickly.
* Claude Bernard, * Legons sur la Chaleur animale.' Paris, 1876.
t Vallin, Archives de Medecine.
72 THE SIGNS OF DEATH
[Possibly one cause of the early putrefaction of over-
driven animals may be found in the following explanation
given by Dr. Aurel Schulz,* a medical man as well as an
accomplished traveller and hunter of big game in Africa.
When the sportsman discovers that this (exhaustion from
over-driving) is likely to be the case, he must kill the animal
immediately, for now the flesh reaches a stage when further
driving will cause it to decay rapidly after the beast is killed.
This is caused by an interstitial apoplexy of the muscles that
astly facilitates the decomposition of meat, which cannot
be used for making biltong, and consequently becomes value-
less. Nature has provided a good indication when this un-
desirable event is about to take place. The hunter has only
to watch the movements of the animal's tail, which, as long
as he continues fairly fresh, turns and twists about in the
most lively manner, but as soon as the condition of the
beast arrives near spoiling-point, the tail now droops and
hangs down like a limp rag.]
I believe that rigor mortis can teach us nothing of scientific
value in cases of poisoning. The results of different obser-
vations do not agree, and they vary of course according to
the poison that is used, its dose, and the accompanying
circumstances. We have seen that in poisoning by a large
dose of strychnine rigidity may be immediate ; but when
the dose of strychnine absorbed has not produced death
speedily, but has caused a succession of convulsive attacks,
with more or less well-marked intervals of quiescence, and
the individual dies during one of these periods of calm,
rigor mortis does not take place. It would seem that in
such cases the muscles had spent all their force in con-
vulsions. Well-contrived experiments could alone give us
the key to these variations.
Laennec states that rigidity lasts a long while in cases of
sudden death. You will see in the course of these lectures
that the causes of sudden death are too numerous to permit
us to accept this formula. In paralysed persons it is more
marked in the paralysed than in the healthy muscles. In
•^ ' The New Africa,' by A. Schulz, M.D., and A. Hammar. London
i8q7, p. 330.
RIGOR MORTIS 73
childhood and old age, rigidity would appear earlier and last
longer (Louis).
What is rigor mortis, then ? What is its nature ? I will
not say anything about the discussions to which these
questions gave rise in bygone times. Amongst our con-
temporaries, Ktihne of Heidelberg, a former assistant of
Claude Bernard, believes that rigidity is due to the coagula-
tion of myosin, an albuminous substance contained in the
muscular tissue. Brown-Sequard has raised objections to
this theory on the ground that the coagulation of an albu-
minoid substance, however complete it might be, could not
produce in the contracted muscle a rigidity equal to that of
rigor mortis.
MM. Tourdes and Feltz have examined microscopically
muscles in the state of rigidity, but they have found nothing
which distinguishes them from others. Some observers
have shown that muscles present an acid reaction during
rigidity (lactic acid had already been detected in the muscles
of over-worked or over-driven animals) ; the conclusion has
been drawn that the production of rigidity is due to the
transformation of alkaline substances in the muscle into
acids ; but Achtakaweski has proved that in tetanus the
muscles are not acid, and that the injection of an alkali
into the muscular tissue does not prevent rigidity.
Beclard tied all the vessels of a Hmb, and made the
posthumous circulation, of which I have spoken to you, im-
possible, yet rigidity takes place all the same ; moreover, the
nerves have been divided, and rigidity appears nevertheless.
M. Achtakaweski has shown that muscles in tetanic con-
traction had no acid reaction ; M. Laborde has reached the
same conclusion by thrusting steel needles into muscles in a
state of rigidity ; these needles did not become oxidized,
although they did so rapidly under the same conditions
during life. Brown-Sequard removed the spinal cord from
an animal, and found that rigidity was not produced in such
a case. He has drawn from this experiment, which I have
not repeated, conclusions which absolutely contradict those
of Beclard ; is not division of all the nerves equivalent
a priori to removal of the spinal cord ?
74 THE SIGNS OF DEATH
Rigor mortis is probably only one of the first phenomena
of putrefaction, not as regards the sense of smell, but as
regards the chemical processes which cause the muscles to
contract. Herzen* has proved that there is found in the
muscular tissue of a dead animal an acid which he calls
* sarcolactic acid ' ; it is to the action of this that he attri-
butes muscular contraction. By injecting some drops of
this acid into the muscles of dead animals he caused rigor
mortis to appear in cases which had not as yet exhibited it.
To sum up, we may conclude that rigor mortis is an
almost constant sign of death, that it manifests itself in from
three to five hours after death, that it lasts on an average
twenty-four to thirty-six hours, and that it sometimes is
present in an extreme degree of intensity. But the actual
data of science do not allow us, from a medico-legal point of
view, to deduce any positive conclusion. The mode of pro-
duction and the causes of rigidity are still almost unknown
to us ; it is probable, however, that the muscular tissue is
invaded after death by micro-organisms, to the secretions of
which rigidity is due.
■^ Herzen, Semaine medicale^ 1886.
LECTURE V.
PUTREFACTION.
/ Gentlemen, — The study of putrefaction is of great im-*
portance in forensic medicine. It is caused by the persistence
of the chemical phenomena which take place in the human
body after death ; its effect is to alter to a singular degree
the appearances of the lesions resulting from disease or from
wounds.
It produces alterations in the colour, and transports the
blood into regions of the body which were not at all con-
gested during life. There are, then, sources of fallacy for
those medical men who are not accustomed to make
autopsies, and which we must take pains to explain.
Lastly, we may be able, thanks to what we know to-day
of the phenomena of putrefaction, to say to the magistrate :
* The individual, whose body you have laid before me, died
at such and such a time.' The observations of M. Megnin,
who has carefully studied the insects which prey on dead
bodies, and which he has picturesquely styled ' the labourers
of Death,' sometimes allow us to fix the dates with almost
mathematical exactness.
GENERAL THEORY.
From a theoretical point of view, the study of putrefaction
is based on the well-known experiments of M. Pasteur. It
is he who has actually proved to us the non-existence of
spontaneous generation, which F. A. Pouchet, of Rouen,
maintained with much authority. M. Pasteur experimented
76 THE SIGNS OF DEATH
on blood and urine, i.e., the most fermentable or putrescible
of organic liquids. He obtained them from the veins and
the bladder, quite out of contact with the air, by means
of pipettes that had been passed through the flame
of a lamp and then hermetically sealed. These liquids
might be preserved for an indefinite time without ever
becoming tainted by putrefaction. M. Pasteur's experiments
date from 1854, y^t the tubes containing blood and urine,
which he took from the animals forty years ago, still exist in
his laboratory, and their contents have undergone no change.
We are authorized to say, therefore, that organic material
derived from a healthy animal, so long as it is sheltered from
the air, does not putrefy.
Gentlemen, when an individual dies, putrefaction may
affect his body in different ways, according as it takes place
in the open air, underground, in the water, or in a privy.
In order to give an account to you of the phenomena
which follow when putrefaction occurs in the open air, let
us first see what takes place in a blood-clot which has been
obtained by venesection. The clot contracts, and soon
becomes greenish on the surface. Take a drop of this clot
and examine it. You will find in it micro-organisms which
have the effect of liquefying the clot progressively from the
outside to the interior ; you will find evidence of the
existence of colonies of micro-organisms, only able to live
in the presence of oxygen, which are called aerobic. These
aerobic organisms produce carbonic acid, and then they dis-
appear. They are replaced by a second colony of micro-
organisms, able to live either with or without oxygen, i.e.,
aerobic or anaerobic, and which M. Bordas, who has
written a masterly thesis* on the subject, calls ' amphibious '
ifacultatifs) ; these also produce carbonic acid, but hydrogen
and hydrocarbons as well. Lastly, there comes another
category of micro-organisms, the anaerobic class, which do
not live in oxygen, and which produce hydrogen, nitrogen,
and more or less compound ammonias. Remember this
triple evolution ; we shall often refer to it subsequently.
How do these organisms disappear ? They nearly all
•^ Bordas, ' Putrefaction,' 1892.
PUTREFACTION 77
secrete a substance in the presence of which they are unable
to live. Then they disappear, and are replaced by other
colonies, which again are aerobic. The destruction of the
organic substance itself is hastened, moreover, by fungi,
and the different species of insects which have invaded it.
If it were desired to comprise the phenomena of putrefac-
tion in a general formula, it might be said that these
processes constitute the return of organic matter to inorganic
matter, to the mineral kingdom. The aerobic, amphibious,
and anaerobic micro-organisms produce carbonic acid,
hydrogen, nitrogen, and amines. The quaternary or nitro-
genized matters have a manifest tendency to be transformed
into ternary or fatty substances, and these tend to return to
binary compounds. Place a corpse in the water, and by
the end of a certain time you will find that it has undergone
a fatty degeneration. If its sojourn in the water is prolonged,
the body will assume the appearance of a mummy, because
it will have borrowed from the water part of its mineral
constituents.
Daily experience in the laboratory has for a long while
familiarized us with certain facts which may appear singular ;
every one who has occupied himself with bacteriology knows
that according to the media the colonies do or do not
multiply; it is enough to alter the conditions of the soil,
sometimes in the most insignificant way, in order to put a
stop to the proliferation of the bacilli.
When these facts are known, it can be readily imagined
that there may be considerable variations in the phenomena
of putrefaction, according to the temperature, and according
to the nature of the medium in which the organism is under-
going putrefaction. Let us take an everyday example :
If we watch what goes on in a piece of meat exposed to the
open air, we shall see aerobic and amphibious micro-
organisms appear on the cut surface, and these will penetrate
by degrees into the interior of the meat ; then the aerobic
organisms disappear; the amphibious and the anaerobic
organisms secrete diastase, which soaks into the meat and
liquefies it, and putrefaction becomes established. If, on
the contrary, we place the meat in vacuo under a bell-glass
78 THE SIGNS OF DEATH
in which there is a capsule containing sulphuric acid, it will
be preserved for a very long time, for it is withdrawn from
the contact and influence of the external air.
PUTREFACTION IN THE OPEN AIR.
When the body of an adult putrefies in the open air, it is
very evident that the micro-organisms contained in the
atmosphere, which settle on the epidermis, can penetrate
through this and commence the work of putrefaction.
Nevertheless, the epidermis resists their entrance for a long
time, always much longer than the epithelium placed at the
natural orifices.
It is through the alimentary canal that putrefaction chiefly
takes place.
M. Duclaux, who has paid much attention to the vibrios
of the intestines, has succeeded in determining the part they
play in putrefaction. At death they swarm ; they penetrate
into the intestinal glands, come into contact with dead
epithelium, which they destroy, find their way into the
veins and peritoneum, and produce gases there, and secrete
diastase which liquefies the tissues. What is the conse-
quence of this formation of gas and diastase ? The quantity
of gas produced is considerable; its tension is sometimes
equal to that of ij atmospheres ; it also pushes up the
diaphragm to the third intercostal space, and drives the
liquid contained in the deep vessels towards the periphery ;
that is what I have called the posthumous circulation, which
I have already mentioned to you.
Putrefaction is, therefore, especially a function of the
processes which take place in the intestines.
Have these facts any bearing on forensic medicine ?
Certainly. I have quoted once before the case of Barre and
Lebiez. These two individuals, as you know, had murdered
a milk-woman in the Rue d'Hauteville. Lebiez cut off both
the thighs of the victim, and concealed them in a cupboard
in his room in the Rue de Poliveau, near the Salpetriere ;
the trunk of the body was found at Le Mans. MM. G.
Bergeron, Delens, Tillaux, and Faraboeuf were consulted by
PUTREFACTION IN THE OPEN AIR 79
the magistrate, and all thought that the thighs, when they
saw them, had been but recently removed ; they had not
even begun to putrefy.
Gentlemen, it was more than a week after the murder had
been committed. Barre and Lebiez had separated the
thighs before the micro-organisms of the intestines had had
time to act ; we are therefore authorized to say that the
rapidity of putrefaction is in direct proportion to that with
which the gases of the intestines circulate in the organism.
When we have to do with a new-born child, who has
swallowed nothing, do we find the course of events to be the
same ? According to the experiments of MM. Ogier and
Bordas, the course of putrefaction does not follow the same
rules in still-born infants as in adults ; the still-born infant
has not breathed. On the contrary, in a child who has
breathed, and who dies twenty-four hours after coming into
the world, the phenomena of putrefaction are closely similar
to those which are seen in the adult.
There are also some accessory phenomena. Our tissues
contain oxygen, and the quantity of oxygen favours the
development of the first (aerobic) colony.
But when a person dies suffocated by carbonic oxide, his
tissues no longer contain much oxygen, and this first colony
will have great difficulty in gaining a foothold. And thus
we sometimes find in these particular cases astonishing
phenomena of preservation.
Here is an example : An individual hired a room with an
adjoining dark closet, and suffocated himself in that closet.
The owner of the house was not very much astonished at
the disappearance of his lodger ; but, seeing that he did not
return, he decided to let the room anew, after giving it a
thorough cleaning. The new lodger went into the little
closet on the night of his arrival, and found there the body
of his predecessor.
Death had taken place two months previously, and yet
the body did not present any trace of putrefaction. It is
true that it was winter, and that the temperature of the
closet had always been low.
The phenomena of putrefaction vary also, according to
8o THE SIGNS OF DEATH
whether or not there was food in the stomach at the time of
death ; and in cemeteries they are different, according as
the body has been placed in a badly-closed coffin placed in
loose soil, or in a tightly-closed coffin deposited in a moist
soil ; they differ also according as the corpse is placed in a
lead coffin or in one of wood.
Gentlemen, at the Morgue the bodies are sometimes
swollen with gas, especially in the months of May and June.
The bodies of the drowned present these phenomena par-
ticularly ; the swelling and distension may be extreme.
When these gases are diffused abroad they create an
abominable smell. To avoid this tainting of the atmo-
sphere, I prick the bodies to let the gases escape ; then I set
Hght to them at the pricks, and long bluish flames start
forth, like those of a blowpipe. After a time they are
extinguished, either because the tiny orifices become blocked,
or because there is no more inflammable gas.
When putrefaction is more advanced, and there is no
further distension, the gas does not take fire ; in summer
they may be lighted at the end of the first day, and burn for
two, three, or four days. Then the combustibiHty of the
gases ceases.
What has happened, then ? It is very simple, Gentle-
men. At the beginning of putrefaction we have the
aerobic colonies, which produce carbonic acid chiefly ; their
period corresponds to the phase of uninflammability of the
gas ; then come the anaerobic and amphibious colonies of
M. Bordas, which produce hydrogen, carbonic acid, and
hydrocarbons, which are mostly inflammable ; finally, the
reduction becomes more and more complete, and gives rise
to nitrogen, hydrogen, and compound ammonias, the greater
part being incombustible.
Thus we meet in the post-mortem theatre with the three
clearly defined phases which we have already distinguished
in bacteriology.
I ought to cafl your attention, while dealing with these
inflammable gases, to the possibility of the formation of
phosphoretted hydrogen. Before the time when refrige-
rating apparatus were employed at the Morgue, that is
PUTREFACTION IN THE OPEN AIR 8i
to say, prior to 1882, phosphorescence was often noticed
there, especially in warm weather, Wills-o'-the-wisp which
ran over and around the bodies. It was a very impressive
spectacle.
The development of the gases, and the tension which
they cause in the interior of the body, place the medico-legal
expert in a very difficult position when he wishes to discover
the existence of lesions which have preceded death, or those
which have immediately followed it. The colouring matter
of the blood abounds in the corpuscles, stains the serum,
and passes through the vessels and diffuses itself in the
adjacent tissues : hence arise those spots on the mucous
membrane of the stomach which have been taken as
evidence of poisoning, and that infiltration of the posterior
parts of the body which has been taken for ecchymosis.
I have already said something of the liquefaction of the
blood ; I have spoken to you of what was called in the
Middle Ages ' the judgment of God.' The following example
will suffice to put you on your guard against a fallacy of the
importance of which I need not remind you.
A corpse was found in the Gave at Lourdes ; it was
carried into a shed; the hour was 11 o'clock a.m., and the
weather was very warm. The medical man who examined
the body noticed some wounds on the head, which he
thought were caused by stones rolled down by the torrent.
The public prosecutor was notified of the case, and the law
was put in motion ; some hours had passed since the first
observations were made.
From each of the wounds of the head there now flowed
a little liquid blood, and the physician who accompanied the
officers of the court concluded that these wounds were recent.
Investigation showed, on the contrary, that the man had
thrown himself into the Gave (it turned out to be a case of
suicide) the morning before, and that he had been taken
out of the water twenty-four hours after death.
The fiow of blood was due to the posthumous circulation
induced by the formation and accumulation of gas in the
abdominal cavity. This development took place only after
the removal of the body from the cold waters of the Gave.
6
82 THE SIGNS OF DEATH
When there is no wound by which the blood can escape,
a tolerably well-marked congestion is produced in all the
peripheral parts. Devergie, formerly a pupil of Bichat, who
reniained faithful to his master's theories to the very last,
has accumulated a large number of medico-legal cases. In
the introduction accompanying those dealing with submer-
sion, he says that when a man is drowned he dies either
by the brain, by the lung, or by the heart. Devergie has
included in the category of those who died from cerebral
congestion all the drowned in whom there was this post-
humous circulation, and yet Devergie was a scientific man
and a very learned and conscientious observer.
PUTREFACTION IN DIFFERENT MEDIA.
When putrefaction takes place underground, the epidermis
becomes covered with blebs, filled with bloody serum, just
as in putrefaction in the air ; then the epidermis separates
in flakes ; the grave-diggers sometimes think that they hear
a noise in the grave three weeks after burial ; this noise is
due to the bursting of the abdominal wall when distended
by gas. The tension of the gas in the intestines would not
in itself be sufficient to lead to the bursting of the belly, if
the micro-organisms had not already liquefied the tissues,
and so diminished their resistance.
When the body putrefies in the water, the first green
patch which appears does not show itself in the region of
the caicum, as it does when the body putrefies in the open
air, but over the sternum ; I cannot explain to you the cause
of this variation. It is much more important to know that,
in spite of the difference of the medium, the phenomena of
putrefaction, as far as the production of gases and their
order of succession are concerned, are nearly the same, since
these phenomena are determined by what takes place in the
intestines. Only, as the body sooner acquires the surround-
ing temperature in the water, the phenomena of putrefaction
will be hastened or retarded according as the water is warm
or cold. Devergie was accustomed to say that in summer a
corpse took as many hours to putrefy in the water as it took
days in the open air.
PUTREFACTION IN DIFFERENT 'MEDIA ' 83
Hofmann estimates that putrefaction is twice as rapid in
air as in water.
It may be conveniently remarked here that during sub-
mersion the water penetrates abundantly into the blood,*
that this coagulates but little or not at ail, and that the
phenomena of posthumous circulation are found at their
maximum in the bodies of the drowned ; also, when the
bodies of the drowned are withdrawn from the water, putre-
faction takes place with extreme rapidity.
Bodies more frequently undergo transformation into fatty
matter in the water than in the open air ; this transforma-
tion is sometimes complete by the end of five or six months.
If it had remained exposed in the open air, the corpse might
have been putrefied before so long a time had elapsed ; if it
had been placed in the earth, it would be necessary to take
into consideration the state of the coffin and of the soil ;
putrefaction might be hastened or retarded thereby. In
the water the phenomena of putrefaction follow the same
evolutionary course as those of fermentation within the
intestines. The Fenayrou case affords a demonstration of
this. A druggist named Aubert was murdered in the
country by a husband and wife of the name of Fenayrou,
assisted by their brother. To get rid of the corpse, they
threw it into the Seine, after having enclosed it in a piece
of lead pipe. They hoped that thus it would stay at the
bottom of the water. Three days afterwards Aubert floated,
though still enclosed in the lead pipe.
An enormous quantity of lead would be requisite to
prevent a body from rising to the surface ; the only means
of keeping it at the bottom would be to open the abdomen
and perforate the intestines ; in this way the gases would
escape as soon as they are produced.
It happens often enough. Gentlemen, that the medico-
legal expert is called upon to investigate putrefaction in
bodies that have been thrown into a privy ; the bodies of
new-born children are very often thus met with, though it
would be scarcely possible to find records of seven or eight
such cases in adults.
* Brouardel and Vibert, Ann. d'Hyg.^ 3* s^rie, tome iv., p. 452.
6—2
84 THE SIGNS OF DEATH
When the privy is bady ventilated, and the air is only
renewed with difficulty, and when nothing is cast in except
urine and faeces, the phenomena of putrefaction go on slowly
therein. Bodies buried in a thick layer of such matter are
sometimes taken out, at the end of five or six months,
intact, without presenting any sign of decomposition what-
ever ; the colonies of microbes seem to have been failures ;
these facts have been observed especially in new-born
infants. But when a good current of air passes through
the cesspool, and plenty of water, especially soapy water, is
thrown in ; when the seat, as is often the case in the country,
is pierced with several holes, which consequently allow a
free influx of air, putrefaction follows the same course as in
the water or the open air. Remember this fact simply :
that in certain conditions putrefaction may be retarded,
and that Tardieu managed to detect in the body of a new-
born child that had lain in a cesspool for three months, spots
of ecchymosis on the pleura and pericardium, spots which
have been called * Tardieu's spots,' and which prove, ac-
cording to him, that death took place by suffocation. The
little body was not putrefied.
CADAVERIC ALKALOIDS.
Gentlemen, during the time that putrefaction is taking
place, a certain number of toxic products — cadaveric alka-
loids— are produced in the interior of the organism.
The first medico-legal researches were made by Selmi of
Boulogne, with regard to the supposed poisoning of a
General. The medico-legal expert had concluded that there
had been poisoning by delphinine. Selmi repeated the
experiments, and found that it was sufficient to allow meat
to putrefy in the open air in order to obtain from it this
supposed delphinine. He pursued his investigations and
isolated some other alkaloids ; these are very volatile, and
consequently there is some danger that they maybe absorbed
in respiration. In 1872, M. Armand Gautier, studying with
quite a different object, and merely as a chemical question,
the decomposition of albuminoid matters, had already shown
that that decomposition gave rise to toxic substances.
PUTREFACTION— CADA VERIC ALKALOIDS 85
I myself witnessed the following occurrence in conjunc-
tion with M. Boutmy, and I was absolutely ignorant at the
time of M. Arm. Gautier's experiments :
A woman who sold poultry in the market, having a
stuffed hen-turkey that had not been sold, and which she
feared would be spoilt, invited her friends and relations to
eat it with her. Twelve persons partook of that repast,
and no one noticed any peculiar smell or flavour about the
turkey. The woman herself, who had not eaten more than
her guests, was taken ill in the night and died. Her guests
also became ill, but none of them died.
We were appointed by the magistrate to make an in-
vestigation. We found in the stuffing inside the turkey a
product analogous to conicine, and we met with the same
product in the viscera of the dead woman.
I repeat that this woman had not eaten more of the
turkey than the rest, but at the autopsy we discovered that
the kidneys were diseased, and unable to eliminate the
toxines.
Those alkaloids which are found in the body after death
are called ptomaines ; those which are generated in the body
before death are called leucomaines, and have been described
by M. Gautier.
In former times. Gentlemen, when people were taken ill
after having swallowed any articles of food, the cooking
utensils were always blamed ; the copper saucepans were
badly tinned, and the acetate of copper set at liberty during
the preparation of the food was said to be the culpable
agent.
It is a curious fact that this idea of poisoning by copper
owes its origin to Jean Jacques Rousseau. You know how
fashionable his ideas were for a certain period ; you know
the infatuation they created. It is not very wonderful,
therefore, that the opinions he professed on the injurious-
ness of copper should have gained acceptance. Neverthe-
less, it has been forgotten that the ancients did their cooking
in copper vessels. The tinning of copper saucepans was
only introduced, into the West of Europe at any rate, by
the gipsies, who were the first to line the interior of copper
86 THE SIGNS OF DEATH
vessels with tin more or less pure. Lastly, at all times,
and even to-day, certain culinary preparations are only
made in untinned pans. Such is the case with preserves,
which have never poisoned anybody yet, and yet which are
capable — for example, when preserves of currants are being
made — of producing soluble salts of copper.
We know now that copper utensils are quite harmless so
long as they are kept in good order.
When the writings of MM. Selmi, Armand Gautier,
Boutmy and myself, had been published,"^ a German
named Brieger made a very complete study of ptomaines.
He divided them into two classes : the first in which neurine
predominates, and whose action is convulsive ; the second
in which other substances are more abundant, and which
have a narcotic action.
The important point to remember about this classification
is that certain ptomaines come into existence at the same
time that the inflammable gases of which I was lately
speaking to you are formed, and that these ptomaines pro-
duce exactly the same effects as strychnine and its salts.
This identity may become a source of fallacy, against which
you ought to be on your guard.
A second point, not less important to grasp, is that cer-
tain toxic alkaloids, to which M. Gautier has given the name
of leucomaines, may be developed during life in the course
of certain maladies. Here are some examples :
In 1881, when the cholera epidemic raged in Paris, M.
Gabriel Pouchet had arranged a series of experiments on
the urine and dejecta of cholera patients. He had suc-
ceeded in extracting from these organic substances a certain
number of alkaloids, which Vulpian brought before the
Institute in his name. At the very moment when M. Pouchet
had enclosed the products of his experiments in hermetically
sealed tubes to be forwarded to Vulpian, he himself felt
indisposed, and became very ill. He had dilatation of the
* Brouardel and Boutmy, ' Sur le Ddveloppement des Alcaloides
c adavdriques, Ptomaines ' {Ann. d' Hyg.^ 1880) ; ' Des Ptomaines, React if
propre k les disiinguer des Alcaloides vegdtaux' {Ann. d'Hyg., 1880);
'Conditions du D^veloppement des Ptomaines' {Ann. d'Hyg.^ 1881).
PUTREFACTION— CADAVERIC ALKALOIDS 87
pupils, suppression of urine, aphonia, cramps in the ex-
tremities, and, in a word, all the symptoms of cholera
except vomiting and diarrhoea. He had been poisoned by
the products manufactured in his own laboratory by those
alkaloids which he had isolated, and which are very volatile,
and not by any substances developed in the intestines.
When he became convalescent he had albuminuria and
glycosuria, just like patients recovering from cholera.
This is not the whole of the story. Gentlemen, for when
M. Pouchet returned to his laboratory, he asked what had
become of his assistant and laboratory servant. He was
told that both had been suffering from the same sort of
illness that he had. Like him, they had been poisoned by
the extremely volatile products extracted from cholera
dejecta.
There exists a certain class of lunatics, among those who
suffer from melancholia, who scarcely ever have their bowels
moved ; their temperature is subnormal, their extremities
cyanotic, and their life extremely sluggish, almost vegetative.
Their urine contains a considerable quantity of alkaloids.
I will not pursue this subject further. Gentlemen ; I only
want you to appreciate that there is from the point of view
of the future study of mental alienation a very interesting
suggestion contained herein, which you will do well to bear
in mind, and even to grasp thoroughly.
Here is another case. A druggist, who does not wish his
name to be made public, married. During his wedding
night, his young wife had an epileptic seizure : the attacks
recurred. The husband analysed his wife's urine before,
during, and after the attacks ; when the attack was coming
on, the urine always contained an enormous quantity of
ptomaines or leucomaines.
Finally, Gentlemen, the existence of these alkaloids has
been demonstrated in various kinds of spirits, and not only
in those spirits derived from grain, potatoes, etc., whose
quality leaves something to be desired, but even in brandy
distilled from fruit or grapes. You have heard mention
made more than once in medical jurisprudence of cases of
poisoning by ingestion of pork in various forms or of tainted
88 THE SIGNS OF DEATH
meat. There is something peculiar about these fatalities :
wherever they have been observed, v^hether in France,
England, Austria, Belgium, Germany, etc., they take place
chiefly from April 15 to June i, and from September i to
October 12.
How is the production of these accidents to be explained ?
In certain towns of the North of France the working classes
are accustomed to eat at their evening meal meat in the
form of sausage spread on bread. One day at Lille seventy
persons fell ill, and seven or eight of them died, after having
eaten some pork that was all bought at the same pork-
butcher's. The symptoms observed resembled those of
cholera.
Being sent to Lille on a commission of inquiry, I noted in
all the patients whom I visited — and there were about fifty
of them — dilatation of the pupils, headache, some digestive
derangement and extreme prostration. The investigation
revealed the following facts : Two pork-butchers had pur-
chased a pig, but whereas the customers of one all fell ill after
eating sausages made of the flesh of one half of the carcass,
the customers of the other remained absolutely free from
anything of the sort. It could not therefore be the previous
condition of the pig that was to blame ; the shop, the stall,
and the workshop of the butcher were clean and in good
order. It was necessary to search further. The pig had
been killed on a Friday, a day on which the pork-butchers'
shops are closed at Lille. The meat had been exposed for
sale on Saturday, May igth, and Sunday, May 20th, and
none of the buyers suffered at all. Those, however, who
bought sausages on Monday and Tuesday (May 21st and
22nd) were all taken ill, and four of them died. The law
interfered, and the sausage-meat was withdrawn from sale
on the Wednesday. On that day and the day following the
pork-butcher, not wishing to lose his goods, fed himself and
his household on the remains of the pork, and no mishap
followed.
We find identical facts in a case related by an Irish
physician ; instead of sausage-meat, pork-pies were in ques-
tion, but the events occurred in absolutely the same fashion.
PUTREFACTION— CADA VERIC ALKALOIDS 89
The fact is, Gentlemen, that the toxic alkaloids only e'xist
for one or two days (they were not as yet formed on the
Saturday and Sunday, and had quite disappeared on the
Wednesday and Thursday) ; there is a temporary virulence;
they in no way modify the odour or aspect of the meatj and
nothing can reveal to the inspector the existence of any
fermentation.
Facts like those which took place at Lille are not rare,
and epidemics caused by ptomaine-poisoning, which have
lasted only a week or ten days, have been described more
than once under the name of epidemics of cholera or
typhoid fever.
These alkaloids may be produced before death in animals
as well as in man. H. Bouley brought this fact to light
some years ago in a medico-legal report. The question
arose in a case in which a butcher was accused of having
poisoned several people to whom he had sold the meat of
a heifer which had formerly been in an unhealthy condition.
The facts were that the butcher had bought a heifer : it
escaped, had been chased, and died, having been over-
driven by dogs. The butcher cut up the carcass, and
twenty or thirty of his customers who bought portions of it
fell ill. There had been a production of toxic alkaloids
during life, by means of the overwork and exhaustion of the
beast.
From the point of view with which forensic medicine is
concerned, the detection of these alkaloids is extremely
difficult. It is actually very difficult to be quite certain
whether the poison that we discover is one that has been
administered with the intention of killing, or a ptomaine
that has been developed in the course of putrefaction. You
shall judge for yourselves by the following case : A merchant
of stout build, who lived in Paris, bought some colchicine ;
his wife died shortly afterwards ; a foreman who had bought
the colchicine on his employer's behalf let it be known
that he had done so, and people began to chatter ; the
coincidence appeared all the more striking inasmuch as
the widower started on a journey soon after the burial of
his wife, taking with him the chief female assistant in^his
90 THE SIGNS OF DEATH
shop. The law was set in motion, and the body was
ordered to be exhumed.
MM. Gabriel Pouchet, Ogier, and I,* were charged with
the investigation. You know that the tests for colchicine
are colour tests ; those which we obtained in this case
were distinctly those of colchicine, but we did not dare to
conclude that poisoning had taken place, because we were
afraid that the reactions of ptomaines, which we did not
know much about, might be identical, and their presence in
the viscera was possible.
A fresh inquiry was ordered, and M. Schutzenberger was
appointed to join us. We had only used one half of the
viscera of Mme. X. in our previous analysis. The other
half had been placed in jars and carefully preserved. At
the time of the first investigation we had had taken to
the Morgue the viscera of a body which had died about the
same time as Mme. X. ; these were preserved in jars also.
We started afresh with our analysis, first on the viscera of
Mme. X. which remained, then on those of the other body
at the Morgue, as a control experiment. The colour pheno-
mena were identical in both. We had acted quite rightly,
therefore, in reserving our conclusions, and in not affirming
the case to be one of poisoning by colchicine, although we
had obtained the proper colour reactions.
Also, Gentlemen, believe what I say : when, in the course
of investigating a case, a chemist brings you colour reactions
and nothing more, to demonstrate the presence of the poison
that is being looked for, do not be convinced thereby ; there
exist perhaps a thousand ptomaines, though we know of only
a dozen. The actual state of our knowledge does not give
us the right to be positive ; it rather imposes on us the duty
of being cautious.
PUTREFACTION OF DIFFERENT ORGANS.
We are now going to examine the progress of putrefaction
in particular organs :
The eye undergoes changes that are very important to
* Brouardel, ' Accusation d'Intoxication par la Colchicine : Affaire R.,
acquittement, Relation mddico-l^gale ' {Ann. d'Hyg.^ 1886).
PUTREFACTION OF DIFFERENT ORGANS 91
know. The patch on the sclerotic, described by Larcher,
which I have already mentioned to you, appears first ; then
the eyeball shrinks ; the cornea and sclerotic become
wrinkled ; the colour of the iris may generally be distin-
guished for twelve days or so during the intermediate
seasons (spring and autumn) ; then the contents of the eye
escape at the end of two or three months. This last-men-
tioned period appears to me somewhat longer than is gene-
rally the case.
A reddish froth escapes from the mouth and nostrils,
soiling the face. We have already spoken of the green
patch which appears on the skin over the region of the iliac
fossa, and the bullae of sanious reddish fluid into which the
epidermis is raised. In putrefaction in the open air the
nails become loose about the twentieth day.
When the lungs of an adult begin to putrefy, their
anterior and lateral surfaces become covered with blebs of
gas ; this is the rule. The lungs of an infant which has not
breathed are never covered with blebs of gas ; putrefaction
proceeds in them quite in a different fashion to that in
adults ; it seems to be necessary for the external air, or the
blood of the intestines, to bring the germs of putrefaction
into the alveoli in order that they should putrefy, according
to the rules which we know.
The posterior parts of the lungs are the seat of well-
marked hypostatic congestion. The colouring matter of the
blood invades the whole parenchyma, then a certain quan-
tity of serum, coloured by the same material, is effused into
the pleural cavities.
The ciliated epithelium of the trachea retains its vibratile
movements for twenty-six to thirty hours (Gosselin).
The liver changes into an alveolar mass filled with gas ;
when a slice of it is thrown into water it floats ; that is the
best sign of advanced decomposition. If then, in conduct-
ing an autopsy, you meet with a liver that will float, you
may make a note of it, and conclude therefrom that death
must have taken place at a somewhat remote period.
As regards the brain, the progress of putrefaction varies.
In adults generally it takes place slowly ; in the foetus and
92 THE SIGNS OF DEATH
newly-born child it is more rapid, perhaps because the viseus
contains more water ; it is a point which requires elucida-
tion.
Of all the organs, the uterus putrefies last : for a long time
after death its examination is capable of affording precise
information. Casper relates the following instance : The
body of a servant-girl, i8 years of age, was found at the
bottom of a well. She was buried, but after more than a
year had gone by, her master was suspected of having caused
her to become pregnant and thrown her into the well, and
he was arrested in consequence ; however, he denied it
strenuously. An exhumation was ordered, and Casper was
appointed to undertake the investigation. The uterus
eighteen months after burial had still the shape of one that
had never been impregnated. The accused man naturally
was acquitted.
For my own part, I have had to perform an autopsy on
the body of a woman who had been buried in the cemetery
of Ivry sixteen months before. A midwife was charged with
having neglected to give the woman sufficient care and
attention. I was able to determine the measurements of
the uterus, and found them to be 6J inches in every dimen-
sion, which was the proper size of the uterus immediately
after delivery.
When medico-legal examinations have to be made at a
considerable period after death, it is a good plan to soak the
uterus in alcohol for some days, renewing the liquid from
time to time ; by this means the tissues become decolorized
and their consistence firmer, and thus the existence of
lesions may be determined which would escape notice
without this precaution.
The bones last a very long while; the older a bone is, the
lighter it becomes; it loses all its organic matter; it pre-
serves its form, but it becomes friable and its weight
diminishes.
We may conclude from these data whether the bone that
we are examining belongs to a person who has been dead
five, ten, or twenty years. Remember that this approximate
calculation can scarcely go beyond the last figure. Some
PUTREFACTION OF DIFFERENT ORGANS 93
time ago I made experiments on this subject with M. Des-
coust on skeletons found in cellars and procured from bodies
buried after the events of May, 1871. There was appreci-
able loss of weight in these bones. These experiments have
been repeated on the skeletons of animals by M. Ad. Carnot,
Professor in the School of Mines ; but from the special point
of view which occupies our attention now, in spite of the
curious results he obtained from them, and has recorded, they
cannot be turned to any practical use.
PRESERVATION OF DEAD BODIES.
When an exhumation is officially ordered, in cases of pre-
sumed poisoning, the exhumed body may be in a perfect
state of preservation ; must it be concluded, as is too often
attempted, that the presumption of poisoning is justified ?
Gentlemen, there are cemeteries which destroy and ceme-
teries which preserve : in the first the bodies are rapidly got
rid of; they are preserved for an indefinite time in the second.
It is necessary, in a medico-legal report on an exhumed
body, to note the fact of preservation, but it must only be
considered as one of the matters to be inquired into ; when
there has been poisoning by arsenic, preservation of the
corpse is the rule. One of the women poisoned by Pel was
found, four years after death, in the exact condition in which
she was when put into her coffin.*
Another point which is quite as important is to find out
the nature of the soil of the cemetery ; it is of hygienic as
well as of medico-legal interest. I shall not say very much
about it.
There are some cemeteries or portions of cemeteries in
which the corpses are exceedingly well preserved. Let us
just consider what happens in the case of ordinary corpses
placed in shells made of deal boards. Buried seventeen
months before in the temporary graves of the cemetery of
Ivry, these bodies had all the soft parts completely stripped
from the bones. Other corpses, placed separately in deal
coffins, buried in a very damp clay soil, the clay of which
* Brouardel et I'Hote, 'Affaire Pel : Accusation d'Empoisonnement —
Relation mddico-Iegale ' {Ann. d' Hyg.^
94
THE SIGNS OF DEATH
formed a thick coating over the whole of the coffin, were
in a state of perfect preservation at the end of the same
period ; the soft parts remained, but transformed into
adipocere.
We know that gases are produced during the destruction
of bodies. It had been inferred that these gases were
dangerous to health ; all the legislation of Prairial relating
to cemeteries is based on that theory. It was a matter of
serious interest to determine whether it was true ; it was
especially with regard to large towns that these pre-
possessions arose. A commission was appointed ; I took
part in it with MM. Carnot, Ogier, Schutzenberger and Du
Mesnil. We contrived numerous experiments : we found
that the gases taken at the surface of the cemetery are in
no way different from those taken elsewhere under the same
conditions ; beneath the surface down to the level of the
coffin, there was a larger quantity of carbonic acid than at
the surface. Whence does this carbonic acid proceed ? Is
it from the decomposition of the dead bodies ? Perhaps,
but in my opinion its origin is much more general.*
When an analysis is made of the gases of the soils round
populous towns, a considerable amount of carbonic acid is
always found ; when pits are dug in these soils, these rapidly
become filled with carbonic acid, whether there is a corpse
at the bottom or not ; lighted candles one above the other
at intervals of 20 inches show this when they are lowered
into these pits. Moreover it is notorious that in Paris the
well-sinkers are often asphyxiated by the carbonic acid which
is given off when wells are being sunk. The soil is saturated
with animal, and still more with vegetable, matter, in a state
of decomposition, and yielding carbonic acid. The presence
of this gas, even in the ground of a cemetery, proves
nothing ; thus, we must abandon all fear of danger in the air
arising from cemeteries. I believe that when the coffins are
placed from 5 to 6J feet deep, and covered with earth, the
hydrogen and hydrocarbons which are given off during
* Rrouardel et Du Mesnil, ' Des Ccndiiions d'Inhumation dans les
Cimetieres : R^forme du Ddcret de Prairial sur les Sepultures' {Ann,
d'Hyg., 1892, p. 27).
PUTREFACTION -PRESERVATION OF DEAD BODIES 95
decomposition are absorbed by that thickness of earth ; at
Marseilles, where the subsoil is actual rock, so that it is im-
possible to dig graves more than 20 inches deep, it is
necessary to cover them with earth and raise a mound ovtr
them, in order to ensure the conditions necessary for the
absorption of the gases. When the soil is very loose, and
consists of very warm sand like that of Mauritius, or of the
desert, bodies are preserved by being mummified. In damp
soils, in moist clayey earth, putrefaction is not complete five
years after burial (and that is important from the point of
view of the re-occupation of the space) ; the tissues have
undergone fatty transformation, and have become adipocere,
under the influence of the wet surroundings.
We must not, therefore, infer the probability of poisoning
from the preservation of the corpse, without assuring our-
selves on the spot as to the preservative powers of the
cemetery, and that all the bodies buried there do not present
the same characters, or that no portion whatever of the
cemetery possesses this preservative power. Those ceme-
teries whose soils have preservative properties ought to be
made sanitary ; this is easily accomplished by means of
drains placed at intervals of 3 or 4 yards ; it is a curious
fact that the water does not flow away by these drains, but
it is absorbed, and does not penetrate deeply, while the air
circulates freely ; a non-oxidizing soil is replaced by a soil
which allows the passage of abundance of oxygen. The
most conclusive instance in reference to this matter is sup-
plied by the cemetery of St. Nazaire : the bodies used not
to be destroyed ; but when drains were laid down, imme-
diately a new order of things was instituted, and by the
end of eight, eleven or twelve months, the corpses had
undergone complete destruction.*
There are variations in the rapidity of putrefaction; in
Paris it is the usual custom to throw antiseptic powders
into the coflins, such as sawdust impregnated with carbolic
acid, nitro-benzene, etc. ; the commission proved that the
use of these substances prolonged the preservation of the
* Brouardel et Du Mesnil, ' Conditions d'Inhumation dans les Cime-
ti^res' {Ann. d'Hyg.^ 1892, tome xxviii., p. 27).
96 THE SIGNS OF DEATH
bodies greatly. Impermeable coffi^s^^Lidia-rubber have
been invented ; at the end of two years, a phthisical woman,
who weighed 69I lb. when buried in one of these, had lost
only 2I \h.J^ weight.
In these indi^rubber coffins, also, the body is destroyed
in three or four years, and there is formed a liquid greasy
substance, like black axle-grease, which rolls about in the
coffin, and when the coffin is opened gives forth an abomin-
able stench.
The Commission therefore discountenanced, as far as the
re-occupation of the burial-ground in the cemeteries of large
towns is concerned, the addition of antiseptic substances and
the use of india-rubber coffins. It is a fear of the possibility
of contagion that has given rise to these practices. It is
quite enough to have the coffin firmly closed, and to make
sure that no organic liquid can leak out of it during its
conveyance from the house of the deceased to the cemetery.
This is the only matter of importance, and the result is
easily attained by surrounding the body with a layer of plain
sawdust, without the addition of any antiseptic.
Moreover, this addition of corrosive sublimate, carbolic
acid, nitro-benzene, etc., complicates medico-legal problems
quite unnecessarily. These substances are generally impure,
and may contain a variety of poisonous principles which at
the time of disinterment and toxicological analysis might
embarrass the most competent medical jurist.
The process of putrefaction in lead coffins differs from that
in wooden ones. Lead coffins are seldom used except when
it is required to transport the body for burial a long distance
from the place where decease occurred, or where the relatives
wish to make a display of luxury. Metallic coffins, whether
of lead or zinc, are nearly always enclosed in an oak shell.
If one of these coffins is opened at the end of three months,
the corpse looks as if it were in a bath of sweat ; it is
covered with moisture, and the skin is corrugated. When
the first aerobic colonies commence their work of destruc-
tion, the coffin is filled with gases, the tension of which may
become excessive, so as to make the metallic lid bulge, and
even burst. But at the end of six months the surface of the
PUTREFACTION— PRESERVATION OF DEAD BODIES gT
lead is depressed instead of being bulged ; the increased
pressure within has given place to diminished pressure.
The tension of gases in the first periods of putrefaction may
be formidable.
An English actress came to Paris and stayed at the Grand
H'Otel ; then, in the company of two of her fellow country-
women and her maid, she went one day for a walk in the
Pre Catalan, and drank a glass of milk there. Almost imme-
diately she became unwell, and was taken to the Armenon-
ville pavilion, where she died. Immediately after her death,
the maid returned to the Grand Hotel, carrying all her
mistress's clothes with her, and sent a telegram to a person-
age of high social position in London, who was interested in
the young woman. The other Englishwomen remained at
the Armenonville pavilion with the body, totall}' unable to
give any explanation of the occurrence (they could not speak
French), and the superintendent of police interfered. He
found the body of the young woman stretched on a bed,
wearing a red silk chemise ; but he could obtain no enhght-
enment.
He decided to send the Englishwomen to the Boulogne*
pohce-station, and the body to the Morgue. It was there
that I saw the body, and had to make the post-mortem
examination. I may add that the personage to whom the
maid had telegraphed arrived at the very moment when I
was beginning the autopsy, and before the EngHshwomen
had left the police-station ; he had therefore made great
haste. When the autopsy was finished (I will not say here
what results were found), the body was placed with the
separate viscera in a lead coffin.
It was late in the day ; the undertaker may not have had-
enough time, or perhaps he had not received precise direc-
tions. I do not know how it was, but, at any rate, he did'
not enclose the metallic coffin in one of oak. In the night
the lead coffin exploded from the pressure of gas evolved by
the first colonies ; the metal was extensively split, and yet-
the abdomen and intestines had been opened.
* Boulogne-sur-Seine, a suburb of Paris.
98 THE SIGNS OF DEATH
You see, then, what expansive force these gases may
acquire.
I have told you already that the soil of a cemetery is not
injurious to the health of those who are walking about on
it. It is highly dangerous to the grave-diggers, who are|
surrounded by an atmosphere of carbonic acid while digging
the graves. But the danger is much greater still when it is
necessary to enter one of those sealed-up vaults, known by
the name of ' permanent concessions,' which are full of very
dangerous gases.
When, as most frequently happens, the oak coffin is placed
in the vault without being covered with earth, the decom-
position of the body causes a sort of black grease to filter
through the seams of the coffin, and to spread over the
stone slabs. The smell is much more infectious than that
disengaged by coffins buried directly in the earth.
Gentlemen, I have tried to present to you an exact picture
of the various forms that putrefaction takes, according to
differences of medium and circumstance. Well, there are
other influences besides which elude us, the causes of which
we cannot explain. Certain diseases hasten putrefaction,
others — notably cancer — retard it. But there are other
things more singular still. When several individuals die
at the same time, in the same accident, and are buried"
together, they still may not putrefy in the same manner.
After the memorable days of July, 1830, some National
Guards who had fallen in the combat were buried in the
Place de la Bastille. When the excavations for the founda-
tions of the Column of July were dug, five years after, their
bodies were found. Some of them were skeletons, clothed
with remains of their belts, etc. ; others were still in such a
state of preservation that their features could be recognized.
The fact cannot be explained at present. All sorts of hypo-
theses are possible. We may assume that all these men
had not the same species of micro-organisms in their
digestive tubes.
LECTURE VI.
CREMATION .—MUMMIFICATION.
CREMATION.
Until 1889, burial was the only legal means of disposal of
the dead. Since then we have enjoyed a wider liberty: we
may be burnt to ashes if we choose. Certainly, it may seem
preferable to some persons to be oxidized by fire after death,
instead of being slowly destroyed underground by successive
colonies of micro-organisms and ' labourers of Death '; but,
from the medico-legal point of view, cremation has a certain
inconvenience. When there is a presumption of poisoning,
it is usually only at the end of three or four weeks that ex-
humation is ordered. If the body of the person suspected
of having been poisoned has been burnt, the proof of the
crime has vanished for ever.
The extra-Parliamentary Commission appointed in i88g
to study this question of cremation does not seem to me to
have thoroughly comprehended the importance of this objec-
tion. On the other hand, it was much struck with the fact
that in the time of an epidemic cremation might render the
greatest service by. making the bodies disappear quickly, and
with them the possibility of an ulterior contamination of the
soil.
I am obhged to make these reserves, which are justified
by a case observed by Henri Sainte-Clair Deville. When this
learned chemist was Professor and Dean of the Faculty of
Science at Besangon (in 1854), ^^ '^vas summoned to make
a medico-legal investigation. An entire family had died
7—2
loo THE SIGNS OF DEATH
during an epidemic of cholera. The fact seemed strange,
and certain rumours were flying about, so the public prose-
cutor ordered the six members, of whom the family consisted,
to be exhumed, and M. Sainte-Claire Deville was entrusted
with the chemical analysis. Four out of the six had suc-
cumbed to poisoning by arsenic, and this happened at the
height of the cholera epidemic. The murderer, who would
inherit the property, hoped that from the similarity between
the symptoms of cholera and those of arsenic-poisoning his
crimes would thus remain unknown for ever. If those bodies
had been submitted to cremation, the toxicological analysis
would have been impossible. Another consideration also
deserves attention. Suppose that a person has been wrongly
suspected of administering poison to some one. If the sup-
posed victim has been buried, it will be possible for the in-
criminated person to establish his innocence. If the body
has been burnt, it will be impossible for him to remove the
stigma which will be attached to him all his life.
The Commission decided, in order partially to meet these
medico-legal objections, that in Paris two physicians should
be appointed to visit the corpse which is about to be cre-
mated, and make a report. What will these two physicians
manage to see ? They would have great difficulty in recog-
nizing poisoning by the aspect of the body. If they are in
any doubt, they may make an autopsy. An autopsy.
Gentlemen, in cases of poisoning, often reveals nothing
definite, and it does not enable us to form a positive con-
clusion. In order to be quite certain, they will be obliged i
to demand a toxicological analysis. This analysis will take ■■
three months, and during those three months the relatives ^^
will be a prey to suspicions and disquietude.
There is here a real social danger, and I should reproach
myself if I did not lay stress upon it, especially with regard to
the suspicions which may weigh indefinitely on an innocent
man, incapable henceforth of proving his innocence.
EMBALMING.
Only two words on a practice which does not prevail much
amongst us. I wish to speak of embalming. If this procedure
MUMMIFICATION loi
were universal, we should have an infinite number of pre-
served bodies. Medico-legal investigations in cases of
poisoning v^ould be equally at fault. The regulations pro-
iiibit, it is true, the use in these operations of salts of arsenic,
corrosive sublimate, etc. ; but embalming can only be per-
formed by employing toxic substances. The regulations also
enjoin that a phial should be placed by the side of the body
containing the same substances that have been used in the
process. This precaution, which is intended to facilitate
research in case of an inquest, is good, but insufficient.
I am not speaking to you of the preservation of bodies by
ice. This procedure, which has found an application in
the refrigerating apparatus of the Morgue,* is only applicable
in Institutes of Pathological Anatomy.
MUMMIFICATION.
Putrefaction, which is the usual mode by which the body
is destroyed, is not the only one. In certain conditions it
may become mummified. Mummification was designedly
performed by the Egyptians, who wrapped the bodies with
closely-applied bandages, impregnated with aromatic, and
probably antiseptic, substances. These mummies are very
well preserved. You have seen them in museums, and
perhaps some of these exhibitions are fortunate enough to
possess the representative of a dynasty that existed 2,000
years ago.
[One of the most remarkable discoveries of this kind has
been made quite recently, by Mr. Loret, early in 1898.*!* In
one tomb the mummy of Amenophis II., who reigned some
1500 years B.C., and those of seven other kings, were found
intact. In an ante-chamber to the royal tomb were found
the bodies of four other persons, all in the most complete
preservation, owing to the dryness of the air, no process of
embalming having been employed at all. The features were
perfect, and have the appearance of sleep, although they had
evidently suffered violent deaths, the body of one man in
* Brouardel, 'Installation d'Appareils frigoritiques ' {Ann, cf Hyg.,
1879).
t The Ti??ies, April 5, 1898.
102 THE SIGNS OF DEATH
particular showing the marks of fatal wounds on the head
and breast, and the mouth was gagged with a piece of cloth.]
Besides this intentional mummification, there exists another
which is more common. The sandy soils of hot countries,
Mauritius for example, mummify the bodies which are
deposited in them.
Mummification may take place in the foetus, in adults,
and in the newly born. In the foetus it takes place when
death has happened while the foetus is still in utero, and
the membranes are intact. It may then remain for years
in the uterus, or in the Fallopian tubes, or in the pelvis if
the gestation is extra-uterine. Mummification takes place
in the foetus when the atmospheric germs have no access to
the dead body.
Mummification of the bodies of adults is somewhat rare ;
nevertheless, some cases of it have been recorded.
Five or six years ago the body of a female servant, who
had disappeared nine months before, was discovered under
a closed brick outhouse at the bottom of a garden belonging
to a medical man living in the suburbs of Nantes.
M. Audouard was commissioned to examine the body.
The skin was like parchment, shrivelled, and of a buff
colour. When it was tapped with the back of a knife, it
resounded like cardboard. The body had become very
light. M. Audouard found also that the skin was per-
forated by an infinite number of holes, like a colander, and
that dust from within escaped through these little holes.
He sent me a thigh and a leg, which weighed one-third of
the normal, as is the rule in cases of mummification of
adult bodies. I showed the fragments of the body which
M. Audouard sent me to M. Megnin, who has devoted great
attention to the study of the natural history of the * labourers
of Death.' M. Megnin was enabled to determine the time
at which the woman had died, and the conditions under
which her death had occurred. How did this female, eighteen
or nineteen years of age, become mummified ? M. Audouard
attributed it to the dryness of the chamber in which the
body had been placed, the time at which death had occurred
(early in the summer), and, lastly, to the layer of wheat
MUMMIFICATION 10.3
and oat straw under which the body had been buried,
and which had absorbed all the moisture of the body. It
is quite possible. M. M^gnin made the discovery that the
body had been devoured by mites, which had somehow or
other eaten all the tissues of this woman. In the leg and
thigh, which were in my possession, there remained only
the aponeuroses and meshes of cellular tissue. All the
muscles had vanished. The dust which escaped in clouds
from the perforations in the skin was composed of the
excretions and debris of the antennae, etc., of the mites.
Mummification of adults is rare in our climates. When
it takes place, the viscera are in close apposition ; they
contain no gas, and the clothes are intimately united to
the body. In those cases which I have had the opportunity
of observing, the liver, stomach, and intestines were abso-
lutely inseparable from the stays in the case of a woman,
or from the jacket in the case of a man.
[These exceptional conditions have been met with at
certain times in several places in Europe. In a crypt under
the tower of St. Michel at Bordeaux a collection of about
seventy mummified bodies is still exhibited. They were
found in this condition on the removal of human remains
from an adjacent cemetery, where the ground was very dry,
more than a hundred years ago. These bodies, most of
which are entire, or nearly so, are quite dried up and
shrunk, and are of the consistence of pasteboard or very
stiff leather ; on some of them the remains of clothing can
readily be traced. They have been placed in an erect
position against the wall of the crypt, and are said to have
undergone little or no disintegration. Instances occasionally
occur of long preservation or partial mummification of dead
bodies in the open air, even on a battlefield. Archibald
Forbes''' thus describes what he saw when he reached
Isandhlana, with the first party who visited the scene of the
massacre in the Zulu War, four months after the event.
The corpses were lying as they had fallen, though they had
been exposed to the sun and rain of Zululand all the time.
For some reason the vultures had spared them, and they
104 THE SIGNS OF DEATH
were completely dried up, * mere bones with toughened and
discoloured skin like leather covering them and clinging
tight to them, the flesh all wasted away.' The faces were
blackened, the beards bleached by exposure. The clothes
were better preserved than the bodies, and helped to keep
the skeletons together.]
Chemical analysis has shown that the alkaloids produced
are identical with those observed in the bodies of the
drowned.
When a mummified body is found, the law requires the
medical jurist to determine the time when death took place.
This question is of great importance, for according to the
answer to it the prosecuting authorities will know in what
direction to turn their attention.
Some years ago a chimney in a house in the Rue de
Tournon was pulled down ; the mummified body of a newly-
born child was found behind the chimney. A servant was
the only person who could be incriminated, but there had
been a succession of nurses in that room, and the precise
settlement of the period of death was the only means by
which justice could fix on the true culprit. I then remem-
bered the work of Dr. Bergeret.
Dr. Bergeret (of Arbois)^ was the first to throw some
light on the question; he has an extensive knowledge of
entomology. Being entrusted with the examination of a
child's body, which he found covered with larvae of insects
and scales, he declared that death must have happened two
years previously. His opinion was not accepted by the
representatives of the law, who then appealed to Tardieu.
The latter sought for information from Alfred Moquin-
Tandon, who was at that time Professor of Natural History
in the Faculty of Medicine of Paris. Moquin-Tandon con-
firmed Dr. Bergeret's report.
In the Rue de Tournon affair, which I had to investigate
in 1878, I asked M. Perier, of the Museum, to lend me his
assistance. M. Perier sent me an interesting note in reply,
but informed me at the same time that M. Megnin had
* Bergeret, 'Infanticide, Momification naturelle [du Ca.da.\re' (Ann.
^'Hyg"> 1855, tome iv., p. 442).
MUMMIFICA TION 105
made a special study of the fauna of the dead body, and
that he alone could enlighten me on certain points. Since
then M. Megnin has several times given me the greatest
assistance in preparing my reports.
The body of a child seven or eight years of age was found
in a soap-box ; how long ago did death take place ? It was
then the month of July. M. Megnin proved, by studying
the succession of flies and larvae which were found among
the remains, that the body had been placed in the soap-box
in the second half of February of the preceding year. The
mother, who suffered from phthisis, was accused, and, as
she felt her end approaching, confessed voluntarily that the
deed had happened on February 23rd.*
You remember the case of Elodie Menetrez at Ville-
momble. A young girl disappeared in suspicious circum-
stances ; some human bones were discovered in a bed of
tulips ; several liliaceous bulbs were found by the side of the
corpse. As the bulbs of tuHps are themselves devoured by
insects, I begged M. Megnin to find out when these bulbs
had been buried in the ground ; they had evidently been put
there at the same time as the human remains which had
been discovered. M. Megnin, without knowing any details
of the history of the case, affirmed that the bulbs had been
put into the ground at the beginning of March in the pre-
vious year, and this was quite true ; in the first days of the
month of March the girl had been to her solicitor to sign an
agreement, and the following day she disappeared.
This is a point to which you should pay particular atten-
tion. Gentlemen. I do not ask you, mind, to make these
observations yourselves ; I should not do so any more
myself; only a first-class entomologist is capable of giving
such good guidance, and if we were to lose M. Megnin
to-day, I should not know how to find any one easily to
take his place,
M. Mdgninf divides the work of the 'labourers of Death '
* Brouardel, * De la determination de I'epoque de la mort d'un nouveau-
ne faite h. I'aide de la presence des acares et des chenilles d'aglosses, dans
un cadavre momifie ' {Ann. d^Hyg., 1879).
t P. Megnin, 'La Faune des Cadavres' ('Encyclopedic Leaute,*
G. Masson, 1894).
io6 THE SIGNS OF DEATH
into four periods : in the first, quaternary compounds are
attacked and destroyed ; in the second, fatty substances are
attacked ; in the third, the soft parts are Uquefied ; lastly,
in the fourth period, the dried-up mummy is filled with
mites.
[The different species of insects appear in a tolerably
uniform sequence, each species having its own work to do
at one particular stage of decomposition. Altogether,
M. M^gnin describes eight * squads,' or gangs of labourers.
Of course all the species of each stage are not found in the
same case ; and the insects described are only those found
in this particular climate, and apply to putrefaction occurring
in the open air.
The first squad includes Musca (the house-fly, etc.), Cyrto-
neura and Calliphora (the blow-fly), the larvae of which com-
mence their attacks early, the ova being often deposited
before life is extinct. The coffin may be literally crammed
with the maggots of these flies. They are followed, as soon
as the characteristic odour of the corpse is developed, by
the second squad, comprising Lucilia (the brilliant metallic
green flies), Sarcophaga (a large grey viviparous fly), of which
there may be two or three generations in one corpse, and
allied genera — Cynomyia and Onesia. The first two squads
occupy the first period of decay, which lasts about three or
four months.
The third squad, appearing about three to six months
after death, consists of Coleoptera, Dermestes, both the larvse
and beetles of which devour flesh ; and the Lepidoptera,
Aglossa, Their operations are attended by the formation
of fatty acids.
The fourth squad appears about ten months after death,
when a caseous succeeds a butyric fermentation. The
insects in attendance are the Diptera Pyophila and Anthomyia,
and the Coleoptera Corynetes. These complete the second
period.
The next stage is an ammoniacal fermentation; the soft
parts of the body are transformed into a black deliquium.
It is accomplished by the fifth squad, consisting of Necro-
pJiorus (the burying beetle), Silpha, Hister, and Saprinus.
MUMMIFICATION 107
This forms the third period, and lasts from four to eight
months.
The sixth squad comprises the Acari, Uropoda, Trachy-
notus, Tyroglyphus, Glyciphagus, CcBpophagus, and Serrator,
which bring about the complete desiccation of the body.
They may even set to work at the beginning of decomposi-
tion, in company with the first squad ; but they penetrate
beneath the skin and devour the muscles and parenchy-
matous tissues, leaving the fibrous parts behind. The bodies
undergo at this period, which varies from six to twelve
months, a mummification which may last a very long time.
The seventh squad includes the same species which
destroy wool, fur, etc. They eat all the dried-up tissues
and hair, leaving dust in its place, which is really their
excrement. This squad consists of the Coleoptera Attagenus
and Anthrenus, and the Lepidoptera Aglossa and Tinesla.
The eighth and last squad, whose presence generally
denotes a corpse three years old, and which consume the
debris formed and left by their predecessors, consists of the
Coleoptera Tenebris and Ptinus.
A study similar to that of M. M^gnin, and originated by
his researches, has been made by Drs. Wyatt Johnston
and G. Villeneuve at Montreal, Canada,* and their results
prove the activity of an almost identical series of insects.
Some species, however, which are common in France, are
not met with in Canada, and vice versa.
Ants also will consume decaying matter ; and it has been
supposed f that in South America, where these insects are
large and numerous, they may take the place of other carni-
vorous genera in the removal of decomposing bodies.]
The seasons have a definite influence on the production
of these insects. When a body is put into the coffin at a
time when there are no flies about, i.e., from November to
February, you will not find any of them in the coffin ; (put
when there are flies at the time of placing in the cofiin,
they are certain to enter.
* Montreal Medical Journal^ August, 1897, quoted in Lancet^ Novem-
ber 20, 1897.
f Lund, quoted by Kirby and Spence, ' Introduction to Entomology,'
p. 148.
io8
THE SIGNS OF DEATH
The study of the animal life of the tomb is extremely
interesting and instructive.
[Bodies that are buried are also the prey of insects ; but
the number of species is more limited than when decomposi-
tion occurs in the open air. Most species belong either to
the Diptera or Coleoptera. The larvae of the former chiefly
gain access to the body before burial, and deposit their eggs
in the apertures of the body. The eggs of the Coleoptera,
however, are laid on the surface of the ground ; and the
larvae, when hatched, make their way down to a consider-
able depth in the earth, and find an entrance into the coffin,
probably attracted by the sense of smell]
Gentlemen, corpses exposed to the air or improperly
buried are sometimes devoured by dogs, wolves, or other
carnivorous animals ; you easily recognize this by the marks
of their bites.
But it sometimes happens that bodies, especially those of
newly-born infants, are eaten by rats. The bites of rats are
sometimes difficult to recognize. They always attack the
parts that are fat, i.e., the cheeks and heels ; they divide the
skin in a straight line, which often has the appearance of
having been cut with a knife ; so close is the resemblance
that it is often difficult to avoid a mistake. Rats will make
a body disappear with extraordinary rapidity. At the
Morgue, before refrigerating apparatus was introduced, the
rats used to devour the bodies in spite of every precaution.
[Vultures also, in the countries where these scavengers
exist, will gorge themselves on dead bodies, whether fresh or
putrid. It is said that the flocks of vultures which swarm
round the Parsee ' Temples of Silence ' at Bombay will eat
all the flesh from a newly-deposited corpse in two hours,
leaving the bones picked clean.]
In submersion in the sea, crabs attack the bodies, choos-
ing the lobes of the ears, the lips, and the nostrils ; and,
according to the climate, other animals, such as carnivorous
fish, cause mutilations, the nature of which it is generally
easy to determine.
Do not forget that you may have, in cases of this sort, to
form a differential diagnosis in certain circumstances.
MUMMIFICATION 109
To sum up, whatever, may be the mode of destruction of
a body, there is always a fermentation of the tissues, a pro-
duction of gas, an oxidation that is more or less rapid,
according to the method of destruction chosen, which lead
to the return of the organism to the mineral kingdom ;
furthermore, except in cremation, the intervention of suc-
cessive colonies of insects is absolutely necessary in order
that the destruction shall be complete.
LECTURE VII.
LEGISLATION.— MEDICO-LEGAL APPLICATIONS.
Gentlemen, — In order to complete the subject of death
from the medico-legal standpoint, it remains for me to enter
with you upon the legislation which governs the matter.
The enactments are not very lengthy. All that has any
concern with it is contained in certain articles of the Civil
Code (Art. 'j'] et seq.), and of the Penal Code (Art. 358
et seq.).
Article yy of the Civil Code is thus expressed :
* No interment shall be made without the authorization,
on unstamped paper and free of cost, of the registrar of
deaths {officier de Vetat civil), who shall only be entitled to
give it after visiting the deceased person to assure himself of
the death, and only twenty-four hours after death, except in
the cases provided for in the police regulations.'
Article 358 of the Penal Code is thus expressed :
* Those who have caused a deceased person to be buried
without the previous authorization of the registrar of deaths
in the cases wherein it is prescribed, shall be punished
by imprisonment of six days to one month and a fine of
sixteen to fifty francs, without prejudice to the prosecution
for those crimes to which the authors may have made them-
selves liable at the same time. The same penalty shall be
inflicted on those who have contravened, in any manner
whatever, the law and the regulations dealing with precipitate
interments.'
The legislator has imposed on the registrar of deaths the
LEGISLATION m
duty of verifying the death ; the office is held by the
mayor or his deputy. In the 36,000 communes of France,
the mayor and his deputy are not necessarily doctors of
medicine ; they are therefore incompetent, and, as they are
fully conscious of their incompetence, they do not take much
trouble about it ; they do not go to the deceased's house to
obtain actual proof of death, and the person who comes to
give information of the death is allowed to take away the
permission to bury. The law, such as it is, makes this
procedure legal. If the defunct had been seen during life by
a medical man, the danger would not be so very great. But
in the country many people die without any professional
man being called in at all. In such a case there is neither
any guarantee nor security. What is the period fixed by
law that must elapse before burial ? In France it is twenty-
four hours, and in Paris it is reckoned from the moment
when the declaration of decease is made to the registrar of
deaths, by virtue of an order made by Frochot in 1805.
Frochot remembered the well-known verses of Moliere :
' Qui tot ensevelit bien souvent assassine
Et tel est cru ddfunt qui n'en a la mine.'*
At any rate, the delay imposes a check on innkeepers and
hotel proprietors, who do not care to keep a corpse in their
• houses for long; it is contrary also to the customs of the
South of France, where, by reason of the high temperature
it is desirable to bury the dead as quickly as possible. .
In Germany the obligatory time to wait is forty-eight
hours, in Spain and Portugal five or six hours, which has
made a witty writer say that a man must not sleep too long
in those countries, for fear of being put under the earth.
In England it is the custom to wait till putrefaction sets in,
thus remaining faithful to the traditions of Greece and
Rome, where six to eleven days were allowed to elapse
between death and the funeral.
[In Australia it is customary to bury the body the next day
or the next day but one after death.]
■^ ' He who buries too soon often commits a murder, and a man is
believed to be dead who has only the appearance of it.'
112 LEGISLATION
The mean adopted in France is good ; it is long enough,
especially when death occurs in small, overcrowded lodgings.
It is impossible to keep the corpse there long, partly because
of the smell it gives off, also because promiscuity with
death rapidly removes the respect for it.
Nevertheless, we have been obliged in France to make
some exceptions to this rule of twenty-four hours ; not in
order to lengthen it, but, on the contrary, to shorten it.
When an epidemic is prevailing, and when putrefaction sets
in very early, the mayor may shorten the obligatory period
of waiting. Thus, in 1884, when cholera was epidemic in
Paris, the prefect of police, after having consulted with the
Council of Health, issued a public notice recommending
every physician attending a case to give notice himself or
to get the family to give notice to the mayor of the district
of every death from cholera that took place in his practice ;
a man was then sent immediately with a coffin ; the public
medical verifier of deaths, who had also been notified, con-
firmed the fact of death, and the compulsory delay might
thus be safely reduced, since two medical men, the one in
attendance and the public verifier, had both ascertained the
reality of death. The public verifier could always obtain a
prolongation of the normal period of delay.* M. Tourdes is
of opinion that the period of waiting should be extended
from twenty-four to thirty-six hours ; this does not remove
all uncertainty ; the danger does not lie in the period of
time fixed by law, but in the incompetence of the persons
appointed to legally confirm the fact of death.
We ask in France, and our neighbours in Germany have
been demanding the same thing since 1846, that all deaths
should be verified by medical men ; we have in France
36,000 communes, 29,000 of which possess neither a physi-
cian nor a medical officer of health {pfficier de sante). Can
■^ The decree of April 27, 1889, made these regulations. It stipulates :
* Art. I. — The registrar of deaths may in an urgent case, notably in a
case of death from a contagious or epidemic disease, or in case of rapid
decomposition, and after obtaining the opinion of a medical man, order
that the body shall be placed in the coffin immediately after death has
been officially ascertained, without affecting the right to order the burial
without the delay appointed by Art. 77 of the Civil Code.'
MEDICO-LEGAL APPLICATIONS 113
the duties therefore be placed in the hands of the medical
officers of the cantons ? One-sixth of the cantons of France
have neither a physician nor a medical officer of health !
It therefore seems impossible to carry out the law ; though
this could easily be rectified by taking advantage of the
organization which is about to be created in order to carry
into effect the law referring to medical assistance in the
country. When the question of the verification of death
was discussed at the Tribunate, and at the Council of State
under the Empire, Fourcroy declared that the registrar of
deaths appeared to him to be absolutely incompetent to
fulfil the duties of verifier. He was told in reply that, as he
had the responsibility, he would take care to be accom-
panied by a medical man, if he thought proper. It is not
desirable for medical men to be assigned duties in this way
which belong to them by right.
The difficulty has been overcome in large towns by a
simple procedure. In Paris, for example, there is in each
quarter a medical verifier, entrusted with ascertaining the
reality of every death in his division. A certain number of
medical inspectors, placed hierarchically over the verifiers,
are retained to ascertain the reality of death in one case out
of every three. This organization exists in many French
towns. It abolishes almost entirely the risk of premature
burial ; but in the country, in isolated communes, in hamlets
and farms when there has been neither a medical man in
attendance nor another to verify death, accidents may
happen like that related by Dr. Roger of Morlaix, and
which I have already related to you when we were engaged
in the study of the signs of death {v. p. 26).
I only know one way of avoiding the recurrence of such
accidents, viz., to enforce by law that the verification of death
should always be performed by a medical man, who would
make a diagnosis of death just as he would make one in the
case of pneumonia or typhoid fever. If any one offers as an
objection the paucity of medical men in the country, I will
say ' Add the duty of verification of death to the other
functions of medical assistance in country places in the law
that is now under discussion. If in Loz^re, for example,
114 LEGISLATION
one-third of the cantons have neither a physician, medical
officer of health, nor apothecary, it is because persons be-
longing to these professions cannot gain a livelihood there.
If you are really desirous of helping the indigent population,
organize the medical service in such a v^ay that the medical
officers may make a living. Nothing is more easy under
■those conditions than to entrust to them the duty of verify-
ing deaths also. Do you complain that there are not
enough medical men to do the work ? You would have
plenty the very day that you would assure them of a liveli-
hood and remunerate them for their services.'
In order that burial may take place, it is necessary to
show the written permission at the church and at the
cemetery. This permission is given on an unstamped sheet
of paper by the registrar of deaths, after the reality of death
has been ascertained ; burial cannot be proceeded with in
the absence of such permission without committing a breach
of the law.
In the case of the death of an adult, the registrar ought to
put at the head of the permit ' Declaration of Death ' ; in the
case of a new-born child, on the contrary, he says that a
* child without life ' has been reported to him ; it is for the
heirs of that child to prove that it has lived, if there is any
question of the inheritance of property.
Until 1881 foetuses expelled prematurely by abortion were
thrown into privies, dustbins, drains, or on to dunghills.
In 1864 Tardieu showed, in an excellent report,* how
immoral it was for such a state of things to exist.
In 1881 M. Floquet, then Prefect of the Seine, issued
an order prescribing that the death of a foetus should be
declared, and that it should be buried ; several events, both
in Paris and the provinces, had called for this administrative
measure.
At Provins, in 1880, a foetus was found on a dungheap ;
public opinion accused a girl of having induced abortion.
At the very moment that girl was being married. As she
* Tardieu, Ann. (THyg.^ 1864, et 'Etude mddico-ldgale sur I'Avorte-
ment, suivie d'une Note sur I'Obligation de declarer k I'Etat civil les
Foetus mort-nes,' 4^ Edition. Paris, 1881.
1
MEDICO-LEGAL APPLICATIONS 115
was actually leaving the church, the deputy to the public
prosecutor, acting too hastily, caused her to be arrested.
The scandal was prodigious.
An investigation took place, and the medico-legal examina-
tion proved that she was a virgin. The deputy was dismissed.
In Paris a series of analogous events happened : tales told
by neighbours, and charges made by hall-porters, led to
inquests being held, whereby the falsity of such stories was
proved.
In consideration of these facts, M. Floquet issued the
order referred to. The district medical officers protested
against the order, as leading to violation of professional
secrecy.
Medical secrecy is in no way affected by M. Floquet's
order, for an excellent reason, viz., because the matter is not
a secret in any case. The order obliges the foetus to be
taken to the mayor's office, in the same manner as the body
of a new-born child would be taken there ; but just as a
physician may say when he is begged not to divulge the
fact of a birth, ' A child has been born in this district at a
certain hour of a certain day, of father and mother both
unknown, residence unknown,' so he is permitted to declare
with the same reservations that a foetus has been born on a
certain day in his district, of father and mother unknown.
A box has been placed in each of the twenty mayors'
houses in Paris, wherein the foetus thus declared is
deposited, and whence it is removed by the men whose
duty it is to bury it.
Since 1881 the number of premature confinements de-
clared, and of foetuses thus deposited, has steadily increased ;
from 80 in 1881, it reached 250 in 1893 ; at the same time,
the number deposited in privies and dungheaps has
diminished in the same ratio.
The opposition to the decree of M. Floquet was very
strong. The opponents, at the head of whom was M.
Durand-Fardel, senior, medical inspector at Vichy, who
published an extremely spirited memoir on the subject,
relied especially on a decision of the Court of Appeal of
August 7, 1874. It declared that 'Art. 345 of the Penal
S—2
ii6 LEGISLATION
Code should be read in connexion with Art. 312 of the Civil
Code, by the terms of which the child is only reputed viable
after a minimum of 180 days or six months of gestation ;
that the being which comes into the world before this
period, destitute not only of life, but of the organic condi-
tions indispensable to existence, constitutes merely a name-
less object, and not a child, in the sense which a legislator
attaches to the expression ; that it was not with the idea of
such a case that the decree of July 3, 1806, ordered that the
body of every new-born child should be taken to the regis-
trar of deaths, inasmuch as the nearer the time of its coming
into the world is to the time of its conception, the less does
it present the distinctive appearance of a human being ;
that such an exhibition would be without any public interest
or utility, and might, in certain cases, wound the public's
sense of decency.' This solution, which has been admitted
by several courts of appeal (Amiens, June 27, 1876 ; Dijon,
May II, 1879), may admit of criticism in more than one
respect. Without inquiring deeply whether the exhibition
of the product of an abortion might or might not ' wound
the public's sense of decency,' and also without examining
whether the exhibition would be ' without any public
interest or utility,' the principal argument on which this
jurisprudence is founded is highly contestable from a
judicial point of view.
For my part, the obligation of declaring the foetuses is
less hurtful to the public's sense of decency than the practice
of leaving them fully exposed on a dungheap or in privies.*
* Jurisprudence on this point has varied to a singular degree. Judg-
ments have decided that Art. 358 applies to unauthorized burial, whatever
period gestation may have reached, provided that the child presents the
form of a human being (Paris, June 1 5, 1865 ; Amiens, December 20, 1873 I
Agen, August 6, 1874. See also Dijon, December 16, 1868 ; Chambdry,
February 29, 1868).
According to the Court of Metz, ' If it is true that the authorization of
the registrar of deaths is not essential for the burial of a simple foetus or
embryo — /.<?., of an unorganized being — it is not permitted that private
persons shall determine the limits within which the obligation of obtain-
ing authorization previous to burial begins and ends. This duty has been
imposed by law on a public man who alone has the right of deciding the
state of the deceased individual' (Judgment of August 24, 1854).
MEDICO-LEGAL APPLICATIONS 117
Innovations, of whatever kind they may be, are always butts
for criticism and sources of recrimination. It is the same
to-day with respect to the law which renders obligatory
the notification of contagious diseases. Meanwhile no one
has any longer any idea of protesting against M. Floquet's
decree, and there has not been a single prosecution.
All the medical verifiers have noted as a danger at the
time of death hasty preparation for burial when the deceased
person dies at his own home in the midst of his family. It
is the practice under such circumstances, due to the fear of
not being able to enshroud the body later, when rigor mortis
has commenced. You know that the attendants shut the
dead man's eyes and mouth — the latter by means of a
bandage — that the face is covered by a sheet, and that the
body is often placed too soon in the coffin, etc. This
custom constitutes a real danger. M. Josat, who has paid
much attention to questions of apparent death and premature
burial, has given in connexion with this matter a very happy
formula which ought to be remembered. He says that the
dead person ought to be presumed to be alive until death
has been verified, and that he ought to be attended to care-
fully until this is done, just as if he were alive. Casts of
the body can only be taken and autopsies made twenty-four
hours after the fact of death has been established ; the mayor
ought to receive notice of an autopsy ; he is bound to be
present or to be represented by a deputy. In Paris this
duty devolves upon the superintendent of police.
What I have just said applies also to embalming. I have
only to say a few words now on the question of the removal of
the body. Your advice will often be sought on this subject.
When a body has to be conveyed a long distance, it is neces-
sary to have a metallic coffin, but a chest composed of sheets
of zinc, like those we see used by packers, and covered with
oak, will answer in the majority of cases. Lead coffins are
very expensive. This expense of transport is still controlled
in France by a series of old legal decisions, which are not
enforced, however, in every department. They belong to
that group of laws, having hygiene in view, which are only
observed in a department where the prefect makes them
ii8 LEGISLATION
compulsory. The authorization of such a practice in one
department does not imply that it is equally so in the next.
However strong may be our love of unity in France, we still
have to deal with many anomalies.
If the body has to be removed only two or three leagues,
and the deceased has not died of any contagious disease, do
not be too harsh ; on the contrary, when the journey is long,
whether death is from a contagious disease or not, you must
insist on the employment of a metallic cofBn, covered with
an oak shell. Remember that the first effect of putrefaction
is the production of gases, which by their excessive tension
may even burst a metallic coffin.
What conclusions are we to draw from this long study ?
A physician need not often hesitate over the diagnosis of
death ; but he must know how to make this diagnosis just
as he knows how to make that of typhoid fever or meningitis-
Some cases present the condition of apparent death, which
may be more or less prolonged. The physician alone is
capable of making the diagnosis in these ; every one else is
incompetent. Also we are convinced that if the verification
of death were everywhere entrusted to medical men, the
danger of premature burial would be almost absolutely
removed.
PART II,
SUDDEN DEATH.
LECTURE I.
SUDDEN DEATH.
Gentlemen, — The question of sudden death is one of the
most important in forensic medicine. I beg that you will
allow me to speak of it in more detail, for medical men are
not, generally speaking, in favourable conditions to become
acquainted with all the numerous causes which bring it
about.
It is easy, as a matter of fact, to study the diseases of the
people who are brought to the hospital, and to explain satis-
factorily the morbid conditions to which they succumb; but
when an individual dies suddenly in the street or in a
house, he is not taken to the hospital. Generally the super-
intendent of police is informed of the sudden death, and
appoints the surgeon attached to the police-station to examine
and report on the facts. The latter ascertains that there is
no mark of violence on the body ; he puts this in his report
quite properly, but he does wrong if he adds that death is
due to the rupture of an aneurysm or to congestion of the
brain. He cannot actually know the cause of death of the
individual whom he is examining ; an autopsy, which he has
not made, can alone tell him that, and sometimes even then
an autopsy will not enable him to be certain. Why, then,
should he pronounce the words * aneurysm ' or * cerebral con-
gestion ' ? Sudden deaths due to the rupture of an aneurysm
are so rare that out of i,ooo cases observed at the Morgue by
120 SUDDEN DEATH
MM. Descoust, Vibert, Socquet, and myself, we have only
met with fatal rupture of an aneurysm four times ;* as to
cerebral congestion, such a thing does not exist — at least,
we have never met with it.
What is the proportion of sudden deaths among medico-
legal cases ? In the total number of medico-legal investiga-
tions, cases of infanticide and of sudden death are almost
equal ; these two groups together constitute two-thirds of
the medico-legal autopsies made in France annually.
The law steps in when death takes place suddenly, by
virtue of Article 8i of the Civil Code and of Article 44 of the
Code of Criminal Proceedings. t
This is, as a general rule, what happens in these affairs :
An individual dies suddenly (it is often persons of advanced
age, from 50 to 70, who are thus struck down) : death has
been preceded by a loss of consciousness more or less pro-
longed, by coma or by vomiting, which suggests the idea of
poisoning by opium in the one case, or by arsenic in the
other. The dead man is buried. The friends of the
deceased, as they are following the funeral, are disturbed
by the thought that they themselves may also be carried off
in a few hours, and begin to discuss the circumstances in
which the deceased met with his death. Comments are
made very freely. If by the fact of the death someone is to
* One reason for this rarity is, of course, the fact that in almost all cases
of aneurysm, the sudden fatal end is preceded by a period of illness,
which confines the patient to his bed, so that his body would not be
brought to the Morgue. — Translator.
t Cod. Civ., 81. — ' When there are signs or indications of violent death,
or of other circumstances which may give rise to suspicion, burial shall
only take place after a police officer, assisted by a Doctor of Medicine or
of Surgery, has drawn up a written report of the state of the body, and
of the circumstances bearing upon it, and shall have added any informa-
tion that he may be able to collect, with the Christian names, surname,
age, profession, and birthplace, of the deceased.'
Cod. Crim. Proc, 44. — * If a violent death occurs, or a death whose
cause is unknown or unexpected, the public prosecutor shall obtain the
assistance of two medical officers of health, who shall make a report on
the causes of death and the condition of the body. The persons referred
to in the present article and the preceding article shall be put upon their
oath, before the public prosecutor, to make their report and to give their
opinion on their honour and conscience.'
SUDDEN DEATH 121
succeed to property, and if the heir should be a man in
embarrassed circumstances, to whom such a windfall would
seem an unhoped-for stroke of good fortune, suppositions
become more definite, suspicions are expressed openly, and
the law is set in motion ; an inquiry is held, and in three or
four weeks after the decease exhumation is ordered, so that
a post-mortem examination may be made.
I repeat that this is the usual course of events when death
has been unforeseen and sudden, without there being any
reason to ascribe it to an injury.
We now enter upon the subject of sudden death apart
from injury.
Why does sudden death occur ? No one dies suddenly
apart from the effects of violence, as long as all the organs
are sound ; but there are some diseases which develop
slowly and secretly, without the attention of the patients
having been called to them by any pain or by any feeling of
illness, and without a physician having ever been called in,
and which terminate naturally by a rapid death. Among
these diseases I will mention diabetes and arteriosclerosis,
accompanied by atrophy of the kidneys. The person
affected with arteriosclerosis apparently enjoys good health ;
he may sometimes present digestive troubles, and fancies
that he is dyspeptic; he attributes any slight temporary
indispositions to his stomach ; moreover, the course of the
disease is long, yet an emotion or a chill may kill the
patient. A diabetic patient may also look well ; he is
cheerful ; he eats well and sleeps well. The day arrives
at last when he becomes comatose, vomits, and dies, while
those around him speak of poisoning.
These, Gentlemen, are not sudden deaths in the strict
sense of the term. Literally speaking, death is always
sudden ; that is to say, life ceases in an instant, if we hold
the opinion, as do the sick man's relatives and friends, that
the moment of death is determined by the last breath or the
last beat of the heart. But that which has received the
name of sudden death, both among ordinary people and in
the law-courts, is a death which is not preceded at all, or
only for a short time, by alarming morbid phenomena. The
SUDDEN DEATH
word ' unforeseen ' ought to be added to the word * sudden.'
It is this condition which, in the eyes of everybody, as well
as of the law, takes precedence of all other considerations.
And in order to avoid giving cause for any future misunder-
standing, we will define sudden death as * the rapid and
unforeseen termination of an acute or chronic disease, which
has in most cases developed in a latent manner.'
When the state of apparent health has continued up to
the last moment, the cause of death may be guessed, not-
withstanding. Here is an example of rapid, unforeseen
death which is easily suspected : the primary and secondary
symptoms of apoplexy are well known to everyone, and
there is no need to give information to the authorities, or
for the officers of the court to intervene in such cases. Of
all sudden and unexpected deaths apoplexy furnishes the
fewest autopsies and inquests.
The officers of the court include in the category of sudden
deaths those cases where individuals who appeared to be in
good health at the time have lived for four or five days after
the fatal seizure.
Sudden death is seen towards the close of certain pro-
tracted diseases, such as phthisis and cancer. You are all
acquainted with the occurrence of fatal syncope in phthisis,
and are aware that embolism may happen in phthisis or
cancer. In certain acute diseases, such as typhoid fever,
sudden death is equally liable to happen, and M. Dieulafoy
devoted his inaugural thesis to the subject. But these are
all accidents in familiar diseases. In the strict sense in
which we are speaking, sudden death is an unexpected
accident in a disease of whose existence we were quite
ignorant, and which has run its course without attracting
any attention at all.
Fifty years ago the doctrine of Bichat prevailed, according
to which it was said that death took place by the heart, the
lungs, or the brain.
To-day we can assert, at any rate as far as sudden death
is concerned, that death is especially apt to be brought
about by the kidneys, and we ought to restore the humoral
pathology to a place of honour.
I
SUDDEN DEATH 123
M. Lesser, a German medical jurist, whose name is of
great weight, takes too narrow a view of the question of
sudden death. He is faithful to the ideas of Galen, and is
convinced of the truth of the old phrase, CoruUimum moriens.
Out of 100 deaths, he attributes 66 to cardiac lesions, the
remainder to unknown causes. But we know that in those
cardiac affections capable of inducing sudden death there
are very often renal lesions, and an analysis of Lesser's
cases proves that he himself met with them.
We ought. Gentlemen, to classify the changes in the
organs which may bring about sudden death. We shall
pass under review successively the alterations in the circu-
latory system, those in the nervous system, those in the
respiratory system, those in the digestive system, those in
the genito-urinary system, specially the female organs and
the kidneys, and also the alterations in the humours — i.e.,
diabetes, albuminuria, haemophilia, etc. I am well aware
that this classification is not free from the charge of being
forced and artificial ; but no natural classification can be
constructed, and I shall try to leave nothing to be desired in
the way of precision and clearness.
I shall then speak of sudden death in new-born infants
and in children under two years of age. Sudden death is as
common in the earliest years as in old age, and it often
gives rise to medico-legal blunders, against which I shall
have to put you on your guard.
Besides organic lesions and alteration of the humours, it
is necessary to allude to circumstances which may be called
' occasional causes,' and it is of importance to be acquainted
with them. They include acts of violence, anger, conflicts,
strong emotions, and sometimes special unfortunate suscep-
tibilities of the individual. The effects of cold and heat will
likewise engage our attention, for popular opinion ascribes
most cases of sudden death to some exceptional external
circumstance or other.
Gentlemen, however carefully we may perform every
autopsy, however minute our exploration of the body may
be, however thorough may be our knowledge of the causes
of sudden death, we sometimes meet with cases which it is
124
SUDDEN DEATH
impossible to explain. The proportion is about 8 or lo per
cent. Often the body submitted to us for examination is in
a more or less advanced state of putrefaction ; with the best
will in the world, our inquiry must remain incomplete, and
present lacunce due to the impossibility of prosecuting our
researches further, and particularly to our inability to ex-
amine with the microscope tissues that are undergoing
decomposition. Sometimes, even although we cannot plead
the existence of putrefactive changes, we cannot ascertain
the real cause of death.
I shall enumerate some of the circumstances which render
us thus impotent. Remember, then, that there is a certain
number of cases wherein it is impossible to assert that
sudden death is the consequence of any specified lesion.
That is an important fact. However, the officers of the
court do not ask you what the disease was which caused the
sudden death of the deceased ; they require you to give
evidence as to whether or not death was due to violence or
to the effects of poisoning. If you find no marks of violence
and no traces of poison in the body, say so simply. Justice
will be satisfied, for it is all that it desires to know.
LECTURE II.
"SUDDEN DEATH DUE TO LESIONS OF THE CIRCULATORY
SYSTEM.
Gentlemen, — Sudden death often occurs as a result of
changes which take place in the circulatory system, but it
is not essential that there should be any lesion of essential
importance. A lesion may remain latent during the greater
part of life, and be only revealed by accident. This fact is
a predominant feature all through the history of sudden
death. A lesion of this kind may have its seat in the heart
or the bloodvessels (arteries, veins, or capillaries), but
especially in the vessels of the brain or kidneys.
I. LESIONS OF THE HEART.
A. Cardiac Muscle. — In the circulatory apparatus the
principal organ is the muscle of the heart. The action of
the cardiac muscle may cease although there is no valvular
lesion ; this may happen in the course of certain diseases in
which it is impossible to make a diagnosis during life. What
are those diseases ?
I. Fatty Overgrowth of the Heart. — A certain amount of fat
is normally deposited on the surface of the heart. This
deposit begins as early as the third week and increases as
age advances. You have all noticed, when examining hearts
in the post-mortem theatre, those yellowish streaks along the
course of the vessels, and those spots of yellow fat sprinkled
over the surface of the muscle, which indicate this condition.
If the fatty overgrowth is considerable, the muscular fibres
126 SUDDEN DEATH
can no longer be seen ; the heart seems entirely enveloped
in a yellow covering of fat.
When the overgrowth is less pronounced, the heart pre-
sents on its surface yellow discs, slightly raised, which may
be likened to the lenses of spectacles or of an opera-glass,
and which conceal, in the form of islets, portions of the
muscle lying beneath. Muscular tissue may sometimes be
found underneath these fatty patches, but the fat may also
infiltrate the muscular tissue itself, forming gaps in it where
the presence of muscular fibres can only be detected by the
aid of the microscope.
The living person who has fatty overgrowth of the heart
does not beheve himself to be ill. He looks well ; he is
perhaps a little short of breath, but he has never had an
attack of severe dyspnoea or any symptoms of angina pectoris,
which would have given warning of his condition ; ausculta-
tion, if practised, reveals nothing. The physician will ascer-
tain that the heart is somewhat enlarged, that the valvular
sounds are a trifle weak, and that the impulse of the heart is
somewhat feebler than normal, but he will not be able to
make a precise diagnosis ; and yet that individual is suffer-
ing from an affection of the heart which renders him liable
to sudden death.
This fatty overgrowth does not always make its first
appearance in the second period of life — i.e., after the 40th
year : it sometimes exists in children 15 or 16 years of age.
I remember two accidents which happened under the
same circumstances at the Sainte-Barbe institution while I
was physician there. Two children died suddenly in a cold
bath. In one case the relatives asked for a post-mortem
examination ; in the other they wished to have the body
embalmed : in both these children the heart was so loaded
with fat that it was impossible to see the muscular fibre.
What was the matter with these children ? You have
doubtless heard the word ' infantilism ' pronounced. It
denotes a condition which has not received all the considera-
tion it deserves. The children of large cities, such as Paris,
Lyons, Marseilles, Lille, etc., exist under certain peculiar
conditions. Take the little Parisian for example : he is
LESIONS OF THE CIRCULATORY SYSTEM 127
confined to very narrow surroundings ; his intellect de-
velops rapidly, and is precocious. That child will become
towards his tenth or eleventh year the street-Arab (gavroche)
of Victor Hugo, if he belongs to the lower classes, or a
* little prodigy ' if he is born in the middle class. At this
age his energies seem to be arrested ; he can no longer
maintain the position he held in his class ; the children from
the provinces, whom he left far behind at the commence-
ment of his studies, now pass him by. At the same time
the development of his testicles is arrested, and he grows
fat ; the breasts enlarge, and sometimes an abscess forms in
them. I have had to open sixty or seventy while I was
physician to Sainte-Barbe. The children grow no taller,
and sometimes they are like bags of fat. These children,
Gentlemen, ought not to undergo the douche or to enter a
cold bath. A violent shock to the circulation is sufficient
to stop the movements of their hearts, and thus bring about
sudden death.
2. Fatty Degeneration of the Muscular Tissue of the Heart. —
Here we no longer find yellow patches scattered over the
surface of the heart ; the alteration is more profound ; the
muscle itself is changed, and is converted into fat. This
transformation of the muscular fibres takes place in patches.
If you make a section of a heart that has undergone this
modification, and wash it, you will see that its substance is
studded with islets of a special colour— a brownish or buff
red — reminding you, as Laennec described it, of the tint of
dead leaves, and its nature is revealed by microscopical
examination. A German author, comparing it to the colour
of a horse's coat, has appropriately called it * dappled.*
Fatty degeneration develops slowly and secretly ; it often
attacks hearts that are hypertrophied, and it gives rise to
the same dangers as fatty overgrowth.
[I have notes of the four following cases of fatty degene-
ration of the heart ending in sudden death. They were all
inmates of the St. Marylebone Infirmary, but in none of
them was the condition recognised during life. Chronic
Bright's disease (granular kidney) was present in all, but
cardiac symptoms were certainly absent.
128 SUDDEN DEATH
(i) A man in full health, with considerable arterial degene-
ration, was admitted for slight stricture of the urethra, for
which he used to pass a catheter when necessary. One
night he was rather sleepless, and went to the w.c. He
died almost immediately after his return to bed. Post-
mortem: His heart was hypertrophied and dilated ; the aortic
semilunar valves rigid and partially calcified ; the muscular
substance showed extensive patches of fatty degeneration,
especially in the wall of the left ventricle.
(2) A woman, aged 63, was admitted with a recent fracture
of the humerus; she had delusions, and was somewhat crazy.
She died one night after returning from the w.c, just as in
the last case. Post-mortem : Heart slightly hypertrophied ;
marked fatty degeneration of the muscular walls ; valves
normal.
(3) A man, aged 69, infirm, blind from an accident, and
somewhat demented and forgetful, died suddenly on get-
ting out of bed early one morning. Post-mortem : The heart
was almost of normal size, the valves healthy ; the walls,
especially of the left ventricle, showed numerous patches of
fatty degeneration. The kidneys weighed together 6J oz.
(4) A woman, aged 71, with spinal curvature and almost
bed-ridden, had lately been subject to epileptic fits. She
died in a slight fit, death occurring within four minutes of
the moment of seizure. Post-mortem : The brain was slightly
wasted ; the heart somewhat hypertrophied, its muscular
substance of a brownish tinge and showing patches of fatty
degeneration ; the valves thickened but competent ; the
kidneys were granular and weighed 4 oz. apiece. Possibly
in this case death may have been due to respiratory
paralysis.
The above cases are mentioned to exhibit how fatty
degeneration may exist without being suspected, or at any
rate without being recognised, during life. It constitutes a
sort of background to other ailments, and makes the founda-
tions of the system shaky ; and the fatal ending is frequently
abrupt.]
3. Fibroid Degeneration of the Heart, — Fibroid degeneration
of the heart, which likewise develops in patches, is due to
LESIONS OF THE CIRCULATORY SYSTEM 129
chronic myocarditis. It has been well described by
M. Letulle. The patches may invade both the muscular
tissue of the wall and that of the musculi papillares ; it is
this condition which leads to rupture of the heart. The
tendons thus degenerated may snap as a result of a fit of
anger or other violent emotion, or of coitus, and their
rupture entails sudden death, the exact cause of which
cannot be determined without a post-mortem examination.
[The opinion that non-syphilitic fibroid disease of the heart
is commonly due to chronic myocarditis, often as a sequel
to acute myocarditis, has latterly been discarded by several
careful investigators ; and it has been more clearly shown
that the majority of cases originate in blocking of branches
of the coronary arteries. Thus, Dr. J. L. Steven says :* * In
a very large number of cases fibroid disease is associated
with disease (obstruction) of the coronary arteries. It is
always at first a localized affection, according to the branch
of the coronary artery affected. It is a slow atrophic pro-
cess, but in a certain proportion of cases the fibroid changes
are inflammatory in origin — true interstitial myocarditis.'
This process (coronary obstruction) has been described
by Dr. Charlwood Turner.t Huchard also says :J ' The
commonest lesion is obliterating arteritis of the small
coronary vessels, and it takes place slowly, so as to allow of
time for compensatory hypertrophy and sclerotic lesions to
develop. If arteritis is more rapid, dilatation of the heart
occurs.' Sometimes a fibroid heart attains an enormous
size and weight. Many cases of fibroid heart have been
recorded, and death often happens suddenly in apparently
perfect health.]
Acute myocarditis accompanies infective diseases, such as
typhoid fever, small-pox, pneumonia, etc. [and is a recog-
nised complication of acute rheumatism and diphtheria].
4. Lesions of the Coronary Arteries. — These arteries are some-
times affected by arterio-sclerosis ; they become thickened
* Lancet^ December, 1887.
t 'Proceedings of the International Medical Congress,' London, vol. i.,
p. 427.
X Quoted in the Lancet, September 24, 1887, p. 662.
9
130 SUDDEN DEATH
and nodulated, their calibre is diminished, and the blood-
supply to the heart is lessened, often to a remarkable degree.
Degeneration of the cardiac muscle is the consequence of
all this, and leads to sudden death.
[5. Syphilitic Affections of the Heart. — Cardiac syphilis was
first noticed by Ricord, and attention was first drawn to the
subject in this country by Sir S. Wilks. A useful collection
of twenty-five cases, in which both the symptoms during life
and the appearances after death have been observed, has
been recently published by Dr. S. Phillips,* and from this
the following description is gathered. Out of these 25 cases,
17 died almost instantaneously. Death in one was due
to an accident ; in another the mode of death is not men-
tioned ; the rest died after a short and severe illness.
Syphilis of the heart appears in the form either of gum-
mata or of general fibroid change. Gummata are soft
yellowish nodules, varying in size from that of a pin's head
to that of a marble, which may sometimes project into the
cavities or lead to cardiac aneurysm. The deposit occurs in
one or both ventricles or in the septum, and may extend to
the cohimnce carnece, leading to their softening, rigidity, or
adhesion.
Gummata in the left ventricle, except very small ones, are
dangerous to life, and when near the apex may cause sudden
death. They may be suspected during life when, with a
syphilitic history, and before the period of life when de-
generative changes are present, there is defective or embar-
rassed action of the left ventricle, and perhaps irregular
action or tachycardia, or else anginal, syncopal, or epilepti-
form attacks. Unaccountable dyspnoea might perhaps sug-
gest implication of the right ventricle. There may simply
be weak action of the heart, or else dilatation, hypertrophy,
or aneurysm may be set up, according to circumstances.
Sudden death is probably always preceded by cardiac symp-
toms of some sort, which may or may not escape detection.
There are two classes of diffuse syphilitic fibrosis of the
heart : {a) the weakened heart tissue leads to dilatation, or
ih) the tissue becomes stiff, tough, and weak. In the latter
* Lancet^ January 23, 1897, p. 223.
LESIONS OF THE CIRCULATORY SYSTEM 131
case, the heart's action becomes extremely weak, the first
sound and impulse being imperceptible. Dyspnoea is an
early and constant symptom of extensive fibroid disease :
there may be great general weakness and loss of energy,
perhaps dropsy, and the patient may die suddenly.
The anatomical appearances of fibroid disease of the heart
due to syphilis do not differ from those of fibroid disease due
to other causes.]
6. Rupture of the Heart. — Rupture of the heart was formerly
known as * aneurysm of the heart.' Aneurysm of the heart,
analogous to that of the arteries, has no existence.
These lacerations of the wall of the heart are rare, it is
true, but they happen occasionally. Thirty years ago Aran
collected 33 cases, of which 25 were ruptures of the left
ventricle, 3 of the right auricle, i of both ventricles, and i
of the right auricle and right ventricle.
These ruptures are not instantaneous ; on the contrary,
there is a preliminary alteration by fibroid degeneration.
The tearing proceeds from within outwards, widening in its
progress, and becoming so extensive that the aperture on
the outer surface of the heart is much^arger than that
on the inner surface. While this process is going on,
the contraction of the heart drives a few drops of blood
into the rent ; the blood thus forced by each impulse into
the rent travels farther forwards, at the same time making
it broader. Those authors were mistaken who believed
that ruptures of the heart could be effected from without
inwards.
[I met with the following case in April, 1901 : J. B., an
old man, aged 80, living in an institution for the blind in
Austraha, was suddenly seized one evening with agonizing
pain in the prsecordia. The pain abated with rest and local
applications. The pulse was very rapid and weak, and for
two or three days there was slight pyrexia and a thickly-
coated tongue. No sign of pericarditis, or cardiac enlarge-
ment, or any other organic disease could be detected, and
the cause of the pain remained obscure. In a few days all
the symptoms disappeared, and, as he seemed to be quite
convalescent, he was allowed to get up at the end of ten
9—2 >
132 SUDDEN DEATH
days. He went to the w.c, and was lighting his pipe there,
when he fell down dead.
Post-mortem. — The pericardium was distended with recent
clots, and an aperture, which would admit the finger, was
found at the apex of the left ventricle. The muscular wall
of the heart was greatly thinned around the opening, and
some rather older adherent clot was found on its inner
margin. The rupture had probably commenced at the time
of his first seizure, and its progress had been arrested until
he began to move about again.]
In cases where the heart is incompletely torn through,
the laceration always starts from the internal surface of the
hear4:.
[Wilks and Moxon* mention a specimen in which there
were two or three merely superficial rents in the heart from
structural disease. Death took place from haemorrhage into
the pericardium.]
Ruptures of the apex of the heart are tolerably frequent.
It was from a rupture of this kind that Talma died.
The heart may give way in the course of certain infective
diseases, such as typhoid fever, small-pox, infective pneu-
monia, etc. The rupture is then due to an acute myo-
carditis, which lessens the resistance of the muscle. When
a physician finds the heart becoming weak in a patient
suffering from one of these diseases, he should anticipate
the possibility of an accident of this kind.
[Traumatic rupture of the heart, unlike that due to
disease, as a rule occurs on the right side. The following
case, narrated by Dr. William Groom, of Wisbech,t is
exceptional and interesting, not only because the left
ventricle suffered the injury, but also because of the interval
of time between the accident and the fatal termination. A
lad, aged i6, fell on his face while walking along a path, and
died almost immediately. Evidence was given that he had
sustained a severe injury a month previously, his chest
having been suddenly and forcibly compressed by the shaft
* ' Lectures on Pathological Anatomy,' second edition, p. ii6.
t Lancet, May i, 1897, p. 1202.
LESIONS OF THE CIRCULATORY SYSTEM 133
of a pony-trap against some railings. He was laid up for
five days in consequence, and remained weak and unwell.
Post-mortem. — The ribs and superficial structures were
sound ; the pericardium was full of blood. A hole about
one-third of an inch in diameter was found through the
middle of the posterior aspect of the left ventricle, the
walls being conical, thin, and bulging outwards here, but
perfectly sound everywhere else. The accident had caused
a partial rupture of the inner surface of the ventricle, that
had led to the formation of an aneurysm which had burst.]
In rupture of the heart, death seems to depend upon the
insufficient quantity of the blood propelled by the heart into
the general circulation, and also upon the resistance offered
to the movements of the heart by the pressure of the clot
poured out into the pericardium. This clot may weigh
7 to 14 oz.
[Rupture or laceration of the heart, causing haemorrhage
into the pericardium, does not always cause sudden death,
or even invariably lead to a fatal ending, even though the
accumulation of blood be large. Mr. Mansel Moullin
showed* a lad, aged 20, who had received a blow over the
heart while playing at football in March, 1896. He was able
to continue playing for twenty minutes, but became pro-
foundly collapsed on reaching home. There was great pain
in the left side, and dysphagia, but not much increase of
cardiac dulness at first. Violent dyspnoea set in, however,
three weeks after the accident ; the whole of the left side of
the chest was found distended and motionless, and the
sounds of the heart were scarcely audible. The pericardium
was incised, and 6 pints of coagulable blood escaped.
The dyspnoea was immediately relieved, and the patient
eventually recovered.]
B. Pericardium. — We will now consider lesions of the
pericardium. The symptoms of acute pericarditis are so
well known that I will not dilate upon them. But it is
necessary to remind you of those numerous forms of peri-
carditis which may exist alone, or may precede by some
days the other manifestations of rheumatism, or which
* Transactions of the Clinical Society ^ London^ March 28, 1897.
134 SUDDEN DEATH
sometimes appear suddenly in alcoholic subjects, for example,
as well as haemorrhagic pericarditis, to which Dr. de Lacrou-
zille devoted his thesis. Abundance of effusion into the
pericardium constitutes a grave danger.
[Drs. Sturges and Williams have published*" the following
case of sudden death in the early stage of latent pericarditis.
A boy, aged 7, apparently in good health, ate a hearty
dinner, and immediately afterwards played at cricket for an
hour and a half. He then ran to school, fell insensible, and
died forthwith.
Post-mortem. — Recent pericarditis was found, with soft
adhesions. Violent exercise, together with an overloaded
stomach, here conduced to bring about the fatal result.
An inquest was lately reported in the newspapers of a
closely similar case.
Two cases of rapidly fatal pericarditis with effusion are
reported by Dr. F. Wilson :f
(i) A man, aged 35, fell into a river on December 25, 1899.
No ill-effects ensued until the 28th, when he felt a stitch
under the heart in the course of the afternoon, with diffi-
culty of breathing. He went to bed early, and a medical
man was sent for at midnight, but the patient died before
his arrival, having been unconscious at last.
Post-mortem. — Slight pleurisy on the left side, and one
pint of fluid was found in the pericardium.
(2) A miner went to work one night after a very heavy
meal. He then became sick, and suffered from dyspnoea ;
he rapidly became unconscious and died.
Post-mortem. — Pericardial effusion was found, as in the
last case.]
For the last forty years paracentesis pericardii has been
performed when the fluid is effused in large quantity. Some-
times during the process of tapping the heart suddenly stops,
and fatal syncope results. The responsibility of the physician
may be called in question under such circumstances ; there-
fore I would advise you never to undertake paracentesis of
the pericardium without the help of a colleague, and without
* Lancet, July 25, 1885. + /did., December i, 1900, p. 1572.
LESIONS OF THE CIRCULATORY SYSTEM 135
having forewarned the patient's relatives of the possibiUty of
a fatal termination.
[Among the causes of pericarditis which may be fatal, the
possibility of the disease being due to the entrance of a
sewing-needle through the front of the chest must be borne
in mind. Several such cases have been reported during the
last few years, and the patient may be quite ignorant of the
presence of a foreign body. In one such case, reported by
Dr. Sainsbury,* a healthy woman was taken suddenly ill
while walking in the street, and was removed to the hospital,
where she died six hours afterwards. At the autopsy a large
sewing-needle had worked itself into the heart and caused
fatal haemorrhage. In the same article another case is men-
tioned where a needle had been swallowed ; it pierced the
oesophagus and aorta, and a cyst between the two contained
blood-clot. Such a condition might, of course, readily
cause sudden death.
A gastric ulcer will sometimes perforate the diaphragm
into the pleura or pericardium. A case of the latter is
reported by Mr. C. Fenwick,t which caused immediate
death.]
As a consequence of pericarditis, false membranes may
have formed, which may cover both folds of the pericardium,
or may form adhesions between them, and then one of two
conditions is met with : either the adhesions are loose, and
long enough to allow of the normal free play of the heart,
and of the movements of the two pericardial surfaces on
each other, or they are so short as to approximate, or even
to closely unite, the two surfaces, and so produce adherent
pericardium. The diagnosis of adherent pericardium is
difficult in the living subject ; it is not an uncommon thing
for it to be found absent post-mortem, though its existence
has been suspected during life ; or, on the other hand, for it
to be found present when nothing had pointed to its presence
during life. It is a very grave condition, notwithstanding,
for in the notes of cases of sudden death due to alterations
in the heart that I have collected at the Morgue, sudden
death has in several instances been due to adherent peri-
* Lancet, November 28, 1896. t /did., August 14, 1897.
136 SUDDEN DEATH
cardium. The heart is somewhat enlarged ; the muscle
presents patches of fibroid tissue wherever the adhesions are
attached, exempHfying the fibroid myocarditis of M. Letulle.
The individual whose heart has undergone this change may
live, and may even feel no appreciable inconvenience, but
after it has lasted some time he may die suddenly under the
influence of some emotion or violent outburst of anger ; his
heart, contracting imperfectly, can no longer perform what
is required of it.
The most typical example that I can cite to you is
the following : A peasant was riding along a road in his
cart, when he saw three women gathering corn-flowers in a
field that belonged to him. He wanted to stop them, and
cracked his whip in order to scare them away ; then, seeing
that the women kept moving about in the field, he descended
from the cart and ran towards them. The women hurried
away, and in doing so one of them fell to the ground. The
peasant went to her and picked her up. Her two com-
panions, furious at having been interfered with and chased,
maintained that he had unmercifully beaten the woman who
had fallen down, which the peasant indignantly denied.
The passers-by collected together, and conducted the two
women, together with the peasant and his alleged victim, to
the police-station. The woman died, succumbing to a
paroxysm of dyspnoea. A post-mortem examination was
ordered to be made, and on the body only insignificant
injuries were found ; but she had adherent pericardium,
which had been unknown to everybody.
This is not a solitary instance. Gentlemen, but it is
typical, because the condition of which we are now speak-
ing was the only lesion that could account for death. Such
a termination is usual, but it would be going too far to say
that it is invariable. M. Lesser thinks that sudden death
can only happen when other morbid conditions co-exist.
C. Aortic Incompetence. — I come now to valvular lesions.
Aortic incompetence, which is one of the consequences of
articular rheumatism contracted in youth, is rightly con-
sidered by many authors as a predisposing cause of sudden
death. A person with undoubted aortic incompetence may
I
1
LESIONS OF THE CIRCULATORY SYSTEM 137
live, it is true, for many years. It is recognised by the
pallor of the face, the cardiac murmur, the visible pulse so
v^^ell described by Corrigan, and which has been called after
him ' Corrigan's pulse ' : the carotid arteries throb in a very
violent manner. How is the mechanism of sudden death
from this cause to be explained ? M. Mauriac has observed
in his inaugural thesis that in aortic incompetence the
blood propelled by each contraction of the ventricle into the
aorta does not remain there ; a certain amount flows back
into the heart ; the coronary arteries no longer receive a
sufficient supply of blood; their orifices are closed by the
sigmoid valves during the ventricular systole, and in diastole
their orifices become patent ; but, as a part of the blood
driven forwards falls back into the heart, the tension at the
mouths of the arteries is much lower than it should be.
When the sigmoid valves are sound, they entirely prevent
the reflux of the blood-stream. In aortic incompetence this
barrier is wanting, and there ensues an emptiness of the
coronary arteries which may lead to arrest of the heart's
action.
This theory of M. Mauriac is partially true; but when
there is aortic incompetence, the left ventricle becomes
hypertrophied, sometimes so much so as to earn the name
of cor bovinum. For a time the cardiac muscle struggles suc-
cessfully with the obstacle which impedes its functions, but
soon, as in all muscular hypertrophies — hypertrophy of the
bladder in cases of stricture of the urethra, for example — its
fibres undergo fatty or fibroid degeneration ; they are larger
than normal, but less powerful. The anaemia of the heart
diminishes the vitality of its fibres, it is true, but there is
also degeneration of those fibres. When the volume of
blood propelled into the aorta falls back in part into the
ventricle, Corrigan's pulse may be felt. It is sometimes
very forcible, and proves that the blood is driven into
arteries which are almost empty. When the blood flows
thus intermittently, some parts of the body are of necessity
insufficiently supplied ; the face is pale, because part of its
share of blood does not reach it — it falls back into the heart,
instead of being projected along the aorta; we find, there-
138 SUDDEN DEATH
fore, a general anaemia, particularly an anaemia of the brain.
Sudden death in aortic incompetence is therefore a product
of three factors — anaemia of the heart, degeneration of the
heart, and anaemia of the brain ; and if an individual suffer-
ing from aortic incompetence is obliged to make a great
effort or undergoes a severe shock, he may die from cardiac
syncope or from cerebral syncope.
[Sudden death from aortic incompetence is often typically
sudden. Dr. Walshe says* : ' I have known death take
place during the acts of walking, of eating, of speaking,
while the patient was emotionally excited, and, per contraf at
a moment when he was perfectly calm.'
It has been maintained with some truth that the combi-
nation of mitral insufficiency with aortic incompetence is
less dangerous to life than aortic disease by itself. Whether
this is always so or not, I can cite the case of a woman who
died a few years ago at the age of 86. She had had rheu-
matic fever early in life, which had left loud double aortic
and mitral regurgitant murmurs, with corresponding hyper-
trophy and dilatation of the heart. She suffered very slightly
from cardiac symptoms, though there was some dropsy quite
at the close of her life, and she died chiefly of old age.]
D. Mitral and Tricuspid Incompetence. — In mitral in-
competence, as a rule, sudden death is less to be feared ; it
necessitates an inquest less frequently. The patients suffer
from dyspnoea and oedema of the lower limbs, and they
present all the well-known symptoms of cardiac affections ;
they are known to have heart disease. A medico-legal
inquiry may be ordered, however, under two particular con-
ditions : either when the mitral incompetence is in a very
early stage, or else when it is very advanced.
In the first case, the symptoms are but slightly pro-
nounced ; the patient is not aware that he has anything
wrong with his heart. If he does know it, he may not have
suffered from dyspnoea, and he has probably had no dropsy;
nevertheless, the cardiac muscle may already have under-
gone very decided alteration. An attack of pulmonary
* ' Practical Treatise on Diseases of the Heart and Great Vessels,'
P- 390.
LESIONS OF THE CIRCULATORY SYSTEM
139
congestion is quite enough, even in a young man, to bring
about sudden death.
A medical student, unaware that he was affected with
mitral incompetence, went to a public ball one evening ; he
danced, but had to stop all of a sudden, as a violent
paroxysm of dyspnoea seized him. He became cyanosed,
and died shortly after. The autopsy revealed the presence
of mitral incompetence ; the lungs were extremely congested
and gorged with blood, so that they looked like two bags of
blood, and were almost firm enough to stand upright. It
was ascertained also that this young man had partaken of a
hearty meal before going to the ball, and no doubt had
washed it down with copious libations. That is one of the
circumstances most favourable to produce congestion. I
cannot too strongly urge upon you to prohibit those of your
patients in whom you have discovered the existence of
mitral incompetence from dancing, running and taking
violent exercise, especially after a bountiful repast.
In England diseases of the heart ending in sudden death
are very frequent. English authors attribute a great many
sudden deaths to mitral incompetence ; they mention the
railway-station as one of the commonest places where these
sudden deaths occur. You know how many Englishmen
live out of town ; they are sometimes pressed for time,
always keeping in mind the hour of the train, and have to
run to catch it, and they sometimes die at the very moment
of entering the carriage.
In the second case, which corresponds with an advanced
period of mitral incompetence, the symptoms are very
evident ; there is a feeble pulse, oedema of the lower extre-
mities, and anasarca. You know the classical picture of
these affections. In contrast with these patients are others
who have had no oedema and no dyspnoea, or, at any rate,
only in a slight degree, and yet their condition may rapidly
change — on the supervention of bronchitis, for example —
from one that is attended by but little danger to one that is
extremely critical.
When there is mitral incompetence, there is usually some
pulmonary congestion; and when, in addition, there is mitral
I40 SUDDEN DEATH
obstruction, the pulmonary circulation is carried on very
imperfectly. Some of the blood which should reach the
heart remains in the pulmonary tissue ; the capacity of the
lungs for air is diminished, stasis of blood becomes persis-
tent throughout, and consequently the tissues become con-
densed ; when bronchitis supervenes, attacks threatening
suffocation develop at once, and are very severe.
This condition is aggravated when there co-exists a de-
formity of the spine. In lateral curvature the heart nearly
always suffers ; and nearly all those who are afflicted with
angular curvature succumb to a superadded attack of bron-
chitis, which complicates the pre-existing cardiac affection.
The same thing occurs when renal mischief exists along
with mitral incompetence. In cardiac affections this asso-
ciation is by no means uncommon ; you know how often
the kidneys may be impaired. There may not be much
albuminuria, and yet oedema of the lungs sets in very
speedily. Also, when an individual who has mitral incom-
petence is attacked by bronchitis, complicated with oedema
of the lungs, he sometimes dies of asphyxia in the course of
a few hours.
What has the law to do with cases of sudden death due
to mitral incompetence ? I have the notes of a dozen cases
which furnish an answer to the question.
For the last ten years, partly in consequence of the
recommendations of M. Huchard, it has been customary to
inject morphine to calm the attacks of dyspnoea of certain
cardiac patients. It is not always the family physician who
is attending the patient who employs the remedy.
The attacks often come on during the night, and the
nearest medical man, or the one who is on public duty for
the night and is prepared to come, is called in. This physi-
cian knows nothing of the patient's history, and he has no
time to make inquiry ; he is under the most unfavourable
conditions for auscultating the patient whose circulation
and respiration are so embarrassed. He gives an injection
of morphine to subdue the dyspnoea ; the patient is some-
what relieved, and his friends think that he is going to sleep ;
he does not sleep, however ; therefore in half an hour the
LESIONS OF THE CIRCULATORY SYSTEM 141
physician repeats the injection, and takes his leave. This
time the sick man does go to sleep. Next morning a mes-
sage is sent to the physician's house to let him know that
he need not trouble to call, as the patient died in the night.
The question that arises here in the forensic aspect is
this : Is the physician culpable ? In nearly all cases which
I have had to examine there was albuminuria. Ursemic
coma is mistaken for sleep due to morphine ; it is impos-
sible to blame the injection of morphine, and say it is that
which has killed the patient. All that it is possible to say
is that the patient had bronchitis or cardiac disturbance
from uraemia, and that the morphine injection would not
hasten the final coma by half an hour, even if it had such
an effect at all.
It is not only morphine that has been blamed for such
accidents ; these have also been ascribed to wet-cupping,
emetics, inhalations of ether, and to every other mode of
treatment.
You see, then. Gentlemen, that you must exercise caution.
When you are summoned to a patient under such condi-
tions, before taking any steps to give relief, warn the rela-
tives of all the accidents which may follow your treatment
— not because of it, but in spite of it.
In tricuspid incompetence the same phenomena are observed.
When there is emphysema at the same time, attacks of
bronchitis are frequent and severe ; when there is what
Trousseau called an ' overstrained heart ' {cceur force) y it
denotes dilatation of the right ventricle, and the pulmonary
circulation is obstructed as much as in the preceding case.
E. Endocarditis. — Endocarditis gives rise to medico-legal
inquiries of a special kind. I do not refer to the endocar-
ditis with hyperpyrexia, which comes on unexpectedly in
the course of acute rheumatism, and sends the temperature
up to 104° or 106° F., and which has a rapidly fatal termi-
nation ; such a case is not followed by an inquest. But
there is infective endocarditis, which has been well described
by M. Haust, who recognizes two forms of it. In the first
the infection is limited to the heart ; in the second it starts
in the heart, and thence becomes general.
142 SUDDEN DEATH
Let me give you an example of infective ulcerative endo-
carditis, limited exclusively to the heart : A young mason,
sixteen years of age, came down the ladder, at the top of
which he had been working one day, because he felt unwell
and out of sorts. He met his father in the street, who
reproached him with being lazy, and ended by boxing his
ears. The boy fell down, but was picked up, and was found
to be hemiplegic and aphasic. He was taken to the hospital
and put under the care of Dr. Lorain, whose house-physician
I was at the time. Dr. Lorain detected a cardiac murmur,
indicating mitral incompetence; the intensity of the murmur
varied from day to day, and in a month was no longer to
be heard ; the patient improved, but he did not altogether
regain the power of speech.
Now, that lad had a wound on his foot which he had
neglected, and which originated the infective endocarditis
limited to the endocardium, and a deposit of fibrin had
formed on the valves.
Under the influence of the emotion caused by the blow-
ing-up his father had given him, an embolus was detached,
which was carried along in the blood-stream till it blocked
the middle cerebral artery and produced hemiplegia.
When the infective phenomena are general, and there is
multiple embolism, we have to do with M. Haust's second
form.
How are we brought in contact with endocarditis in
medical jurisprudence? A little child had received a blow
on his scalp from the ruler of an under-master at school.
Neither he nor his parents paid any attention to it at the
time ; but the child fell ill, became delirious, and the doctor
pronounced it to be a case of meningitis, brought on by the
blow inflicted by the under-master.
The child died, and the body was transferred to the
Morgue. The autopsy revealed the existence of infective
ulcerative endocarditis. Gentlemen, the violence of the
blow had been grossly exaggerated. It was clearly very
wrong of the under-master to strike the child ; but there
was a marked disproportion between the slightness of the
blow and the supposed consequences.
LESIONS OF THE CIRCULATORY SYSTEM 143
Infective ulcerative endocarditis is frequent as a result of
slight wounds, such as a graze of the calf, foot, or heel. It
does not seem to follow lesions of the alimentary canal or
of the bronchi, nor does it appear as a result of surgical
operations or amputations ; it seems rather to proceed from
superficial sores that are attended to imperfectly or not
at all.
Endocarditis often leads to anetirysm of the valves. In
consequence of the ulceration to which inflammation of the
endocardium gives rise, lacerations are produced. Small
excavated foci, caused by ulceration, form in the neighbour-
hood of or upon the sigmoid valves : this may bring about
sudden death by embolism. But, as a general rule, when
there is ulceration on one surface only, fibrin is deposited
on it, and remains there. When ulceration goes on to per-
foration of the septum, numerous emboli form, and are
carried to all parts of the system.
One last word as to endocarditis, namely, on the treat-
ment by salicylic acid and salicylate of soda. The number
of persons treated for endocarditis in rheumatic fever by
salicylate of soda, and who have benefited by this treat-
ment, is enormous. It is only when the kidneys are
diseased, and do not perform their functions duly, that
the salicylate, which has a cumulative action, becomes a
dangerous remedy.
F. Angina Pectoris. — Angina pectoris comes well within
our scope, for an Englishman, Dr. Forbes, states that out
of sixty-four persons thus affected that he has met with,
forty-nine died suddenly ; still, a certain number of persons
affected with this disease live thirty or forty years, and die
of something quite different.
[It is really a matter of some importance to define the term
* angina pectoris,' or to restrict the use of the name as far
as possible to cases which present the regular and classical
type of the disease; but precise definition is a matter of
much difficulty, since we are ignorant of the precise ana-
tomical or pathological condition on which the symptoms of
the disease depend, though it seems to be due to lesion of a
certain branch of the coronary artery. Some authors extend
144 SUDDEN DEATH
the application widely, so as to include all pains of an
anginal character, which are dependent on some disease or
disorder of the heart, or which may be merely the manifesta-
tion of some toxic condition or neurosis. And thus certain
forms of so-called angina, or * pseudo-angina,' which may be
associated with a merely temporary and curable, though
perhaps for the time severe, cardiac affection, may be
regarded with a gravity which does not belong to them. It
is surely a mistake to group together diseases which never
end fatally with one that is invariably fatal. These cases
bear the same sort of relation to true angina pectoris that
epileptiform convulsions do to true epilepsy. In true angina
pectoris the heart commonly appears normal, so far as its
size, position, and action are concerned. Though it is
essentially a disease of middle life or later, a few cases of
sudden death from angina pectoris at a very early age have
been recorded ; e.g.. Wild* relates such an occurrence in a
girl aged lo, and another in a girl aged 12, in whom was
found advanced disease of the coronary arteries. Balfourf
also mentions a case at this age. But, from a practical and
prognostic point of view, it is as well to separate all sympto-
matic cases from the essential form, the account of which,
by Heberden, is classical, and hardly capable of improve-
ment. He says::!; ^I have seen nearly a hundred people
under this disorder, of which number there have been three
women and one boy 12 years old. All the rest were men
near or past the fiftieth year. . . . The termination of the
angina pectoris is remarkable. For if no accident intervene,
but the disease go on to its height, the patients all suddenly
fall down and perish almost immediately. Of which, indeed,
their frequent faintnesses and sensations, as if all the powers
of life were failing, afford no obscure intimation.' The
important point, therefore, to bear in mind is that true
angina pectoris invariably ends in sudden death. This has
been rightly and strongly insisted on by Gairdner.§ There-
* Manchester Medical Chronicle^ May, 1889, p. 146.
f ' Clinical Lectures on Diseases of the Heart and Aorta,' p. 300.
\ • Commentaries,' art. ' Pectoris Dolor.'
§ Reynolds, ' System of Medicine,' vol. iv.
LESIONS OF THE CIRCULATORY SYSTEM 145
fore if we clearly recognize the existence of angina pectoris,
sudden death, sooner or later, may be confidently antici-
pated. Another point to remember is that angina pectoris
is, like gout, a disease of men, and not of women. When it
does manifest itself in females, as is occasionally the case, it
is often so confused with the common and frequent pains in
the left side, due to flatulence or other causes, to which that
sex is expecially prone, that its recognition may be a matter
of some difficulty. Also, though death is sometimes instan-
taneous, and may occur after some shock or exertion or
during sleep, the termination is not usually so sudden, and
the process of sinking may last for an hour or two, perhaps
even longer. A very interesting medico-legal case occurred
in South Australia in 1899. A Mr. X., who had, eleven months
before, increased his life assurance to a very large amount,
was away from home, staying at a hotel. He was suffering
from severe neuralgia, and obtained a full dose of chloral to
relieve the pain and procure sleep. He drank a considerable
amount of spirits before retiring to rest, and there was
evidence that he swallowed the chloral also. He was heard
groaning in the night, and in the morning he was found dead.
An inquest was held, and a verdict of death from natural
causes was returned. The matter was, however, re-opened,
as the assurance society disputed the claim for payment, on
the ground that it was really a case of suicide, which would
render the policy void. At the second inquest, which was
conducted with greater scrutiny, Dr. Marten, of Adelaide,
gave evidence as an expert that the groans indicated death
by angina pectoris, whereas fatal chloral-poisoning would
have been attended by quiet respiration. A letter was also
produced which had been written by the deceased to his wife
a month previously, describing an attack of illness that he
had just suffered. It ran as follows :
* During the night from Friday to Saturday I had an attack which I
find difficult to describe, and so terrible was the sensation that I thought
my last hour had come. Fortunately, it did not last longer than a few
minutes, or I should have been unable to endure it. It was a feeling of
suffocation with which I suddenly awoke, and a sensation of terror which
was dreadful. The rest of the night I passed without sleep, and,
thoroughly alarmed, I went for Dr. Thompson early in the morning. I
10
146 SUDDEN DEATH
requested him to sound nie, to learn what could really be the matter, and
he reassured me, to a certain extent, by stating that there was really
nothing the matter with my heart, and that such an attack could be
brought on by an acute attack of indigestion.'
This letter is natural and characteristic, and describes his
first attack of the disease. The evidence convinced the
jury, who accordingly returned a verdict of death from
angina pectoris, which was certainly correct. The second
seizure was fatal.]
We, as medical jurists, may have to interfere, because
people may die in what seems to be a first attack ; I say
* seems,' for we are never certain that the mishap which has
been witnessed by no medical man, and which has carried
off the patient, was an attack of angina pectoris ; and it is
this uncertainty which looks suspicious to the eyes of the
law. Moreover, a person may die not only during an
attack of angina pectoris, but also in the interval between
the attacks.
What is the danger which threatens a person in angina
pectoris ?
You know that angina pectoris is present when the great
vessels are diseased, and when the coronary arteries are
degenerated, thickened and tortuous. The muscular fibre
of the heart, which receives less blood, and is badly nourished,
undergoes fibroid degeneration ; the altered muscle stops
either in or apart from an attack, and the patient dies of
syncope.
If the medico-legal expert does not find any lesion of the
coronary arteries, or, at most, a slight thickening, should
he say that death is due to angina pectoris ? I think not,
for we find similar lesions without there having been any
angina. The presence of more or less extensive fibroid
patches will suggest the idea of myocarditis. In most
cases it is very hard to decide. Changes in the ganglia and
inflammation of the pneumogastric and phrenic nerves
have been spoken of as causes of angina pectoris ; it has
been said that it is possible to recognize induration and
redness of these nerves even thirty-six hours after death. I
am very sceptical. Gentlemen, as to the value of that red-
LESIONS OF THE CIRCULATORY SYSTEM 147
ness and induration of the nervous tissue. Even admitting
that such an investigation might be successful twenty-four
hours after death, it would be quite useless to look for it
four or five days after death, and I have told you more than
once already that medico-legal autopsies are seldom ordered
immediately after the individual has met with a suspicious
death.
Therefore, as regards the diagnosis of sudden death from
angina pectoris, we have no positive basis in morbid
anatomy ; cases of this sort must be placed in the category
of sudden deaths, of which it is sometimes impossible for
us to give an exact explanation in our medico-legal reports,
and such cases are far from being rare.
G. Neoplasms of the Heart. — Before concluding the sub-
ject of lesions of the heart, I ought to say a few words about
new growths of the wall of the heart, which have in ex-
ceptional cases caused sudden death.
I will content myself with mentioning tuberculosis of the
septum and of the walls of the ventricles, a case of which
has been observed by Dr. Southwood Smith ; cancer of
the cardiac wall, of which one case has been observed
by Segalas, in a child of 11 years old, and another by M.
Laudouzy and myself in a woman 26 years of age; and
hydatids.
It has been said that hydatids have a preference for the
right ventricle ; Richard Smith and Depaul each found one
in the interventricular septum ; cases have been reported in
which the cysts have ruptured and discharged secondary
cysts.
[Hydatids may occur at any age. If the heart is affected,
other organs may or may not be involved also. The cysts
invariably rupture in course of time, and burst, according to
their situation, into the pericardium or into one of the cavi-
ties of the heart. Occasionally there may be previous symp-
toms of circulatory disturbance, but more often there are
none, and death supervenes suddenly. The following case*
reported by Dr. W. H. E. Knaggs, is a good example of this
form of death, though the cyst had not burst. A man on board
a South African liner was sitting in his cabin one evening,
10 — 2
148 SUDDEN DEATH
smoking and talking to his companions, when he suddenly
fell over on his back. He was found in a state of profound
syncope, and expired within one minute from the moment of
his seizure.
Post-mortem. — All the organs were healthy except the heart,
which was enlarged, and had a mass of hydatid cysts em-
bedded in the walls of the left ventricle. Typical booklets
were found in the fluid of the cysts, but there was no com-
munication with the ventricular cavity. The patient had
previously enjoyed excellent health.]
Gentlemen, allow me to tell you of a post-mortem in
which, on opening the heart, we thought we had to deal
with a hydatid cyst that had burst into the right ventricle.
Microscopical examination did not confirm the diagnosis
made by the naked eye. We found instead, little cubes full
of fibrin (petits cubes remplis de fibrine)^ in the midst of which
were red corpuscles more or less degenerated.
I cannot tell you what these little cubes were or how they
were produced, although I know of two similar cases ; but
I can state confidently that you will not be able, in a case
that ends in sudden death, to make a diagnosis of cancer
of the ventricles during life, any more than that of hydatid
cysts.
II. LESIONS OF THE ARTERIES.
* A man is as old as his arteries ' is an aphorism which
has, I think, been attributed to Cazalis, but which I now
know to be much more ancient ; from the point of view
of sudden death, it is absolutely exact. A man actually
is as old as his arteries. Of all diseases of the arteries,
fibroid degeneration (arterio-sclerosis) concerns us most;
it may manifest itself even in young people. Before
entering upon the study, it will be convenient to turn our
attention first to the congenital arterial lesions which may
lead to sudden death.
A. Congenital Lesions. — One of these lesions, contraction
of the aortic orifice and narrowing of the aorta, has been demon-
strated by Virchow. M. Lesser, of Breslau, has studied it
afresh, and has found that the aorta had, in subjects of this
malformation, who were 20 or 22 years of age, the size of that
LESIONS OF THE CIRCULATORY SYSTEM
I4(>
of a child of 8 or lo ; like Virchow, he has founded a theory
of chlorosis upon it. I have not ventured to discuss chlorosis
here ; it is evident that the arterial circulation, and conse-
quently nutrition, must be defective when the calibre of the
aorta is so much reduced, and it may produce a peculiar
form of anaemia.
Virchow only goes so far as to say that narrowing of
the aorta might at a given moment cause sudden death.
M. Lesser, deducing his results from the events observed in
certain diseases, goes further, and asserts it as a fact. It is
necessary, therefore, when one has to do with sudden death
in young adults, to measure the size of the aorta.
It is to a congenital malformation of another sort that
the following case of sudden death must be ascribed;* it
made a great impression on me. I believe it is a unique
case, and the one that most closely resembles it is a case
recorded by Laennec :
A medical student, 20 years of age, who had spent the
whole of the afternoon in the dissecting-room, went home
by rail to Perreux, where his family resided. He dined,
and afterwards played at cards with his parents and sisters.
The family retired at 10 o'clock ; he himself went to his
room, wrote a letter of six pages to a friend, and then went
to bed. In the middle of the night his mother heard her
son walking about, and, thinking that he was ill, rose and
found him complaining of excruciating pain in the right side
of his chest. A physician was fetched, who thought he had
to deal with a case of biliary colic, and gave an injection
of morphine. Mind, I am not finding any fault with this
physician's diagnosis. The pain lasted throughout the next
day, and at 7 p.m, the young man died. The father asked
for an autopsy, and I was appointed to make it. In the
right pleura I found about 7 oz. of non-coagulated blood,
the parietal pleura was separated from the ribs, from the
third rib to the diaphragm, and there was thus formed a sac
containing more than 63 oz. of fluid blood ; the mediastinum
was full of blood, the aorta was surrounded by an effusion of
^ Brouardel et Vibert, * Rupture de I'Aorte thoracique chez un jeune
Homme de Vingt Aos' {Ann. d'Hyg.^ 1892, tome xxvii., p. 45o)»
I50 SUDDEN DEATH
blood which reached up to the retropharyngeal cellular tissue
and descended to the commencement of the femoral artery;
the posterior third of the mesentery was full of blood; the
aorta was ruptured in two places ; there was one transverse
laceration, nearly half an inch long, a little way beyond the
origin of the carotid, and a second tear, almost identical with
the first, about an inch above the diaphragm.
The aorta was not atheromatous, but its walls were like
paper, owing to the atrophy of the middle coat ; the muscular
and elastic fibres had disappeared ; the vessel was narrow,
and small also. The young man had had typhoid fever when
15 years of age. Was the arterial lesion a result of the fever,
or was it congenital ? He had never suffered from any pain
that might retrospectively be attributed to this lesion ; he
had practised gymnastics, had ridden a bicycle, and had not
deprived himself of any of the pleasures of his age ; in this
particular case the rupture of the aorta had not been
preceded by any fall, struggle, or any sort of violence.
There is here something very interesting, but which is
very little known, perhaps because in the majority of these
cases death does not seem to present any characters by
which it might have been suspected, and because an autopsy
is neither demanded by the friends nor insisted on by law.
B. Arterio- sclerosis.* — Arterio- sclerosis causes sudden
death more often than any other arterial lesion. The name
denotes a particular degeneration of the walls of the arteries,
which begins generally at the arch of the aorta, and may
then spread so far as to involve the whole arterial system ;
it has, however, two seats of election, viz., the arteries of
the brain and of the kidneys. This generalization and pre-
dilection concern us equally. When an artery has under-
gone this change, its walls become fragile and friable, and
its calibre is diminished, and may even be obliterated.
Fragility of the walls tends to produce rupture of the
artery. Any artery may rupture. Rupture of the aorta is
■^ The term arterio-scle'rose, used in the original, is translated literally
to denote a morbid condition of the arteries for which there is at present
no well-recognised name in English, though such a term is wanted. —
Translator.
LESIONS OF THE CIRCULATORY SYSTEM 151
nearly always determined by an accident, such as a strug^gle,
a rather heavy fall, or a dispute — circumstances which all
call for the intervention of the law, which attributes the
death to violence. At the autopsy there is found a lacera-
tion of the aorta, sometimes completely through the wall,
sometimes incomplete, with separation of the cellular coat,
and a second tear a little lower (' dissecting aneurysm ' of
Laennec). The coronary arteries may rupture likewise and
give rise to haemorrhage into the pericardium. Along with
fragility of the walls, we must take notice of their hyper-
trophy, which lessens the calibre of the artery and no longer
permits the normal amount of blood to reach the neighbour-
ing tissues. This point is chiefly of importance with regard
to the brain, where there are but few anastomoses, and
where the diminished supply of blood immediately induces
anaemia, which manifests itself as hemiplegia, such as was
called * temporary hemiplegia ' by Cruveilhier. This is what
happened to a coachman, who all at once let his whip fall,
and who was carried to the hospital with one side of his
body paralysed, though he recovered his senses and the use
of his limbs after a few days' rest.
These accidents may be met with even in individuals who
are not the subjects of generalized arterio-sclerosis ; aphasia
and hemiplegia are sometimes due to cerebral arterio-
sclerosis, which may remain localized for a long time. When
the blood-supply is not merely irregular, but completely
shut off, it forms a focus of softening in the part which is
no longer nourished, and this leads to death, sooner or later,
according to the region implicated. From the point of view
of sudden death, the vessel that concerns us most is the
basilar artery, which is formed by the union of the two
vertebral arteries, and which supplies by its branches the
medulla and pons.
I know of about 35 reported cases of thrombosis of
the basilar artery. The symptoms occur very much as in
the following case, which may serve as a typical example :
A man, aged 50, felt unwell ; as he was walking along the
boulevard, he entered a cafe to rest ; he sat down and could
no longer speak ; he had not aphasia, however, but paralysis
152 SUDDEN DEATH
of the hypoglossal nerve. He was taken to the hospital,
whence he was discharged temporarily cured.
When the obliteration is immediate and complete, death
may supervene suddenly in a few minutes; there is an
abrupt stoppage of all the vital phenomena, just as if the
* vital knot ' of Flourens had been divided.
[Syphilis may also cause arteritis, either indistinguishable
from the former or in the form of gummata. It most
commonly affects the vessels of the brain.]
C. Aneurysms. — Arterio-sclerosis may lead to the forma-
tion of aneurysms of the great arterial trunks.
Aneurysms of the aorta often take us by surprise in
making an autopsy. They may escape notice altogether
during life, especially if the pneumogastric nerve is not in-
volved in the aneurysmal sac, and if the bronchi are not too
much compressed. A professor of this faculty was one of
the most fervent believers in the doctrine of ' the arthritic
diathesis.' He said that he himself was the subject of this
diathesis, and attributed thereto the violent pains that he
felt in the back and in the chest. He was suddenly seized
during the night with a violent fatal haemorrhage from the
air-passages. He had an aortic aneurysm, though its exist-
ence was totally unknown to himself and to his friends who
had examined him, and it had burst.
Aneurysms of the aorta which eat their way through the
ribs, and reach the surface of the chest, rarely give occasion
for medico-legal investigations ; but when they burst into
neighbouring organs it is otherwise. These aneurysms may
actually open into the spinal canal after having eroded the
vertebrae, into the bronchi, [oesophagus,] or the pleurae. I
know of two cases of aneurysm of the aorta which led to an
inquest being held. They were aneurysms of the abdominal
aorta, and death, attended by vomiting and coldness of the
extremities, was attributed to poison.
[The descending thoracic aorta is perhaps the most
common seat of an aneurysm, which escapes detection
during life and will cause sudden death by rupture. Some
years ago I saw a man in the hospital, suffering from
bronchitis ; he was repeatedly examined with the greatest
I
LESIONS OF THE CIRCULATORY SYSTEM 153
care, but nothing further was discovered. Soon after his
recovery and his return home, he suddenly fell down dead,
and it was found that a good-sized aneurysm of the descend-
ing aorta had burst.]
Those little aneurysms which arise from the commence-
ment of the aorta, where it is still within the pericardium,
may burst into the pericardial sac, and lead to death as
rapidly as does rupture of the heart.
I shall not speak to you of aneurysms of all the arteries.
I must, however, mention those of the large arteries of the
brain, and especially those of the basilar artery. I will add
that the arteries of the brain may be affected with arterio-
sclerosis though all other arteries in the body may be
sound.
It is usually the suddenness of these affairs which leads to
a medico-legal inquiry. But the opposite case happens
sometimes. I was directed one day to make an autopsy on
an old cachectic woman, who had a large bedsore over the
sacrum, and who died in the last stage of exhaustion. The
medical verifier of death, seeing that the trunk and limbs
were covered with ecchymoses, refused permission for burial.
At the autopsy I found general arterio-sclerosis, with an
aneurysm of the aorta, which had burst into the left pleura.
[D. Spontaneous Rupture of the Aorta. — A few cases have
been placed on record, and recently, too, of the rupture of
an apparently healthy aorta, sometimes quite spontaneously,
sometimes as the result of a strain. They are inexplicable.
The following are instances :
Dr. R. Fetch reports* the case of a man aged 56, having
the appearance of a tramp, who was seen to fall suddenly
while walking along a level road. At 9 p.m, he was ad-
mitted to the York County Hospital, and was then uncon-
scious and in deep collapse. The pulse was perceptible and
the diagnosis of cerebral haemorrhage was made. He died
at 2.30 a.m, the same night.
Post-mortem, — 6 oz. of blood were found in the peri-
cardium. There was complete rupture of the aorta in a
slightly oblique direction, about | inch above the semilunar
* Lancet^ vol. i., 1898, p. 85.
54 SUDDEN DEATH
valves. The ascending part was invaginated into the trans-
verse.
The patient does not appear to have been making any
violent exertion at the time of the accident, and the aorta
was remarkably healthy for his age.
Another case is related by Dr. O. J. Kauffman, of Birming-
ham.* A groom, aged ig, was admitted to the Queen's
Hospital, suffering from collapse, due to great internal
haemorrhage, and the presence of a large hsemothorax on
the left side was recognized. There was no history what-
ever of any strain or injury or of any previous disease, but
he had complained of an aching and shooting pain in his
back, opposite the eighth vertebra, for the last month,
though the urgent symptoms only came on immediately
before his admission. He remained in the hospital a week,
seeming to improve slightly. Then fresh collapse came on
suddenly, and he sank rapidly and died.
Post-mortem. — Nearly 5 pints of fresh clots in the left
pleural cavity. There was an oblique tear of the aorta,
opposite the eighth rib, through three-quarters of the cir-
cumference of the vessel, with a false aneurysm of fibrine
outside. The aorta was healthy, but rather thinner and
wider than usual.
The same writer refers to the following two cases : (i) by
Dr. J. Lumsdenf — a woman, 23 years of age, died from
rupture of the aorta after lifting down a box from a shelf;
(2) by Mr. E. A. Lightbourne+ — in a boy, aged 12, the
aorta was perforated by an exostosis of one of the ribs,
causing fatal haemorrhage into the pleural cavity.]
A certain number of individuals exist in whom ecchymoses
are produced with almost incredible facility ; these are the
subjects of general arterio-sclerosis. The slightest violence,
the least effort, even the effort of pressing strongly on the
handle of a door that they are trying to open, is sufficient in
such persons as these to produce ecchymoses. I should not
like to terminate this rapid review of arterial lesions capable
* Lancet^ February 9, 1901.
t British Medical Journal^ January 7, 1899, p. 21.
II, 1896, p. 99.
LESIONS OF THE CIRCULATORY SYSTEM 155
of inducing sudden death, without speaking of rupture of the
pulmonary artery. The fact has been observed once by
Devergie ; he has given us a very abbreviated description of
the case ; and for my part I do not know to what to attri-
bute the rupture.
[The aorta may also be pierced, causing fatal haemorrhage,
by foreign bodies that have been swallowed and become
impacted in the oesophagus. A case in which a needle had thus
found its way has been already mentioned (p. 135). Another
case of like nature occurred as follows:* A domestic servant,
aged 18, complained one day after dinner that a bone had
got into her throat. A medical man was unable to find it,
and she appeared to get better ; but a week afterwards she
was heard groaning one night, and was found lying across
the bed. When lifted up blood spurted from her mouth.
She was removed to a hospital, where she died later on the
same night.
Post-mortem. — A large ulcerated hole was found, caused by
the penetration of a piece of bone from the oesophagus into
the aorta.]
III. LESIONS OF THE VEINS.
Lesions of the veins are not generally considered to be a
frequent cause of sudden death. Nevertheless, such in-
stances are not rare.
A. Rupture of Veins. — Veins may burst. Portal has
described rupture of the pulmonary vein where it opens
into the left auricle. Morgagni has related, with abundant
details, a case of lupture of the vena azygos into the right
pleura, which contained 4 lb. of blood ; the anatomical
specimen prepared by him is still to be seen in the museum
at Padua. This rupture of the azygos vein happened in a
tuberculous girl as a result of a violent fit of coughing.
Andral has mentioned a case of rupture of the vena cava
inferior in a young man who had been wrestling with one of
his comrades, without the wrestling having at all amounted
to a violent struggle.
[Varicose veins of the leg may of course burst occasionally
* Inquest, reported in the Tzmes.
156 SUDDEN DEATH
and bleed profusely. The patient may even bleed to death.
Dr. Fox* reports such an event in the case of a lady ; death
occurred before he arrived.]
B. Thrombosis and Embolism. — The lesions of the veins
which, beyond any doubt, provoke the largest number of
sudden deaths are thrombosis and embolism of the pulmonary
artery. Chief among the varieties of thrombosis which lead
to sudden death, I should place inflamed varicose veins.
Individuals who die under these conditions do so because
the clot coming from an inflamed varicose vein has been dis-
charged into the stream of the circulation, and has blocked
one of the branches of the pulmonary artery. Such an
accident does not usually call for an inquest, though excep-
tions are not very rare.
Some years ago a professor of this Faculty died suddenly.
His brother-in-law wished to undertake all the necessary
duties, and you know how multifarious they are. He fol-
lowed the body on foot in the procession to the cemetery.
He was very tired when he returned, and almost immedi-
ately was seized with great difficulty of breathing. He
would not take any rest, however, and although he was
no better the next day, he received many visits. Another
attack of dyspnoea came on, and he died in it. He had
varicose veins, which became inflamed in consequence of the
fatigue which he had incurred during the last few days, and
clots detached from the inflamed vein had been carried to
the lung, where they had caused a blocking of the artery,
which ended fatally.
The same phenomena occur also in phlegmasia alba
dolens. The clots found in the femoral and iliac veins, as-
well as in the uterine veins, extend into the vena cava
inferior. If the clot gets dislodged, it enters the pulmonary
circulation as an embolus, and if this is large the patient
dies.
[Playfair, writing of thrombosis and embolism of the
pulmonary artery in the puerperal state, says, (t) * From an
analysis of twenty-five cases, in which an accurate post-morten^
* British Medical Journal^ August 25, 1894.
t ' Science and Practice of Midwifery,' first edition, vol. ii., p. 337.
LESIONS OF THE CIRCULATORY SYSTEM 157
was made, cases of spontaneous throm bosis and true embolism
may be divided from each other by a clear line of demar-
cation, depending on the period after delivery at which the fatal
result occurs.' In all but one of fifteen cases of thrombosis,
in which there was no evidence of embolism, death occurred
before the fourteenth day, often on the second or third. In
seven cases of true embolism, death occurred in none before
the nineteenth day. It thus appears that thrombosis is more
frequent than embolism. The causes of thrombosis of the
pulmonary artery appear to be the same as those of peripheral
thrombosis, and occur about the same period. Thrombosis
probably begins in the small branches of the pulmonary
artery and spreads centripetally.]
It is not only in lying-in women that such accidents may
happen. It is essential that you should know that even
before confinement the peri-uterine veins may be the seat of
thrombosis, which only attracts attention when the inflam-
mation spreads to the superficial veins. Women suffering
from phlebitis are often allowed to walk about too soon.
Out of 150 cases of sudden death due to displacement of
blood-clots, death happened 112 times in the first two or
three weeks after the thrombosis began. After this time,
if it is dislodged, it is in the form of a number of small clots
instead of a single large one, which enter the pulmonary
circulation and produce embolism of less gravity. The
results of these are infarcts and haemoptysis, and the woman
only dies if too little of the pulmonary area remains.
When there is a fibroid tumour of the uterus, the veins
and uterine sinuses may be attacked in like manner ; and in
other ways uterine fibroids are often accompanied by pheno-
mena resembling those of confinement.* It is necessary,
therefore, to adopt similar treatment in cases of fibroid
tumours to that of lying-in women, and to take similar pre-
cautions. I will say the same of ovarian cysts.
Thrombosis and embolism may take place in cachexia,
such as that of phthisis or cancer, as you know. The
patient may be sitting up in bed, eating, or obeying the calls
* Bastard, ' Des Thromboses veineuses dans les Corps fibreux de
rUterus.' These inaugurale, 1882.
158 SUDDEN DEATH
of nature, when all at once he feels suffocated and drops
down dead. These accidents are particularly prone to
happen in the case of cancerous growths affecting certain
organs, where they may remain latent for some time ; these
are, cancer of the breast, which induces thrombosis of the
axillary vein, cancer of the womb, before haemorrhage has
called attention to it, and cancer of the prostate.
[A man, aged 38, suffering from ulcerated epithelioma of
the tongue, rose to go to the w.c. one night, and on getting
back into bed called out to the nurse that he was choking ;
his face immediately became very blue. I was sent for, and
arrived almost at once, but the man was just dead, though I
noticed that respiration continued after the action of the
heart had ceased to be distinguishable.
Post-mortem. — The air-passages were quite free, but a pale
granular non-adherent clot, the size of a kidney bean, was
found in the right branch of the pulmonary artery.]
Among these forms of venous thrombosis I shall place
caries of the petrous portion of the temporal bone, which
follows inflammation of the middle ear. Toynbee has shown
that the circulation in the brain or meninges is connected
by numerous anastomoses with that of the middle ear.
Thrombosis of the sinuses, especially of the lateral sinus,
may be the consequence of otitis. When otitis exists, and
the physician or surgeon fears that caries of the petrous
portion may supervene, it is necessary to remember that
sudden death may occur. The clots may be in existence a
long while without attracting attention.
Here is an instance : A man, 36 years of age, who had
inflammation of the middle ear in December and January,
but which had been neglected, went to dine with his sister
one day in the following June, without having sought the
advice of a physician. There was music after dinner, and
he played the violoncello. He was seized all at once with a
terrible feeling of suffocation, and died. At the autopsy a large
clot was found in the pulmonary artery, which corresponded
exactly with the main portion which was situated in the
lateral sinus, and whence it had become detached, without
the deceased having made any effort or violent movement.
LESIONS OF THE CIRCULATORY SYSTEM 159
[In most of such cases of thrombosis of the lateral sinus
from otitis and caries of the temporal bone, the clots are
septic, and give rise to pyaemia if left to themselves.]
Similar occurrences have been met with in the later stages
of typhoid fever.
The same thing may follow boils on the face, especially
those on the lips. A Danish physician, Dr. Ch. Trude,
has particularly called attention to this complication. In
these cases there is often produced an inflammation of the
veins of the face, which may spread to the cerebral sinuses
and give rise to thrombosis. I ought to mention that all
examples of this were observed before the introduction of
the antiseptic method into surgery. They are therefore
probably due to infection, for they have not been witnessed
since. I remember that when I was physician to the St.
Antoine Hospital, I saw in consultation with M. Duplay,
one of the surgeons to the hospital, a foreigner who had
been admitted ; he had a well-marked dermatitis of the face,
which might have been mistaken for erysipelas, nasal
catarrh, and giddiness ; and he had become blind. Our
diagnosis was ' inflammation of the sinuses of the dura
mater,' and the autopsy proved that we were correct.
[In the following case, which was under my care, a large
boil on the breast was complicated by thrombosis of the
pulmonary artery, which proved fatal. It is probable that
the thrombosis was started by an embolus conveyed to the
pulmonary artery. A female, aged 66, had a large boil over
the lower part of the sternum. This was incised, and soon
got nearly well ; the patient got up daily, and seemed in
pretty good health. She sat up in bed one morning, feeling
short of breath, and, after gasping for a short time, fell down
and died almost instantaneously.
Post-mortem. — The heart was large and contained a little
loose clot, not extending into the arterial trunks. The
pulmonary artery and all its branches were packed with
blood-clot : that in the smaller branches was mostly pale,
firm, and adherent ; but in the larger branches there was a
large proportion of loose black clot also. There was no
consolidation of the lungs or pleurisy. The spleen weighed
i6o SUDDEN DEATH
12 oz. The kidneys together weighed 7 oz. and were granular,
though there had been no albuminuria during her illness. A
singular and inexplicable case is related by the late Dr. J. L.
Bristowe.* A young woman who had entered the hospital,
suffering from dry pleurisy on the right side, but who
apparently recovered in a few days, died suddenly when
she was about to be discharged.
Post-mortem. — Most of the branches of the pulmonary
artery of each lung were full of ante-mortem clot : there was
also a clot in the internal iliac vein, and another in the left
innominate vein. Dr. Bristowe expresses the opinion that
this was a case of thrombosis, not embolism, the clots having
the appearance of having been formed in situ.]
In Germany four or five cases of sudden death have been
observed in the course of gonorrhoea in the male ; I only
know of one case in France ; at the inquest it was shown
that there had been phlebitis of the sinuses of the prostate,
and that a clot was carried thence into the pulmonary circu-
lation. Death was due to embolism.
I made an autopsy on a young girl, sixteen years of age,
whose mother had a lover. To attach this man to her still
more, the mother gave him her daughter. The latter con-
tracted gonorrhoea, which led to inflammation of the veins
of the broad ligaments ; there was thrombosis of the left
iliac vein. While sitting on her bed, taking some soup,
embolism occurred, which carried her off; the remainder of
the clot was found in the iliac vein.
Sudden death after a fracture or dislocation may be caused
by thrombosis of the veins which are in direct relation with
the seat of fracture or dislocation. This complication has
been described by Azam of Bordeaux. f
[Perhaps the following case of thrombosis of the heart
after amputation is somewhat analogous. Dr. P. N. Gerrard,
of Selangor.J narrates it. A man got his hand smashed
* Reynolds' * System of Medicine ' : ' Thrombosis and Embolia,' vol. v.,
p. 122.
t Azam, ' De la Mort subite par Embolic pulmonaire dans les Con-
tusions et les Fractures ' {BuH. de VAcad. de Med., 1864, tome xxix.,
p. 816).
X Lancet, October 5, 1901, p. 908.
I
LESIONS OF THE CIRCULATORY SYSTEM i6i
by a dynamite explosion, which necessitated amputation,
though this was not performed until the fifth day. By this
time the wound had become septic, but the amputation
wound was healthy. Eight days after the operation he
died suddenly — in five minutes, without any premonitory
symptoms.
Post-mortem. — A long thrombus was found extending from
the right auricle into the right ventricle.]
It is more frequent in injuries of the lower than of the
upper limbs. It is interesting for several reasons : when
the surgeon is reducing the fracture or dislocation, he can-
not at first recognize the existence of thrombosis, and
ascribes the swelling directly to the injury, and not to the
thrombosis which is the consequence of it ; then he may
be blamed if he has given chloroform to set the fracture or
reduce the dislocation ; in such cases death due simply to
embolism has sometimes been ascribed to the chloroform.
I could tell you of the case of a provincial surgeon who was
actually found guilty of homicide through want of care.
And yet, when we think of the number of patients who
died before, during and after an operation, before chloro-
form was introduced into practice, we are not a little
astonished at the small number of accidents which have
to be put to the account of the anaesthetics, ether and
chloroform.
I shall conclude this medico-legal study of sudden death
from embolism by relating to you the following case, which
shows in what manner you may be called upon to give
evidence :
Some years ago, at Nanterre, a house inhabited by an
old couple was found shut up one morning. The neigh-
bours were uneasy, and informed the son, who lived in Paris.
He arrived, and went into the house. There he found his
father dead, in his shirt, lying on his back in bed, with his
feet on the floor. He looked for his mother, and found her
dead also, at the bottom of a flight of steps leading down
to the cellar ; a candlestick was by her side. The law was
properly set in motion to investigate these two deaths, and
an inquest was ordered. The autopsy revealed the fact that
II
i62 SUDDEN DEATH
the old man had cancer of the prostate, thrombosis of the
sinuses, and a large embolus in the pulmonary artery.
The woman had a fracture of the sixth cervical vertebra,
and haemorrhage into the spinal cord. From these data it
was easy to reconstruct the scene.
On entering the old man's room, there was evidence that
a meal had been going on, and that the bottle placed on the
table was empty. The woman had lighted a candle in order
to go and fetch some wine from the cellar ; she had slipped
on the stairs and broken her spine; the noise of her fall
and the cry she must have uttered roused her husband to
jump off his bed and hasten to help her. The effort was
too sudden or the excitement too much for him. Directly
his feet touched the ground an embolus was detached from
the prostatic sinuses, and he died.
Gentlemen, when you have to search for the cause of
sudden death, and you have reason to believe that it may
be due to embolism, do not conduct the autopsy according
to the usual manner in which it is performed in the hospital.
At the hospital you are especially desirous of verifying
the accuracy of your diagnosis, therefore you open the
thorax and remove the organs contained in it, so as to
examine them with greater ease. If you proceed in that
way, you will fail to find the embolus you are looking for ;
the clot which has been carried into the pulmonary artery
obliterates one of its branches ; there is formed behind it a
more or less long coagulum ; and if, in order to remove the
thoracic organs, you pull on the larynx and trachea, you
change the relations of the parts, displace the clot, and will
not find it in situ.
Instead of this, open the chest freely, open the pericar-
dium and dissect the heart in situ, feel with your finger for
the clots formed during the last hours of life, which you will
be able to remove easily ; follow the ramifications of the
pulmonary artery ; if there is an embolus, you will find it
without difficulty, and you will be able to compare the
broken surface of the clot thrown into the blood-stream
with the remainder of it left in the vein where the thrombus
was formed.
LESIONS OF THE CIRCULATORY SYSTEM 163
C. Air in the Veins. — Allied to this subject of sudden
death by embolism is another, which has occupied the
attention of former generations for a long time, and about
which I must say a few words. The two Berards (especially
the surgeon), Dupuytren, and others also had noticed that
in cases of wounds of the neck, when the wounded man
made any effort, air might enter the veins implicated in the
wound, producing a peculiar hissing sound as it did so, and
that the individual died almost immediately. This was
certainly a sudden death.
You know that the aponeuroses of the neck form a sort
of framework, the meshes of which keep the jugular veins
patent. If one of these veins is opened, the air may enter
it ; this air mixes with the blood in the form of bubbles and
blocks the capillaries ; it is like a plug of gas, which plays
the same part as a clot, and which brings about sudden
death. This is an exact statement.
But the theory of sudden death due to the entrance of
air into the veins has been peculiarly extended in its appli-
cation. The uterine sinuses have been considered to be
included within its scope. It has been thought that entrance
of air into the uterine sinuses might give rise to sudden
death, and that in some cases of abortion death might be
due thereto.
Gentlemen, examine the documents published on this
question ; you will be astonished at the readiness with which
facts are adapted to any theory which is fashionable at the
moment. And this theory, in as far as it deals with the
uterine sinuses, cannot be accepted. As a matter of fact,
during confinement, if the sinuses are gaping, there must be
haemorrhage, and consequently the entrance of air into the
circulation is difficult ; if the uterus is contracted, the sinuses
are closed up, and their canal is obliterated. In abortion
these sinuses can scarcely be patent.
Well, this theory reigned for more than fifteen years,
and has been supported by the most eminent and scientific
men. It was founded mainly on two cases. The first was
observed by Depaul in the Lying-in Hospital. A pregnant
woman who had a deformed pelvis was admitted into the
II — 2
i64 SUDDEN DEATH
hospital. It was necessary to induce premature labour,
and several instruments were passed into the uterus for
that purpose. The women died without having been de-
livered. Depaul resolved to perform Cassarean section
post-mortem. He opened the woman's abdomen, and found,
as soon as he incised the uterus, that air escaped from the
uterine vessels.
The record of this very interesting case ought to be pre-
served. I do not know what explanation to give of it; but
it does not prove that air enters the vessels, for the placenta
was not separated and the veins were not open.
The second case is as follows : A little operation had been
performed on a body which was going to be submitted to a
post-mortem examination, although leave to do so had not
yet been obtained. The operation consisted in tying one or
more veins at two points of their course. At the autopsy,
on cutting these veins between the ligatures, gas was noticed
to escape.
This is a simple example of putrefaction, which is ex-
plained by the succession of aerobic, amphibious, and
anaerobic colonies, and the gases they produce.
Observe that from the day on which the discussion on
the theory of entrance of air into the veins took place no
one else has published any cases of the kind. Now, that
happened in 1859 or i860. When, during the course of
twenty or thirty consecutive years, there has not been a
single instance of a condition which seemed to be very
common before, there is good reason to believe that the
facts have been wrongly interpreted, and that the conclu-
sions which had been drawn from them were false.
I do not say that there never can be any gas in the blood ;
it may be there in cases like those of Dr. Parise, of Lille,
who has twice seen gas escape from the wound at the same
time as the blood, while performing venesection ; but his
patients were suffering from gangrene, and the gangrene
was of that intense kind which is apt to follow bites,
especially rat-bites; he therefore met with phenomena of
putrefaction during life. *.
It may happen also in the case of navvies who have to
LESIONS OF THE CIRCULATORY SYSTEM 165
work in compressed air. You know that, in order to con-
struct certain works — fixing the piles of a bridge, for example
— the labourers are obliged to work in diving-bells filled with
compressed air. Nowadays the pressure seldom exceeds
two atmospheres ; formerly it was not so ; this degree was
far exceeded, and no precaution was taken at the moment
when the workmen came out of the bell, and under those
conditions accidents were numerous. They were particu-
larly common during the construction of the Bridge of Kehl,
where several workmen died suddenly.
The mechanism of this form of sudden death has been
demonstrated in the case of those who have been recalled
to life. One of these men was completely blind in one eye.
Ophthalmoscopic examination showed that the ophthalmic
artery was obliterated, and that a bubble of air had ob-
structed the artery of the optic nerve. The case is not an
isolated one.
When compressed air is absorbed as a consequence of
respiration, and the compression is abruptly removed, the
air tends to escape, and may produce plugs of gas in the
bloodvessels, which, by arresting the circulation at certain
points, may cause fatal results.
Workmen are less exposed to these dangers nowadays
than formerly, because they are made to pass, on leaving
the diving-bell, through a series of chambers, in which the
atmospheric pressure is reduced by degrees.
[Dr. Snell has pubhshed an elaborate memoir on the
subject,* founded on events occurring during the construction
of the Blackwall Tunnel ; but also giving a historical account
of similar undertakings, with an analysis of cases in which
accidents occurred. Paraplegia is not very uncommon, and
is supposed to be due to the giving off of gas in the minute
vessels of the spinal cord. It is found necessary to keep
the caissons very well ventilated and free from excess of
carbolic acid ; for carbolic acid is freed from solution in the
blood more rapidly than other gases, when the atmospheric
pressure is reduced.]
* ' Compressed Air Illness.' London, 1897.
i66 SUDDEN DEATH
IV. LESIONS OF THE CAPILLARIES.
A. Miliary Aneurysms. — You all know what miliary
aneurysms are, so I will not describe them. Their favourite
seats are the brain and spinal cord. Charcot and Bouchard
have pointed out that miliary aneurysms are the most
common cause of cerebral haemorrhage.
In what way may our opinion be called for, from a medico-
legal standpoint, in a case of sudden death from cerebral
haemorrhage ?
I have told you that we very rarely have to make medico-
legal reports after attacks of apoplexy. Death is only
suspicious in certain special circumstances ; for example, if
the deceased had not reached the age at which cerebral
haemorrhage usually occurs, or if it is attended by more or
less unaccustomed phenomena, then the law requires an
inquest to be held.
Miliary aneurysms are most common in aged people, yet
children of 2, 5, 6, 7, or 11 years of age sometimes die of
cerebral haemorrhage. An inquest is rendered obligatory
in such cases as these, either because the child has fallen
down, or because its body presents ecchymoses, or especi-
ally because the public — which has not much knowledge of
these matters — attributes the accident to some extraneous
cause.
[Ordinary cerebral haemorrhage may also take place in
the prime of life : the two following cases, on each of which
an inquest was held, have been reported within the last few
years. — (i) A man, aged 31, undergoing a sentence of four-
teen years' imprisonment at a convict prison, was seized
with apoplexy, which proved speedily fatal. (2) A lady,
aged 39, who had previously enjoyed perfect health, was
riding on a bicycle one very hot day, when she fell and died
suddenly. In both these cases cerebral haemorrhage was
found post-mortem^ and was the cause of death.
An inquest was reported not many years ago on the death
of a lad aged 15. He had gone out with a companion one
Bank Holiday, and during the day ate 30 oranges, one
cocoa-nut, and one mince-pie, and drank cider and ' mineral
LESIONS OF THE CIRCULATORY SYSTEM 167
water champagne.' Returning home in the afternoon, the
boys had tea at a coffee-house, and spent the evening at a
music-hall. Though he had already complained of pains in
his stomach, he partook of further refreshment in the form
of cake and lemonade. Soon after midnight the police
found him standing on the kerb, 300 yards from the music-
hall, rubbing the back of his head, and he seemed dazed.
He vomited while being carried on an ambulance to the
police-station, and died on the way to the hospital.
Post-mortem. — Death was found to be due to sanguineous
cerebral apoplexy, probably brought on by the overloaded
condition of his stomach. There appears to be no evidence
of a fall or any injury.
Cerebral haemorrhage, resembling that from disease, may
sometimes result from a blow. A man was knocked down in
a fight and died soon afterwards.
Post-mortem. — A clot was found in the lateral ventricles,
without any signs of violence on the body that would account
for it.]
If we were to rely only on the statistics obtained from
the cases collected in works of forensic medicine, we should
arrive at the paradoxical conclusion that cerebral haemor-
rhage is more common in the bulb than in the rest of the
brain. As far as that goes I can quote to you thirty or more
cases of bulbar haemorrhage, which have been reported
because they are haemorrhages of an unusual kind. I myself
have only met with two such cases — one at the Morgue, the
other in my private practice — and yet I have made a con-
siderable number of autopsies in my life.
Death is sudden when the haemorrhage into the brain is of
considerable magnitude, and especially when the blood has
found its way into the lateral ventricles. The amount of
blood effused varies ; it may amount to io4^ oz. in fulminating
apoplexy, but it may be safely said that recovery is impossible
when the effusion exceeds 7 to 9 oz.
Allow me to mention to you three cases in which an
inquest was held ; they will enable you to grasp, in a some-
what general way, the reasons for your interposition as
experts in cases of sudden death from cerebral haemorrhage:
[68 SUDDEN DEATH
A man fell down in the street in a seizure due to cerebral
haemorrhage ; he cut his head on the kerb ; no one witnessed
the scene. The body was found, and, as there was a wound,
the law required that an inquest should be held. At the
autopsy it was demonstrated that this individual died natur-
ally of haemorrhage in the brain.
Again, a woman was found dead at the foot of her bed,
with a wound on her forehead ; her chamber utensil was
broken. As she was living on bad terms with her husband,
he was accused of having killed her, and was arrested. The
autopsy showed that she had succumbed to a haemorrhage
into one of the crura cerebri. Whether she had been over-
come by the stroke at the very moment that she was about
to obey a natural call to make water, or whether, on the
contrary, she had been first struck by apoplexy, and under
the influence of the stroke had executed the movement of
rotation, which is commonly seen in cases of haemorrhage
into the crus, and consequently had fallen off the bed, I do
not know ; in any case, the wound was only the result of an
accident, and her husband was acquitted.
The third case gave rise, in the last century, to a judicial
error. Two individuals were arrested at Calais, and accused
of having killed their mother. The first medical experts
who had examined the body had indeed remarked that
there existed in this woman a sub-epicranial and a cerebral
haemorrhage. As the two sons had had a dispute with their
mother, they were immediately accused of matricide. Louis
was consulted. Louis had for a long time been physician to
the Salpetriere, and was aware that sub-epicranial ecchymosis
is a very frequent occurrence in those who are struck down
by cerebral haemorrhage ; he declared that the woman had
died a natural death.
There is nothing that ought to astonish us in the pro-
duction of sub-epicranial ecchymosis, which was thoroughly
studied by Charcot and M. Lepine some years ago.
In cerebral haemorrhage, ecchymosis may appear under the
scalp, or in the pleurae, stomach, or liver. There is only
one important point about this fact which it is necessary
for us to remember : we ought not to conclude, when we
LESIONS OF THE CIRCULATORY SYSTEM 169
meet with ecchymosis outside the skull in a case of cerebral
haemorrhage, that there has been any violence at all ; that
ecchymosis may be produced naturally and spontaneously,
as a consequence of the stroke.
When a lying-in woman dies suddenly from cerebral
haemorrhage, her death may give rise to a medico-legal
investigation ; not that in her case the haemorrhage pre-
sents any symptoms different from the ordinary, but because
sudden death in a lying-in woman, who has had to undergo
certain manipulations, or has had to swallow certain medica-
ments, astonishes the relatives or the attendants, who ask
whether the physician is not responsible for the catastrophe.
If, on the other hand, the woman has had no medical
attendance, suspicion of an induced abortion arises at once
and gives cause for an inquest.
B. Meningeal Haemorrhages. — Meningeal haemorrhages
frequently occasion medico-legal investigations. You know
that they take place in individuals who are predisposed
thereto by alcoholic excess, who have syphilitic caries, or
who are insane. As an effect of one or other of these
conditions, pachymeningitis is set up, which leads to effusion
of blood into the arachnoid space. Baillarger, Longet,
Virchow, Lancereaux, and Cornil have studied the patho-
logical anatomy of these pachymeningites. I only remember
at this moment one point of importance, viz. : that the
vessels of this newly-formed product are extremely fragile,
and possess no middle coat. The readiness with which they
give way is thus easily explained.
The medical jurist's services may be called for in these
cases for different reasons. The individuals who are affected
with pachymeningitis are either alcoholic subjects or are in an
early stage of insanity ; in either case the disease (alcoholism
or insanity) may have hitherto run a certain part of its course
unnoticed, and pachymeningitis may have developed unper-
ceived even by the patient himself Suppose that one of these
individuals gives way to a violent outburst of anger, or that
he gets involved in some commonplace fight or scuffle ;
he may return home without manifesting any extraordinary
appearance ; but the next day he may be found dead, and
17©
SUDDEN DEATH
the superintendent of police will remove his body to the
Morgue.
Meningeal haemorrhage does not take place suddenly ; the
little vessels which give way do not permit the escape of
very much blood at a time. Life is compatible with the
existence of haemorrhage, as long as the compression of the
brain is not excessive ; according to the calibre of the
ruptured vessel, life may be prolonged for five, six, seven, or
eight hours ; and even recovery is possible.
MM. Motet and Vibert met with the following case,
which is somewhat perplexing: An old woman was the
victim of a burglar, who, receiving unexpected resistance
from her, struck her over the head with his jemmy. The
woman became unconscious, and suffered in various ways
from the injury, but recovered after a time. Meanwhile
the burglar had been arrested ; the trial was nearly at an
end, when the woman died suddenly. An inquest was held,
and the autopsy revealed the presence of pachymeningitis
and considerable haemorrhage into the arachnoid. This
woman was neither addicted to alcohol nor insane ; she had
not exhibited any of the conditions which predispose to
pachymeningitis. What was the right conclusion to come
to ? Could the pachymeningitis and consecutive haemor-
rhage be attributed to the blow inflicted on the head ?
MM. Motet and Vibert did not venture to affirm this; it is
probable that this was the actual course of events, but the
medical experts, quite properly, did not feel justified in
interpreting the facts so rigorously.
C. Capillary Embolisms. — Capillary embolisms will not
detain us long ; besides, they are rarely met with ; septic
emboli are the commonest. When there is a wound on any
part of the body, especially when that wound is gangrenous,
as in bedsores of the sacrum, fatal septic emboli may be
deposited in the lungs. Here is "an example :
A lunatic died in the St. Evrard Asylum. He complained
before death of pain and sense of suffocation. The patients
around him accused an attendant of having ill-treated the
deceased. An inquiry was held, and I was directed to make
an autopsy. There were no marks of blows on the body.
LESIONS OF THE CIRCULATORY SYSTEM 171
but there was a bedsore over the sacrum, and there were
some infarcts in the lungs. The patient had died of septic
embolism.
I ought to say, Gentlemen, that since the introduction of
antiseptic dressing these cases have become much more
rare.
I cannot pass silently over a certain form of embolism
which has been called ' embolism of fat,' the emboli having
been deposited in the little vessels.
It was about the year 1880 that Fournoy and von Reck-
linghausen believed that they could trace sudden death
following fractures to these fat embolisms. I have had the
opportunity of examining cases similar to those in which
Recklinghausen had attributed death to embolisms of fat.
According to his view, these emboli were formed out of
the medulla of the fractured bones, which penetrated the
veins and then blocked the vessels. For my part, I think
that these fat emboli are often produced by the putrefactive
colonies of micro-organisms, which were but little known
fifteen years ago. Since microbiology has made the pro-
gress with which you are familiar, and since the colonies
of putrefaction have become better understood, cases of
death attributed to embolism of fat have become extremely
rare.
D. Local Disturbances of the Circulation. — I come now
to the last chapter of the disorders of the Circulatory
System which may lead to sudden death.
An individual may die from anaemia or congestion result-
ing from a considerable disturbance of the general or local
circulation. You know that these two circulations are to
a large extent independent of one another. I will name to
you as an instance a blush, the erythema of modesty, which
follows even a very trifling emotion. Here is a phenomenon
of congestion, which, if it shows itself in a very marked
degree, may entail anaemia of some other part of the system.
In cases of fatal syncope from anaemia, it is of post-
haemorrhagic anaemia that we should think first of all.
I must mention to you the following case observed by
myself :
172 SUDDEN DEATH
A pregnant woman, having very large vulvo-vaginal
varices, was returning from a visit to a midwife ; a formid-
able haemorrhage came on, and she died of syncope. The
midwife was quite innocent of causing this accident. I have
many times had to make an autopsy on women who have
died of post'partum haemorrhage. I will add that these
women were often those who had just committed in-
fanticide.
A man covered with blood and giving no signs of life was
found one evening on a seat in the outer boulevard. The
superintendent of police thought that a crime had been
committed. I made an autopsy, and found a clot reaching
from the mouth to the trachea ; in the trachea was found a
fibrinous clot, like those which form in the heart. I was
able to follow up this clot, and proceeding farther and
farther, I at last came to an open aneurysm in a cavity in
the lung.*
When paracentesis abdominis is performed, at the moment
that the blood flows again into the little abdominal vessels
which the pressure of the contained fluid had kept closed,
a congestion is produced here which may entail death from
cerebral anaemia; even a moderate degree of congestion
may suffice to bring about this catastrophe.
It used to be the practice when an individual was attacked
with copious haemoptysis to apply cupping-glasses or Junod's
boot — you know that apparatus which fits closely on to the
leg and is then exhausted of air ; the blood is drawn with
force towards the lower extremity. In America, where Junod's
boot is still frequently employed, though almost exclusively
by quacks, fatal syncope is frequent. The quantity of blood
displaced by this attraction to the leg can scarcely be more
than if pints, yet it is enough to cause syncope.
When individuals get up for the first time after a long
illness, fatal syncope may take place ; it is therefore neces-
sary not to allow convalescents to rise hurriedly. In fact,
a sudden congestion takes place in the lower limbs when we
move from the horizontal to the upright position.
* It is perhaps open to question whether death in this case was not due
to asphyxia rather than to syncope from anaemia. — Translator.
LESIONS OF THE CIRCULATORY SYSTEM 173
There is no need to have been kept to bed a long while to
experience these sensations. We have all sometimes felt
giddy or dizzy on jumping out of bed in the morning, due to
anaemia of the brain produced by sudden congestion of the
lower limbs. It is obvious that these phenomena will be
much more pronounced in convalescents and lying-in women,
and may even be sufficient to cause fatal syncope.
Owing to the doctrine of embolism being now in favour,
this syncope will nearly always be attributed thereto, while
in reality it is simply due to cerebral anaemia.
You will not find anything remaining at the autopsy which
will enable you to conclude that syncope has occurred. We
possess no characteristic sign of this accident.
In connexion with the subject of death due to cerebral
anaemia, the result of disturbance of the general circulation,
it is appropriate to say a word or two about certain forms
of congestion which may likewise entail death. I refer to
those attacks of congestion to which the subjects of alcoholic
excess are liable. Generally these persons have taken food,
and eaten heartily while intoxicated ; they go to bed, then
in the middle of the night they turn sick and vomit, but
cannot effectually expel the contents of their stomach. The
food that they have eaten enters the nasal fossae, the trachea
and bronchi, and they die, literally drowned in their own
vomit*
* Is vomiting in these cases due to cerebral congestion, or merely to
irritation of the stomach by undigested food ? — TRANSLATOR.
LECTURE III.
SUDDEN DEATH IN LESIONS OF THE CEREBROSPINAL
SYSTEM AND THE MAJOR NEUROSES.
Gentlemen, — Certain lesions of the cerebro-spinal system
may in an unexpected way give rise to sudden death which
appears to the eye of the law to be of a suspicious nature.
I. MENINGITIS.
I will place latent meningitis^ acute or chronic, first. I
shall appear to you to be guilty of an enormous medical and
scientific barbarism. You have been brought up clinically
in the idea that meningitis reveals itself by fever, pain in
the head, vomiting, muscular spasm, etc. How, then, you
will say, can meningitis, going on to suppuration of the
meninges, develop secretly, without attracting any attention,
without displaying any of the classical symptoms of inflam-
mation of the coverings of the brain ? Well, Gentlemen,
latent meningitis does exist . . . and its existence is only
discovered post-mortem.
Let me give you some examples. An individual felt out
of sorts all at once, having been in good health hitherto.
He went to a druggist who gave him two pills ; the patient
swallowed the pills and died. The druggist was accused of
having poisoned him. Tardieu made the autopsy, and found
suppurative meningitis, with a layer of pus of appreciable
thickness spread out over the pia mater.
Ollivier, of Angers, has related the case of a workman
attacked with a sudden illness while he was at his work; he
LESIONS OF THE CEREBROSPINAL SYSTEM 175
went to bed and died in four hours. Suppurative meningitis
was found at the autopsy.
Lastly, M. Vibert made an autopsy on the body of a
prostitute who was found one morning in a bedroom of an
hotel with the death rattle in her throat. She was brought
to the hospital and died there. As the girl had come to
the hotel the evening before in the company of a man who
had left again an hour afterwards, the idea of a crime
naturally arose. M. Vibert ascertained at the autopsy
that there was a sheet of pus two-fifths of an inch thick
spread over the whole extent of the meshes of the pia mater.
Each of these patients performed all the normal and
physiological acts of life until within a few moments of their
death ; none of them had any mental disturbance, pain,
vomiting, or paralysis ; their meningitis was therefore quite
latent. I should add that they were addicted to alcohol.
Tubercular meningitis runs its course under the same
conditions as suppurative meningitis. The results of in-
quests on such cases are nearly always the same ; they are
generally held on children of 12 to 15 years of age. These
children all at once become dull and sullen ; they have
fits of ill-humour, become quarrelsome and sometimes are
beaten, then they rapidly die in the course of 12, 15, or
24 hours. The autopsy reveals the presence of tubercular
meningitis that must have lasted 8, 10, or sometimes
20 days, and that has developed without any of the earlier
symptoms or signs.
[An inquest was held on a child whose death was supposed
to be due to ill-treatment at school.* A boy, aged 15, known
to be delicate, had been ailing obscurely for several months;
he had a discharge from one eye and one ear up to the time
of his death, which occurred after a sudden attack of vomit-
ing and frothing at the mouth. It was stated that his
schoolmaster had been in the habit of boxing his ears for
slight misdemeanours.
Post-mortem. — Cerebral tuberculosis was the proximate
cause of death, and was probably quite independent of the
blows.]
* Lance/, February 28, 1885, p. 395.
76 SUDDEN DEATH
Chronic meningitis, so well described by MM. Hanot
and Joffroy, evidently has fewer surprises for us. The two
individuals on whom they made autopsies had been for a
longer or shorter time inmates of a lunatic asylum. The
suddenness of death might have caused an attendant to be
suspected, and it is such suspicions that might give occasion
for an inquest. They found dropsy of the fourth ventricle,
which was flattened and increased in breadth to double its
size.
[The following is a rather singular case of latent chronic
meningitis ending somewhat suddenly. A stableman, aged
20, was admitted to the St. Marylebone Infirmary on account
of acute tonsillitis, the right tonsil and uvula being chiefly
swollen. Nothing was known of his early history, but his
present illness had lasted only a few days. He was very
drowsy, and passed most of his time sleeping heavily, though
he was restless at intervals. Four days after admission he
had an apoplectiform fit while sitting on the edge of the
bed, and next morning had another fit with convulsions.
(He was said never to have had fits before.) He remained in a
state of stupor, and died later in the day.
Post-mortem. — The brain showed signs of long-standing
chronic meningitis, the arachnoid being thickened and
extensively adherent to the brain ; the convolutions were
flattened, and the ventricles slightly dilated. The heart was
large and the kidneys atrophied, the pair weighing only
70Z.]
Cerebro- spinal meningitis is happily not very common
in France ; it prevailed there all through the second third
of this century. It assumed an epidemic character. The
epidemic which raged three or four years ago in Cyprus
was very severe. Cerebro-spinal meningitis is attended by
vomiting and paralysis, and death takes place in some cases
in three or four hours. Often the disease does not manifest
itself by any symptom; it runs its course rapidly and secretly.
When there is an epidemic of this complaint anywhere, it
serves to explain any sudden death that may happen, and
there is hardly ever any need for an inquest ; but when such
cases occur either at a time when no such epidemic is
LESIONS OF THE CEREBROSPINAL SYSTEM 177
prevalent, or at a place at some distance from the seat of
the epidemic, they cause astonishment and baffle explana-
tion, and the officers of the court order an inquest.
[Fatal meningitis may have a traumatic origin which
might easily be overlooked.* A Polish child was admitted
into a Berlin hospital in a somnolent condition, with a
distended abdomen, high fever, diarrhoea and opisthotonos,
but without trismus, and died shortly afterwards.
Post-mortem. — No signs of typhoid fever. There was puru-
lent deposit on the cerebellum and copious effusion of pus
into the spinal canal. A sewing-needle was found firmly
impacted in the tenth dorsal vertebra, though there was no
mark of entry in the overlying skin.
A very similar event led to the sudden death of a woman,
and an inquest not very long ago. The husband of the
deceased stated that she had been of intemperate habits, and
that while he was attempting to take some drink from her
she fell, and when he picked her up he found that a hairpin
had penetrated her neck. She died next morning from
syncope supervening on injury to the spine.]
II. ABSCESS OF THE BRAIN.
Abscesses of the brain may run their course without attract-
ing the attention of the patient, or of his medical attendant,
or of those about him. This seems all the more extra-
ordinary, because I am not speaking here of those miliary
abscesses the size of which does not exceed that of a pin's
head, but of those abscesses which are as big as a pigeon's
egg, or even a hen's egg. These abscesses may cause death
after symptoms which only last a few hours.
When I was a young doctor and physician to the Sainte-
Barbe College, I had one day to examine a young servant
of the institution who was attacked with otitis. I sent him
into the hospital, where he came under the care of Bernutz.
He was discharged in a fortnight, apparently completely
cured. On the evening of his return home, to celebrate the
occasion, he went to the Vieux-Chene ball, where he drank
* Medical Press and Circular.
12
78 SUDDEN DEATH
freely and danced all night. Next morning, after his return
to Sainte-Barbe, he set to work to polish the floor of the
dormitory as it was his duty to do. All at once he fell
down, and I was summoned to see him ; as he had become
unconscious, I sent him back to the hospital, where he was
re-admitted, this time under the care of Gallard. The latter
noticed that the running from his ear had nearly ceased ;
the patient gradually recovered his senses, but died suddenly
on the following day. At the autopsy an abscess the size of
a hen's egg was discovered in the temporo-sphenoidal lobe.
This abscess which had caused death in a very sudden
manner, evidently did not originate merely on the night of
the ball, but must have developed at the time when he was
under Bernutz. Thus, this man had for a fortnight an
abscess in process of formation in his brain, and yet he was
able to accomplish all the normal acts of existence.
I had been much struck by this case. In 1866, I read
before the Anatomical Society a memoir on * Caries of the
Petrous Portion of the Temporal Bone,'* and I found in the
writings of Itard, as well as in those of other authors, fifteen
almost identical cases of abscess of the brain recorded. These
abscesses are usually consecutive to caries of the cranial
bones, but very rarely to syphilitic lesions ; these abscesses
are very frequent as a result of caries of the petrous portion.
Only once was an abscess of the brain, due to a lesion of
the bones, provoked by a blow. This case was reported
by Closmadeuc. There was a peripheral haemorrhage.
Toynbee has made a study of this question : the plate of
bone which separates the tympanum from the meninges
is very thin ; it is sometimes congenitally absent. On the
other hand, the capillary circulation of the middle ear com-
municates with that of the meninges. It is intelligible,
therefore, how easily inflammation may be propagated from
the middle ear to the meninges. It is less easy to under-
stand how an abscess of the brain comes to be produced
under such conditions, because abscesses of the brain are
never in contact with the carious surface. The gray matter
is intact ; the white matter alone contains the abscess
^ Brouardel, ' Carie du Rocher' {Bz^/l. de la Soc. Anat., 1866).
.
LESIONS OF THE CEREBROSPINAL SYSTEM 179
r cavity. It would seem as if the gray matter served as a
barrier to the abscess. I will not attempt to explain to you
why things happen thus ; I only beg you to remember this :
an individual who has lost a large portion of one cerebral
hemisphere may live for a certain time without the lesion
being made manifest by any disturbance of health whatever.
Is this contrary to physiology ? No.
As a matter of fact, long before the occurrence of the case
which I have just related to you, M. Chauveau injected
different substances into the brains of living sheep. This
was during the epoch when great endeavours were being
made to determine the question of cerebral localization, and
M. Chauveau hoped to throw some light upon the question
by his experiments. He began by injecting water; the
sheep was somewhat stunned at first, but soon recovered
and went on grazing in the field ; then suddenly, on the
following day, it sank and died. After water, M. Chauveau
injected other substances, including chloride of zinc, which
transformed that part of the brain with which it came into
contact into a firm magma. The results were always the
same, but the experiments have not been published. But
I remember this fact, that the animals could live with a
portion of their brain destroyed, and that the lesion would
not be revealed by any external sign. Well, Gentlemen, it
is the same in the case of man.
Some time ago Itard, a celebrated aurist at the com-
mencement of this century, paid great attention to this
subject. He collected a great number of cases, and wrote
that Nature was very provident, inasmuch as the cerebral
abscess, which was trying to work its way towards the
exterior, attacked with caries the very thin bony lamella
near which it was almost always situated, in order to give
vent to the pus. This description is true if we take it the
reverse way, for it is not the abscess, but the caries of the
petrous portion, which is the initial phenomenon.
12-
i8o SUDDEN DEATH
III. CEREBRAL TUMOURS.
Cerebral and cerebellar tumours behave almost exactly like
abscesses of the brain.
We are less surprised to find them at the autopsy, for we
know that these tumours often develop without giving rise
to any indications of their presence. Individuals thus
affected may have attacks of vomiting, which are put down
to dyspepsia ; if they are young or adolescent, they may
have hemichorea, which sometimes suggests the idea of a
cerebral lesion. Others have vertigo, diabetes insipidus, or
diabetes mellitus. None of these symptoms attract much
attention ; but when the patient suddenly falls down either
in the street or in his own house, the more or less singular
circumstances in which he has been struck down, or else a
wound or abrasion occasioned by the fall, causes the law to
intervene.
Here is an example : A dozen years ago I was directed to
make a medico-legal autopsy in a case with the following
history : It was the commencement of a strike. Some
paviors who had a disagreement with their master wished
to enter his office, and lay their complaints before him before
they left their work. Sharp words passed between them,
a dispute followed, and the master, who had been driven to
the further end of the office, tried to extricate himself by
pushing aside two or three of the workmen who were stand-
ing nearest to him. One of these men suddenly fell dead.
The master was arrested and locked up, as much to pre-
serve him from the fury of his workmen as to keep him
within the grasp of justice. At the autopsy I found in the
brain of the deceased workman three little pediculated
fibrous tumours on the anterior wall of the fourth ventricle,
the largest of which was the size of a small haricot bean.
This man had been for some time in imminent danger of
sudden death. The excitement of the circulation provoked
by the quarrel had sufficed to bring it about. His body
bore no trace of violence, and the other witnesses of the
scene declared that he had not been struck.
[The following case was reported by Sir W. H. Broad-
LESIONS OF THE CEREBROSPINAL SYSTEM i8i
bent.* A man was admitted to St. Mary's Hospital, and a
diagnosis was made of syphilitic tumours of the pons
and medulla. He improved to a certain extent, and left the
hospital at his own request. Soon afterwards he got out of
bed one night to smoke a pipe, and was found dead in his
chair next morning.
Post-mortem. — Two separate tumours were found, yellowish
and encapsuled ; one was in the pons, the other in the
medulla oblongata, close to the posterior surface in each
case.]
These examples are not the only ones. In Germany,
Maschka looks upon alcoholic excesses, fatigue of all kinds,
and dancing, as the immediate cause of death during the
development of these tumours.
These tumours are most often tubercle, cancer, or fibroma ;
sometimes hydatid cysts have been observed. Lancisi
reported i* a case a long time ago in which death was due
to the presence of a large hydatid on the surface of the
brain, fatal either by rupture or by compression of the
brain.
The indifference that the brain sometimes shows to the
presence of tumours is confirmed experimentally by its
tolerance of foreign bodies, e.g., the projectiles of fire-
arms. In one autopsy we found a revolver bullet, J inch
in diameter, lodged in the left occipital lobe, where it had
been encysted for a long time, and a second similar bullet,
the base of which was embedded in the squamous portion
of the right temporal bone. Both were the results of
attempted suicide which happened several years previously.
The individual at last put an end to his Hfe by hanging.
Those tumours which most commonly give occasion for
medico-legal investigations are located in the bulb, pons, or
crura cerebri. They may compress the veins of Galen, and
sometimes reveal their existence by clouding the intellect,
or by causing vertigo or visual trouble, but very often
nothing occurs to make their presence suspected. I shall
only mention sudden death as a result of glosso-labio-laryngeal
■**■ 'Transactions of the Clinical Society, London,' April 12, 1872.
t Lancisi, ' De subitaneis Mortibus,' libri duo. Romse, 1707.
1 82 SUDDEN DEATH
paralysis, to refresh your memory. You know that this
affection is due to destruction of the cells of the nuclei
where the motor nerves of the tongue, lips, and larynx have
their origin in the bulb. The hypoglossal is the first to
suffer, then the facial, then the pneumogastric.
[It has been noticed many times in fatal cases of various
gross cerebral diseases — tumour, abscess, haemorrhage, etc. —
that death takes place from failure of respiration, circula-
tion continuing for some time after. Sir Dyce Duckworth
referred to four such cases :*
1. Purulent otitis and cerebellar abscess in a female,
aged 15. The skull was trephined, but no pus was found.
Respiration ceased. Artificial respiration was performed,
and it was four hours before the heart stopped.
2. A female, aged 21, with otitis and headache, due to a
fronto-sphenoidal abscess. The skull was trephined and pus
found. Respiration ceased, but the heart continued to beat
for four and a half hours with artificial respiration.
3. Male, aged 36, with otitis, headache, and coma, due to
a temporo-sphenoidal abscess, which was opened. Respira-
tion ceased, but was maintained artificially for two hours
before the heart finally stopped.
4. Male, aged 46, with haemorrhage on and in the brain,
causing hemiplegia and coma. Trephining was performed.
Respiration ceased, but was maintained artificially for five
hours before the heart stopped.
McEwen notes t the same fact, and says he has often
noticed respiration to fail while the heart remained strong.
In one case artificial respiration was continued for twenty-
four hours, the pulse being strong all the time. In two
cases natural respiration was re-established after it had
been kept up artificially for several hours.
V. HorsleyJ also maintains that patients suffering from
cerebral haemorrhage, or tumour, or sudden violent concus-
sion, especially when due to a blow on the occiput, die from
failure of respiration, not of circulation ; and sudden death may
* International Medical Congress, Lancet, September 4, 1897, p. 632.
t Ibid.
% Quarterly Medical Journal^ July, 1894.
LESIONS OF THE CEREBROSPINAL SYSTEM 183
occur from this arrest. It is the common end of all cases of
increased intracranial tension, especiall}^ when very chronic.
He suggests that in cases where patients fall apparently dead
after blows on the head, and are believed to die from cardiac
failure, the real cause may be arrest of breathing, and they
may possibly be restored by artificial respiration.
In death by hanging, also, respiration ceases before
circulation.]
Sudden death is also one of the anticipated terminations
of acromegaly.
IV. LESIONS OF THE SPINAL CORD.
I come now to lesions of the spinal cord. I shall not
say much about medullary haemorrhages, which are ill
understood. As far as my experience goes, they have only
given rise to medico-legal investigations in the case of
women either during pregnancy or after confinement. Potfs
disease, when it affects the spine just below the occiput, may
at an early stage lead to sudden death. By the name * Pott's
disease ' is understood tubercle of the vertebrae. This often
only manifests itself by localized pain or by torticollis. An
abrupt movement or violent effort may cause the odontoid
process to break and compress the spinal cord. There
is loss of consciousness, and more or less rapid death.
Heurteaux, of Nantes, has narrated a case of sudden death
resulting from the opening of an abscess due to Pott's disease
of the spine just below the occiput into the spinal canal.
[Dr. Weir Mitchell mentions two cases of tabes dorsalis
in its late stages, the medulla being affected, which ended
in sudden death.
Instantaneous death may, of course, be produced by
dislocation of the axis by violence, such as a hard blow
with the fist beneath the jaw. An inquest was recently held
on a case where two men had been fielding at cricket, and
both ran together to attempt a high catch. The head of
one struck the other under the chin. Both men fell to the
ground and could not get up. The former revived by the
use of artificial respiration ; the other was dead, his neck
being broken.
1 84 SUDDEN DEATH
Lobingier reports* a case of fracture and dislocation of
the axis produced by muscular effort. An experienced
athlete fell dead while practising; on the horizontal bar. It
is said that he did not strike any part of the structure.
Post-mortem, — The axis was displaced forwards and to the
right ^ inch, the anterior ligament being torn, and the
adjacent lips of the first and third vertebrae being broken.
The cord was softened for about an inch opposite the
displaced bone. The injury was ascribed to powerful con-
traction of the posterior muscles of the left side of the neck.
V. LESIONS OF THE NERVES.
Pneumogastric Nerve.— The vagus may be affected
among other nerves in peripheral neuritis, and may thus
induce sudden death. Pressure on the trunk of this nerve
has also been fatal. The case has been reported t of a girl,
aged 3, admitted to a dispensary in New York with a slight
cough. There was no dyspnoea, dysphagia, or pyrexia. At
the end of a month, in a paroxysm of coughing, she was
seized with intense dyspnoea, became cyanosed, and died.
Post-mortem. — Miliary tuberculosis was found in the lungs
and trachea. The first and second dorsal vertebrae were
deeply carious and in front of these was a large abscess.
Just below and to the right of this was a large caseous gland,
and the right vagus was compressed between the gland and
the abscess, just where the cardiac nerves were given off.
Immediately above this point the vagus was found swollen
and fusiform, and microscopical examination showed it to
be in a state of chronic interstitial neuritis. No previous
slowing of the heart had been observed.]
VI. EPILEPSY.
The question of sudden death in the course of an attack
of epilepsy is of great interest. When even an experienced
medical jurist publishes a treatise on post-mortem examina-
* Colorado Medical Journal, quoted by the Hospital, November 28,
1897.
t New York Medical Journal, March 15, 1884, quoted by the Medical
Times and Gazette, June 7, 1884, p. 781.
LESIONS OF THE CEREBROSPINAL SYSTEM 185
tion in relation to forensic medicine, he finds it very difficult
to assign definite and pathognomonic characters to death
in an epileptic fit. In the treatises which you have in your
hands, it is stated that death is due either to rupture of the
heart, or to the passage of food from the [mouth or] stomach
into the trachea and bronchi, or else to asphyxia resulting
from the position occupied by the patient during the fit,
such as may cause the mouth and nose to be pressed into
the pillow. In the first case it is clear that death must be
attributed to a lesion of the heart ; in the other two, to a
merely mechanical asphyxia. There is nothing therein
peculiar to epilepsy.
[It is probable that spasm of the glottis sometimes
accompanies the tonic stage of an epileptic fit, and it is
possible that this might be fatal. But besides this there is
another mode of sudden death which in all probabihty
sometimes occurs during a fit of epilepsy — viz., sudden
paralysis of the respiratory centre. Its occurrence was
firmly believed in and taught by the late Dr. Hilton Fagge ;
and it is, perhaps, the best explanation that can be given of
the death of those chronic epileptic patients who are occa-
sionally found to have died in their sleep in the dormitories
of lunatic asylums, without any evidence of their having
been seized with convulsions or of their having been acci-
dently asphyxiated. Dr. Fagge says* with reference to this :
' Within the last few years, several cases of tumour or
abscess of the brain have terminated in this way quite
suddenly and unexpectedly at Guy's Hospital. I know of
at least one instance where the same thing would have
happened in an epileptic fit, had it not been for the diligent
maintenance of artificial respiration. And in cerebral
haemorrhage I believe that this form of death is not in-
frequent. It also occurs in various diseases of the lungs
and air-passages. Probably death from obstruction of the
respiratory passages is due to this rather than to syncope.
... It is doubtful whether intracranial diseases ever cause
death by inhibition of the heart, though death by reflex
inhibition is known.'
* ' Principles and Practice of Medicine,' vol. i.
1 86 SUDDEN DEATH
In all the works of Charcot or of M. Grasset or of the
Salpetriere School, we could not find twenty cases of death
from epilepsy. And yet M. Lesser reports 17 cases of
individuals dying in an attack of epilepsia gravior. Looking
at these cases closely, it is evident that he includes under
the name ' epilepsy ' all sorts of convulsive seizures —
uraemia, etc.
What are the signs of death that are to be found in the
true epileptic neurosis ? After an attack we find that the
neck and shoulders are covered with spots like flea-bites,
that the conjunctivae are injected, that the tongue is bitten
in one or several places, and that the bronchi are filled with
froth. These are the signs that we shall meet with in the
body of an epileptic who has died in a fit. We have no
others whereon to base our conclusions, aud these signs
are almost the same as in death by strangulation by means
of a somewhat pliable ligature, such as a handkerchief or
scarf, which does not leave a mark on the skin and sub-
cutaneous cellular tissue.
A dozen years ago, the body of a child was found under
a heap of sacks on one of the quays of Paris. The marks
found on the body had those characters which I have just
described to you. There was no very distinct mark of
strangulation round the neck, and there were but few
ecchymoses forming punctate lines. The case was about
to be dismissed. I expressed my conviction to the pubhc
prosecutor that that child had been strangled. The inquiry
was resumed, and the truth was discovered. The child wore
a scarf round its neck, with the ends waving behind. His
companions had pulled the ends hard, so that the child was
strangled ; and then, being frightened at what they had
done, they had hidden the body under the pile of sacks,
in the midst of which it had been found.
Many diseases also may produce similar lesions.
[When death occurs during the convulsive stage of a
prolonged fit or series of fits, the rigid contraction which is
the attitude of one or more of the limbs, especially of the
elbows, wrists and fingers, may persist after death, and may
last till rigor mortis sets in ; so that, if the body is seen very
LESIONS OF THE CEREBROSPINAL SYSTEM 187
early after death, this condition may afford evidence of the
mode of death. I observed this very plainly in a case
where an inquest was held on the body of a man whom
I had formerly known as the subject of epilepsy, and was
said to have died in a prolonged seizure.]
The law interferes in the case of death in the course of
an attack of epilepsy on account of attendant circumstances
which may make the death look suspicious. I know of
two such cases, one of which has remained deeply graven
on my memory by reason of the tragic consequences it had.
A tradesman, 33 years of age, whose business was beginning
to prosper, accompanied his wife to the station, as she was
going on a journey. On returning from the station he met
a girl, whom he accosted and took home with him. After
having performed a certain number of acts, the nature of
which you may guess, the girl went to the water-closet, but
did not return. The man became uneasy, rose up, and
knocked at the door, but obtained no answer; and from
sheer weariness he went to fetch the porter, who broke
open the door. The girl had died in the water-closet, and
as she had fallen from the seat she had injured herself in
several places ; among other injuries she had a scalp wound.
The police superintendent took the matter up, and an inquest
was ordered. This girl had a hard chancre, gonorrhoea, and
pus in the bladder. She presented also punctate ecchymosis
of the conjunctivae and shoulders ; the tongue was bitten
and there was froth in the bronchi. My conclusion was
that this young woman might have died from an epileptic
fit. The superintendent was informed from other sources
that she was subject to epileptic convulsions.
The unfortunate tradesman acquired syphilis and gonor-
rhoea. The scandal induced his wife to petition for a
divorce ; he had to give her back her fortune. Deprived
of this capital, he could not pay his debts ; he became
bankrupt, and I am told that he blew his brains out some
years afterwards.
In the country the question may present itself under a
different aspect. Individuals may fall into the fire during
epileptic fits, and burn themselves more or less severely.
SUDDEN DEATH
This fact, known to criminals, has sometimes led them to
throw the body of their victim into the fire, or to set the
house on fire. In every case there are difficult problems to
solve in medico-legal inquiries concerning sudden death in
the course of an epileptic fit.
I can relate to you another still more recent case :
A reckless young fellow, i6 or 17 years of age, was found
dead in the prison van which was carrying him from the
police-station to Mazas prison. The municipal guard who was
in the van said that the individual must have had an epileptic
fit. At the autopsy I only found a little froth in the bronchi;
there was no punctate ecchymosis under the conjunctivae
or on the shoulders, or any biting of the tongue. The
inquiry threw no light on the epileptic antecedents of the
lad. He was morally abandoned, and had no relatives; he
had run away from the situation which had been found for
him. No one could supply any definite information. I
think that the opinion of the municipal guard was correct*
but you will understand that I could not base my conclu-
sions on the diagnosis of a Parisian municipal guard.
I do not know any more difBcult question for the medical
jurist to solve, if he is not already aware that the individual,
whose body he is examining, had a history of epilepsy.
VII. HYSTERIA.
Sudden death in the course of a hysterical fit is much
rarer still than in an epileptic attack. The cases published
by M. Grasset of Montpellier* do not seem to me to be
very conclusive ; they refer to individuals who suffer from
albuminuria, cerebral tumours, sclerosis, etc., in addition.
It seems to me that in this complicated condition it is not
the hysteria, but the organic lesion, to which sudden death
must be ascribed.
MoUiere of Lyons is the only author who has published a
case where it was impossible to discover any cause of death
whatever, beyond hysteria.
[Dr. Weir Mitchell statesf that he has seen three deaths in
♦ Grasset, 'Maladies du Syst^me nerveux.'
f ' Lectures on Diseases of the Nervous System,' p. 22.
1
LESIONS OF THE CEREBROSPINAL SYSTEM 189
hysteria, one of which was almost sudden : A lady, who had
formerly had hysterical paraplegia, died after a brief illness,
which seemed more like a sudden and complete paralysis of
the pneumogastric nerve than anything else, ^o post-mortem
was allowed. The other two deaths were due to congestion
of the kidneys.
A singular case of death in a hypnotic trance was reported
a few years ago,* the following account of it in the news-
papers being given, it is said, by a medical man who was an
eye-witness of the scene. A young lady, Miss S., who seems
to have been often hypnotized before, was thrown into a
trance in the presence of distinguished company at her
house. The object of the experiment, previously agreed
upon by all parties, was to obtain, by clairvoyance, an
opinion as to the health of the hypnotizer's brother, who was
known to be ill in a distant place, but about whose malady
medical opinions differed. In about twelve minutes the
subject of the trance exclaimed, ' I am just asleep,' and gave
signs of great excitement. The hypnotizer requested Miss S.
to go and see his brother and say what was the nature of his
illness and what treatment should be adopted. Miss S. gave
a detailed, scientific and technically correct account of the
lungs and their diseases, and declared that the prognosis in
this case was very unfavourable. After describing the
patient's death, she immediately uttered a piercing shriek
and fell back senseless. Attempts at restoration failed. In
eight minutes her pulse began to fail, and she died shortly
afterwards. A post-mortem examination was made, and the
immediate cause of death was said to be concussion of the
brain.]
VIII. INHIBITION.— SLIGHT INJURIES.
Insignificant injuries, even the slightest blows, may bring
about sudden, even instantaneous, death. In such cases as
these the medical expert may be extremely perplexed.
Before proceeding any further, allow me to relate to you
an absolutely typical case :
* The Times, quoting the Pesther Lloyd^ September 18, 1893.
I90 SUDDEN DEATH
Two boys, aged 12 and 14, apprenticed to a typographer,
were playing in the workshop after luncheon ; they rolled on
the ground, wrestling together and throwing one another
over, but were laughing all the time and had no quarrel or
dispute. The bell rang for them to resume work ; the little
apprentice, who was at that moment lying uppermost, rose
up laughing, and gave the other a slight kick in the epigastric
region, saying : ' You are conquered ; your shoulders have
touched the ground.' The other attempted to rise, but fell
back dead. There was much excitement about it in the
workshop. A medico-legal examination was made, but no
trace of ecchymosis could be found. We did not even find
anything which would explain the fact of death, unless it was
due to a small haemorrhagic point in the bulb no bigger than
a pin's point.
This case is the type of absolutely sudden death provoked
by a blow in certain regions of the body, although the blow
may not have been violent.
There are certain regions which present this susceptibility ;
the epigastrium is the chief. Lancisi, Astley Cooper, and
Maschka have reported cases of sudden death following
slight violence inflicted here.
Sir Astley Cooper's case is as follows* : A man belong-
ing to the India House was attempting to lift a weight, when
another came up and jocosely said : * Here, stand on one
side, and let an abler man attempt it ;' and at the same
instant gave him a slight blow on the stomach, when the
poor fellow dropped down and expired. His body, upon
being opened, showed no marks of violence. -
[Chevers relates-f a case of sudden death from concussion of
the solar plexus, independent of discoverable injury to any
organ, caused by a thick pole on the right loin. He also
says that native Indian grooms are frequently killed by being
kicked in the abdomen by horses : in some cases there is
rupture of the bowel and consequent peritonitis ; in others,
death is due merely to shock.
* Cooper, ' Lectures on the Principles and Practice of Surgery,' Eighth
Edition, p. 9.
t ' Medical Jurisprudence of India,' p. 475.
I
LESIONS OF THE CEREBROSPINAL SYSTEM iQt
Vincent* also says : * A man received a blow from a stick
in the epigastrium. He had an anxious expression and
suffered from oppression. There were also irregular action
of the heart and shivering, that disappeared during the day.
In the evening his appetite returned and he felt well. During
the night he died without a struggle, and at the autopsy there
was absolutely nothing to be found.]
What happens in such a case ? It used to be said that
death took place from syncope, by reflex action upon the
heart ; nowadays, since the works of Brown-Sequard have
been published, we call it death by ' inhibition.' Instead of
a reflex movement, there is produced, on the contrary, an
arrest of one of the functioijs which was in action at the
time the violence was suffered. What are the functions
which are always in operation in the human body ? They
are those of circulation and respiration; and these are the
ones which are arrested.
It has been observed that every time that the action of
the heart has been stopped after a blow on the epigastric
region, the process of digestion was going on. I have
already spoken to you of M. Mirenowitch's experiments on
frogs ; I shall not recapitulate them ; but remember that
there exists an intimate relation between the stomach and
the heart, by means, no doubt, of filaments of the pneumo-
gastric.
Next to the epigastrium must be placed the hypogastric
region ; a kick in the lower part of the abdomen may induce
sudden death.
[A blow over the region of the heart may prove fatal. A
lad, aged 15, was tried at the Guildford Assizesf for the
manslaughter of his mother. The boy had been teasing his
mother one day, and she appealed to his father to stop the
annoyance. He then punished the boy, who ran out of the
house and returned with a stone which he threw at his father
through the open door. He struck his mother instead on
the left breast, and she fell down and died almost immedi-
■ * Balti?nore Medical and Surgical Journal and Review^ quoted by
Gould and Pyle, op. cit. p. 526.
\ The Times, June 15, 1896.
192 SUDDEN DEATH
ately. The medical evidence showed that the heart was
diseased ; but it was stated that, apart from the shock, she
might have lived for several years.
Several cases are on record of death from violent injury to
the testicles. Chevers says :* * It can scarcely be doubted
that this alone has repeatedly killed, probably by nervous
shock.' He quotes the case of a man who killed the husband
of a woman with whom he had an intrigue by seizing him by
the testicles, which he wrenched in a most violent manner.
The victim was in rude health, and after the violence the
scrotum was swollen to the size of a cocoa-nut. Another
case is quoted by the same author where death was caused
by crushing the testicle and bruising the abdomen.
Ivanhoff, of Bulgaria,"!" speaks of a man, aged 45, who
received a violent blow on the testicles in a street fight. He
staggered and fell insensible, and died in three-quarters of an
hour.]
Records of sudden death after violence, even though this
be slight, applied to the laryngeal region, are rare. Never-
theless, such cases exist.
You remember a case which I narrated to you, while we
were studying the 'moment of death,' of what befell a certain
priest (p. 6), who was dismissed for his misconduct, and
accused of having killed his mistress, just as she was packing
up her trunk. The priest maintained that he had only
clasped his quondam mistress's neck, without using any
force, and only in fun, and that she dropped dead immedi-
ately.
The medical jurists of the time did not venture to assert
or deny the possibility of such a fact.
I mentioned to you also that, in consequence of the feeling
excited by that case, an officer of dragoons said that one of
his comrades had been nearly killed in the same manner.
Since then, examples have multiplied. Tardieu has re-
corded the case of an old woman who sold some snuff to a
little urchin. While he was waiting for his screw of snuif,
the boy, tickled by the sight of the old woman's pomum
* Op. cit., p, 478.
t Gould and Pyle, op. cit., p. 525.
LESIONS OF THE CEREBROSPINAL SYSTEM 193
Adami moving up and down in her neck, struck her a blow
on the larynx as if he were trying to catch a butterfly ; the
woman died instantaneously.
[Maschka* reports the case of a boy, aged 12, who was
struck on the anterior portion of the larynx by a stone. He
fell lifeless to the ground. No local or other lesion was found
post-mortem.']
It has been stated, as an objection to the medical jurists
who believe in the explanation of these cases by inhibition,
that there have been many others in which individuals have
not died after sustaining injuries of considerable violence
over the region of the larynx, e.g., after having survived
attempts at strangulation. We do not as yet know the
mechanism of such processes, but we know that they occur ;
so when you are asked in a court of law if it is possible for a
person to die when placed in those conditions which we
have just been examining, you should reply : * It is possible.*
Gentlemen, there are also other parts of the body which
possess this special sensitiveness : such are the mouth and
nose.
Volkmann relates that he had to operate one day on a
hare-lip in a child a year old. He inserted the pins; the
child became blue and ceased to breathe ; he removed the
pins, and the child returned to life. Four hours afterwards
Volkmann wished to proceed with the operation ; this time
no accident occurred. Volkmann even remained for some
time by the side of the child to see that all was going on
well. He then went home, but was sent for again in great
haste ; the child had again presented the same grave
symptoms as at the first operation. Volkmann hastened
back, but the child was dead.
The experiments of Brown-Sequard have shown that the
regions over which the branches of the trigeminal nerve are
distributed have the same susceptibihty as the epigastrium
and the larynx. It has also been thought that the nape of
the neck might be included among these 'privileged' regions:
there is only one case on record, and that is not conclusive.
■^ Gould and Pyle, p. 526, quoting Warren's * Surgical Pathology and
Therapeutics,' Philadelphia, 1895.
13
194 SUDDEN DEATH
Some students at Aberdeen thought that they had reason
to complain, rightly or wrongly, of the conduct of the
University porter, and resolved to play him a trick in return.
They carried him off, led him into a dark room in which
there was a block of wood, blindfolded him, and told him
that he was going to die. The porter was naturally very
much agitated. He was made to lay his head on the block,
then, by means of a wet cloth twisted into a lash, one of the
students gave him a blow on the nape of the neck. The
man died immediately, to the stupefaction of the students.
What was the cause of death ? I do not know at all.
Was it the blow on the nape of the neck? It is possible.
But do not forget that the larynx rested on the block, and
that it might have been the seat of a shock by contrecoup, or
of such a violent injury as would occasion death.
Certain minor operations and insignificant wounds some-
times bring about rapid or sudden death.
[Cases of death rapidly following the sting of a single
wasp or bee are tolerably numerous. In two cases that
happened not long ago death ensued within a quarter of an
hour after having been stung on the hand. In most fatal
cases the sting is inflicted about the lips, tongue, or throat,
causing swelling of the mouth and fauces and great irritation;
death follows from this and from interference with breathing
and swallowing. In igoi a lady at Chepstow was stung in
the face by a bee, and died in ten minutes. If a single bee
can thus sometimes cause death, it is not to be wondered
at that the simultaneous infliction of countless stings must
be far more dangerous. Major Macdonald says* that a
native was set upon and overcome by a swarm of bees in
East Africa. When found, he was lying insensible on the
ground, and his black skin seemed to be covered with brown
fur from the innumerable stings imbedded in it. He survived
a few hours. Cheverst mentions three cases where death
resulted in an hour or two from the sting of a scorpion.
By being repeatedly stung by bees, etc., it is said that
immunity can be acquired, the victim being protected
* ' Soldiering and Surveying in East Africa.'
t Op. cit., p. 29.
LESIONS OF THE CEREBROSPINAL SYSTEM 195
against suffering from similar stings in future.* The same is
said to apply even to snake-bite, and Professor Calmette has
applied it by using an anti-venomous serum as an antidote.]
In Schmidt's Jahrbilcher I find, under the author's name,
the following case :
A peasant v^as stung by a bee ; the sting was followed by
syncope, but the man came to himself. Two years after-
wards he was again stung by a bee, and died. This man
had evidently an exceptional susceptibiHty.
I quote this case to you because there was no question
here of chloroform, or of any accident complicating surgical
procedures. The same applies to the following cases.
Martineau quotes the case of an individual in whom a
hydatid cyst was to be punctured ; the trocar did not enter
the cyst, and was withdrawn. Only two or three drops of
blood escaped ; the patient suddenly expired. Were any
small branches of the pneumogastric nerve injured?
[Mr. Bryant reportsf the following case of sudden death
following the operation of tapping a hydatid cyst. A
man, aged 40, had a large hydatid cyst of the liver. A
small trocar, not larger than a probe, was passed not
more than one inch through the liver substance, and g
ounces of fluid were withdrawn — clear, watery, and non-
albuminous — enough to relieve tension. A pad of Hnt was
then applied. A few seconds after he became intensely
flushed, and complained of agonizing pain in the face and
jaws. He then became livid and unconscious, and, after
vomiting three times, had a kind of epileptiform seizure,
from which he never rallied, in spite of artificial respiration,
etc., and he died in five minutes.
Post-mortem. — A large partially-collapsed cyst was found
projecting from the liver. There was about J pint of
blood-stained fluid in the peritoneum, and 3J pints in
the cyst. Round the margin of the cyst were numerous
large veins, and on careful dissection it was found
that the point of the trocar had pierced the main portal
vein. It is probable that the vein had sucked up the
* Nature, 1897, vol. Iv., p. 533, etc.
t 'Transactions of the Clinical Society, London,' May 24, 1878.
13—2
196 SUDDEN DEATH
hydatid fluid. The cavities of the heart contained only
uncoagulated blood. The vena cava inferior was partially
obstructed. No anaesthetic was employed, or death might
have been ascribed thereto. It is generally recognised now
that there is a certain amount of danger from tapping
hydatid cysts.]
Desnos relates a different case, also concerning an in-
dividual suffering from a hydatid cyst. Desnos applied
Vienna paste in order to procure the formation of adhesions.
Everything went on well at first, but in four or five hours
after the application of the caustic, the person died sud-
denly, although no lesion of the heart or of any other organ
could be detected post-mortem.
Therefore, under the influence of certain extremely super-
ficial lesions sudden death may ensue. Suppose, now, that
chloroform had been administered, the responsibility of the
operator would be called in question.
Sudden death may even take place before an operation is
commenced. A patient on whom lithotomy was about to be
performed died at the very moment at which the surgeon
was introducing the sound into the urethra. There was no
autopsy, and I will do no more than mention the case.
I can, however, relate a more recent one of the same sort :
M. Legroux sought the aid of M. Routier in applying a
splint to one of his patients who had broken the neck of
her femur. While these gentlemen were making their pre-
parations in an adjoining room the woman died. Suppose
this death had happened in the course of an operation after
the administration of chloroform or cocaine, I need not tell
you what the consequences would be. You ought always
to keep these cases in your mind, especially if you happen
to be called upon as experts to sit in judgment upon your
fellow-practitioners.
[Sir James Y. Simpson mentions* the following cases where
sudden death occurred as the result of an accident or surgical
operation, although no anaesthetic had been employed : (i)
While shaving the groin, as a preliminary to an operation
for strangulated hernia. (2) After division of the skin in a
* Lancet^ February 26, 1870, p. 298.
I
LESIONS OF THE CEREBROSPINAL SYSTEM 197
similar operation. (3) Opening an abscess in a child's neck,
without any haemorrhage. (4) Injecting a small quantity of
haemostatic liquid into a sacculated aneurysm in the neck.
Respiration became stertorous, and the patient died in a few
minutes. (5) Fracture of the radius by a fall. Dr. M. set
it, applying splints and a bandage. A few minutes after
leaving the patient's house, he was recalled, but the patient
was dead. He adds : * Four more cases were related to
me, before anaesthetics, by two surgeons, of death on the
operating-table, and various others have been heard of.
We may probably fairly infer, however, that they were not
rare.'
John Hunter says* : ' I have known a man die immediately
of castration.'
Sir A. Cooper also relates the case of a man who expired
immediately after the opening of a thecal abscess. The case
has been reported of a woman who wished to inhale chloro-
form in order to have a tooth drawn. The dentist had no
chloroform, and, as the tooth was loose, he tried to deceive
her by hold a cupping-lamp to her nose. He then pro-
ceeded to open her mouth, but found that she was dead.
Sir Lauder Brunton-f" says that injuries to bones have a
peculiar power to induce shock, and mentions two cases of
Pirogoff's, quoted by Fischer, in each of which amputation
of the thigh was being performed before the days of anaes-
thetics ; in one case the operation was for severe injury, in
the other for chronic disease. In both, immediately after
the bone had been sawn through, the face became pale,
the eyes staring, the pupils dilated, a peculiar rigidity of the
body took place, and death ensued at once. He also tells
the tale of a Httle daughter of a Covenanter being tortured
by the thumbscrew : on the first occasion she fainted, but
was revived ; it was repeated, she again fainted and died
outright.
I have also seen a man die suddenly on the operating-
* 'Works,' vol. iii., p. 381.
t ' On the Pathology of Shock and Syncope,' Practitioner, October,
1873, P- 249.
198 SUDDEN DEATH
table upon the removal of a splinter of the humerus in
man imperfectly anaesthetized.
A curious case of immediate death from sudden concussion
of the body is narrated by Wilkeson* : * A battle-exhausted
infantry-man stood behind a large oak-tree. His back
rested against it. He was very tired, and held his rifle very
loosely in his hands. The Confederates were directly in our
front. This soldier was apparently in perfect safety. A solid
shot from a Confederate gun struck the oak-tree squarely
about four feet from the ground, but it did not have suffi-
cient force to tear through the tough wood. The soldier
fell dead. There was not a scratch on him. He was killed
by concussion.' It is very likely that this is the correct ex-
planation ; though, in the absence o( a post-mortem examina-
tion, it is impossible to be absolutely certain that there was
no severe internal injury.
Lightning-stroke may perhaps be regarded as allied to
mechanical concussion. Its modus operandi is by no means
fully understood, particularly the way in which clothing is
stripped from the body, and the surface of the body is marked
and lacerated. In some cases wounds are inflicted, exactly
such as a knife might have done. A few years ago, in a
violent thunderstorm in the North of England, where several
young men were struck together, one of them was found
on the ground with his throat cut across as if by a knife,
and the case thus simulated homicide.
Cases of death by torture, either voluntarily or accidentally
incurred, or wilfully inflicted, are by no means rare in litera-
ture ; it is not easy to comprehend precisely the mechanism
of death in such cases. It is particularly instructive to read
them in contrast with the opposite extreme of remarkable
endurance of pain. Numberless cases have been known of
severe surgical operations performed without an anaesthetic
and borne without wincing and without a groan on the part
of the patient. To a large extent this is due to mental
influence. Melancholic patients, or those suffering from
certain forms of delirium, will inflict severe and elaborate
injuries on their bodies without apparently suffering pain.
* Ojp. cii.^ p. i6i.
LESIONS OF THE CEREBROSPINAL SYSTEM 199
It is singular, also, that it has often happened that an entire
limb has been torn off without producing much shock or
pain.
Not much help in elucidating the mechanism of death
from shock has been afforded by experiments. Reflex in-
hibition has been referred to above, and will afford a certain
amount of explanation in many cases.
Wilson Philip* observed the effect on the heart of suddenly
crushing the brain or spinal cord in animals — rabbits and
frogs. He found that the action of the heart immediately
became very weak and fluttering, and almost stopped for a
few moments ; but its action was presently continued, though
more weakly than before.
Dr. John A. McWilliam arguesf with much plausibility,
and on the grounds both of experiments on mammalia and
of clinical observation, that simple ventricular standstill —
i,e., cessation of the heart's auction in diastole — is very rare.
It may be met with where there is some gross cause of death
— e.g., syncope from haemorrhage, asphyxia, anaesthetics, and
perhaps reflex inhibition through the vagus — but as a rule,
he maintains, the fatal effects are determined or insured by
inco-ordinate fibrillar contraction of the ventricular muscle ;
the efforts of the heart being worn out in the muscular turmoil
(delirium cordis) thus set up. The subject is one well worthy
of investigation from as many points as possible.
A few other conditions, which are not very abnormal, may
be briefly mentioned as occasionally giving rise to sudden
death.
Graves' Disease. — Ord and Mackenzie say,| * The end
may be sudden, and due to syncope,' but of course this
termination only follows a marked illness.
Sea-sickness is occasionally fatal, though very rarely. It
is said to have occurred only in persons whose constitution
is weakened or broken by disease. A case was mentioned in
the newspapers§ of an American lady who died at Dover as
« * Experimental Inquiry into the Laws of the Vital Functions.'
t British Medical Journal, January 5, 1889, p. 6.
X AUbutt, ' System of Medicine,' vol. iv., p. 500.
§ The Tiines, 1897.
200 SUDDEN DEATH
the result of a rough channel passage. She suffered greatly
while crossing from Calais, was in a state of collapse on
landing, and died shortly after.
Tetanus. — Chevers* mentions a case where sudden death
occurred in the first paroxysm of tetanus. An apparently
healthy boy in Calcutta was having a small sore on his foot
dressed. Immediately afterwards an opisthotonic spasm
came on, and death was immediate.
Tickling. — Trousseau sayst that women have been killed
by tickling the soles of the feet. St. Foix, quoted by Gould
and Pyle,J says that the Moravian Brothers, a sect of Ana-
baptists, having a great horror of bloodshed, executed their
condemned criminals by tickling them to death.]
The presence of foreign bodies in the pharynx, larynx,
and oesophagus produces a more or less rapid death ; but
these cases do not belong to the special chapter of forensic
medicine upon which I am now discoursing to you.
Gentlemen, you can see that in a large number of cases
medico-legal investigation will only lead to very inconclusive
results if you do not know the manner in which the fatal
accident has happened, and if you have not been made
acquainted with all the details. Suppose the case is one of
a child's death from convulsions, your scalpel will give you
no scientific proof of the pathogeny of death in this case, or
in a great many others.
I advise you also to reply very clearly and without hesi-
tation to the questions which the judge asks you, and to
say, * I can find no lesion which can explain death.' You
will, of course, state all the morbid phenomena that you
have found in the heart, the brain, the liver, the kidneys, and
every other organ ; but you should add that other persons
may have lesions quite as serious without death taking
place ; you should say that you are obliged to confess that
it is impossible for you to say what is the actual cause of
death.
It is no humiliation for a medical jurist to acknowledge,
* Op. cit.^ p. 248.
t ' Clinical Lectures,' Syd. Soc. Translation, vol. ii., p. 205.
:j: op. cit, p. 524.
LESIONS OF THE CEREBROSPINAL SYSTEM 201
after making the most conscientious research, that he does
not know ; but it would be humiliating for him to recognise
that he has made a mistake.
IX. SUDDEN DEATH FROM EMOTION.
[Genuine cases of sudden death from some violent mental
shock or emotion are rare ; but a large number of well-
authenticated instances are on record, which have been met
with in ancient as well as in modern times. Some of the
stories have been so often repeated as to have become
classical.
Mental emotion may cause death directly, per se, through
its violent effect upon the nervous system, without the
presence of any organic lesion that is discoverable after
death, or else indirectly — viz., by causing the rupture of the
heart or some bloodvessel, by causing mechanical choking
by food, or by arousing an attack of some pre-existing
disease. The mechanism of all such cases deserves to be
fully investigated ; and they should be published with all
detail, so as to insure the absence of all sources of fallacy —
e.g., the presence and sufficiency of some local disease or a
slight lesion which might in certain circumstances lead to
fatal consequences, and which might be overlooked unless
great care be exercised.
Sudden death from emotion is a stock incident with
writers of romance; unfortunately, these almost always
belong in every sense to fiction and have no claim whatever
to science. It is important, moreover, to separate myth
from fact in all such cases which occur in real life.
All varieties of emotion are capable of inducing sudden
death.
One of the most striking instances of sudden death from
horror is narrated in the Memoir of the Sansons.* At an
execution in Paris on August 19, 1792, in the early days of
the guillotine, a beardless young man, who wore the red cap,
came forward and, mainly out of curiosity, volunteered his
assistance. Sanson, the head executioner, being short-
* English edition, vol. i., p. 268.
202
SUDDEN DEATH
handed, took him at his word, made him ascend the scaffold,
and gave him the cord to pull which liberated the knife, * in
order that he might display his patriotism.' He then
directed him to pick up the severed head and exhibit it to
the crowd. * He took the head by the hair and advanced to
the edge of the scaffold ; but, as he was raising his arm
to show the bloody trophy, he staggered and fell back.
M. Sanson came to his assistance, thinking that he was
fainting ; but he discovered that he was dead. Violent
emotion had brought on an apoplectic fit, which killed him
instantaneously.'
The Reign of Terror produced other similar cases besides.
The following two are taken from the * Journal of the
Princesse de Lamballe ' :* * They (my English man-servant
and French maid) reached Paris on the very day of the
massacre. The first thing the girl saw, on alighting from
the diligence, was the head of the well-known benefactress
of her mistress. The fellow who was bearing it thrust it so
near their faces that the long hair of the victim entangled
itself on the button of my man-servant's coat, who took a
knife to disentangle himself from the head. . . . The poor
girl, at the sight of the horrid spectacle, gave but a shriek
and died in six hours after she reached the inn.'
In the same workf it is stated that * the Duchesse de
Polignac was informed that her friend and Sovereign (Marie
Antoinette) had been beheaded. Though so long prepared,
by previous events and previous murders of the royal family,
for this fatal news, so great was the shock to her that she
gave but one shriek and expired.'
Another death due to the receipt of bad news was lately
reported. J Dr. P. A., of Milford, co. Cork, was suffering
from typhoid fever, and, when apparently recovering, died
suddenly. On the fatality being reported to his brother,
who was also a medical practitioner in the neighbourhood,
and who was recovering from rheumatic fever, he also
fainted and died.
* ' Memoirs of the Royal Family of France,' vol. ii., p. 289.
t Jdid., p. 17, note.
X Medical Press and Circular^ February 26, 1898, p. 179.
LESIONS OF THE CEREBROSPINAL SYSTEM
203
A somewhat similar case of sudden death from the shock
of grief and horror occurred at Lyons in 1886.* Mme.
Dumas, on receiving the sad news that her husband's body-
had been found in the Rhine, and had been carried to the
Morgue at Lyons, went to identify the corpse. The sight
of it produced such a profound impression on her that she
fainted and died in a few minutes.
Francis t gives the following example of death from fright.
A man living in India Was roused from sleep by feeling
something creeping over his naked legs. He had an innate
horror of reptiles, and fancied it was a cobra. He became
collapsed and died in six hours, though it was found before
his death that the reptile was only a harmless lizard.
The death of John Hunter from an attack of angina
pectoris provoked by a dispute is well known. He used to
say that his life was in the hands of any rascal who chose to
tease and annoy him.
Templeman speaks + of a drunken man who died in ten
minutes after a violent scene without blows with another
person.
Post-mortem. — No obstruction or valvular disease of the
heart was found, or any disease of the coronary arteries.
On December 17, 1896, a considerable shock of earth-
quake was felt over the West of England, with its greatest
force at Hereford. It was stated in the newspapers on the
following day that * one poor woman was so terrified by the
movements of the ground that she died from the shock.'
Similar cases are not infrequently recorded as resulting from
earthquakes — e.g., the late severe shock in India — but
probably exposure also plays a large part in bringing about
a fatal result.
Crichton§ quotes the following from Pechlin : * A lady of
quality, who in the year 1681 had several times seen without
alarm the wonderful comet which then appeared, was one
■^ British Medical Journal^ 1886, vol. i., p. 103 1.
t Medical Press and Circular^ 1883.
t Edinburgh Medical Journal^ 1893.
§ ' Inquiry into the Nature and Origin of Mental Derangement,' vol. ii.,
p. 267.
204
SUDDEN DEATH
night tempted to examine it by means of a telescope ; the
sight of it, however, in this way terrified her so much that
she was with difficulty carried safely home, and, the impres-
sion remaining, she died a few days afterwards.'
An inquest was held not long ago at West Bromwich* on
Arthur R. and Mrs. R., his mother. The boy had been
working in a brickyard, when he became entangled in the
machinery and sustained a compound fracture of the skull,
which resulted in death. When the news of the accident
was brought to his mother, she fainted and subsequently
expired. A verdict was returned that death was due to
shock, but the details are not given.
An inquest was held at the Southwark Coroner's Court f
on the body of a man, aged 70. He had got into a violent
passion with his son, and, when remonstrated with for trying
to strike him, became extremely excited, threw himself on to
the bed and died. A post-mortem examination was made,
and medical evidence was given that death was due to
syncope brought on by violent excitement.
Another inquest was held J on a man, aged 45, who had
worked himself into a state of excitement by reading an
account one night of the execution of two murderers.
During the night cerebral haemorrhage occurred, and he died
next day.
Curiously, jo}^ seems to be more readily fatal than grief.
Bacon says,§ * We know it hath been seene that excessive
sudden Joy hath caused Present Death, while the Spirits did
spread so much, as they could not retire again.' Fouquet is
said II to have died from excessive joy on being released from
prison. A niece of the philosopher Leibnitz fell dead imme-
diately on seeing a casket of gold, left her by her deceased
uncle. Crichton also^f narrates the following : * In the year
1544, the Jewish pirate, Sinamus Taffurus, was lying in a
port of the Red Sea called Arsenoe, and was preparing for
battle, being then engaged in war with the Portuguese.
While he was there, he received the unexpected intelligence
* The Times.
Sylva Sylvarum,' § 715.
t Ibid. % The Globe.
II Gould and Pyle, op. cit.
^ Op. cit., p. 171.
LESIONS OF THE CEREBROSPINAL SYSTEM 205
that his son, who in the siege of Tunis had been made
prisoner by Barbarossa, and by him doomed to slavery, was
suddenly ransomed and coming to his aid with seven ships
well armed : the joyful news was too much for him ; he was
immediately struck as if with an apoplexy, and expired on
the spot.'
Dr. Hack Tuke,* after quoting some examples of sudden
death from joy, adds that * quite recently similar fates, the
result of a rebound from grief to joy, have awaited several
women in connection with shipwrecks, their husbands having
been reported as certainly lost and then turning up.'
An inquest was heldt on the body of a female child, aged 7,
who had been in a London Board School. The mother said
that the child had been generally healthy. On the day of her
death, she came running home from school, exclaiming,
* Mother, I have passed the examination !' and produced her
pass-card. She was very excited and overjoyed at her success.
A short time after, however, she was found lying dead on the
floor.
A post-mortem examination was made, and medical evidence
was given that the excitement had caused the heart suddenly
to stop beating.]
* ' Influence of the Mind upon the Body,' p. 317.
t The Times, February 26, 1897.
LECTURE IV.
SUDDEN DEATH DUE TO LESIONS OF THE RESPIRATORY
SYSTEM.
Gentlemen, — We shall devote our attention successively
to lesions of the larynx, trachea, bronchi, lungs, and
pleurae.
I. LESIONS OF THE LARYNX, TRACHEA, AND BRONCHL
A. Lesion of the Larynx. — I described to you those
lesions of the larynx which may cause sudden death when I
spoke to you of the inhibitory phenomena which follow
blows inflicted on the laryngeal region ; but I am anxious to
tell you, first of all, and I entreat you to keep it in mind, that
sudden death is caused much more often by superficial than
by deep lesions of the larynx. Tubercular or syphilitic
ulceration of the mucous membrane of the larynx may cer-
tainly give rise to oedema of the glottis and asphyxia ; but
this oedema is foreseen : the quality of the patient's voice has
been altered for a long while, he coughs, expectorates abun-
dantly, and has become aphonic. There is no ground for
surprise.
We are, however, baffled by such a case as this : A man,
42 years of age, wished to catch an omnibus. He ran about
ten paces, jumped on to the platform, and, at the very
moment he was entering the vehicle, fell down dead. At
the autopsy, two very small polypi, as large as peas, were
found close to the ventricle of the larynx, and it was then
LESIONS OF THE RESPIRATORY SYSTEM 207
ascertained that this man had come up from the provinces
some days before to undergo an operation for the removal
of these growths. He had had no attack of spasm or of
laryngitis before his death.
[A curious case, in which sudden death resulted from
occlusion of the glottis by a large mucous polypus growing
from the pharyngeal part of the pharynx, has been recorded
by Dr. J. Lowe, of Workington.* The patient, Mrs. B.,
complained of dysphagia and the ordinary symptoms of
indigestion, for which she was treated in the summer of
1884. She was not seen again until the following April,
when she complained of decided choking sensations. On
examining the throat with a spatula, nothing could be seen
to account for this ; but on grasping the throat, compressing
the hyoid bone, and looking into the pharynx, a large portion
of a good-sized tumour was clearly visible. Dr. Lowe says :
' I even caught it with my fingers without difficulty, when it
appeared to have the consistence of the tongue itself. I was
doubtful whether it was prolapsed mucous membrane or a
distinct tumour. I, however, demonstrated the tumour and
its pedunculated attachment by means of the laryngoscope.'
The patient was sent to a hospital in order to have the
growth removed ; but the surgeon at the institution failed to
detect the tumour, and discharged the patient. She went to
the hospital a second time, with the same result, and was
again discharged. She died suddenly a few days after the
last journey.
Post-mortem, — A tongue-like tumour was found plugging
the orifice of the larynx. It was attached to the hyoid bone,
and measured 3 by ij inches, and weighed i:^ ounces. It
was a mucous polypus, and looked very much like a
miniature tongue.]
In adults, sudden death may be due to the presence of a
polypus in the larynx. In children it may occur in the
course of stridulous laryngitis, or at the moment of removing
the cannula after the operation of tracheotomy. Some
children do actually die in these last conditions. In others
* The Lancet^ May 31, 1890, p. 1173.
2o8 SUDDEN DEATH
it may be necessary to replace the cannula, in order to
obviate the laryngeal spasm which threatens to carry them
off, and who will be saved by this means.
What are the causes of these spasms ? Authors differ.
Some have found little vegetations around the cicatrices
which, they say, cause the spasms which compel further
operative interference. Others state that they have never
found anything of the kind, and that death takes place un-
expectedly. I will not say which is true. I merely advise
you to remember the dangers which a child may incur upon
removal of the tracheotomy-tube.
B. Lesions of the Trachea. — I must draw your atten-
tion particularly to fatal asphyxia resulting from the intro-
duction into the trachea of food, the contents of a pulmonary
cavity, or of a lumbricus which has contrived to ascend into
the pharynx and enter the glottis.
[An instance of this happened a few years ago in Austria.
Not long after diphtheria antitoxin had come into use, and
its effects were not very well known, so that it was regarded
with great suspicion in many quarters, a child suffering from
diphtheria died suddenly shortly after an injection of this
substance had been made. Death was supposed, not un-
naturally, to have been due to poisoning by the remedy ; yet
a careful post-mortem examination showed that death was due,
after all, to choking, the child having recently partaken of a
heavy meal, and a portion of the food had passed through
the glottis.
Another case, on which an inquest was held in London,
may perhaps be mentioned. A gentleman, aged 62, in perfect
health of mind and body, was found dead in his chair after
dining by himself on a mutton-chop.
Post-mortem. — The heart and brain were healthy, but a
piece of ' skin of the meat ' had entered the larynx and
lodged behind one of the vocal cords, causing asphyxia.
An inquest was held at Falmouth on a boy who was found
dead on board H.M.S. Ganges, which vessel he had joined
three weeks before.
Post-mortem. — A small piece of wood, f by J an inch
in size, was found at the base of the left lung. He had
I
LESIONS OF THE RESPIRATORY SYSTEM 209
probably had the wood in his mouth, and it had slipped
into his throat.]
The most common cases are evidently those in which food
coming from the stomach has been introduced into the
trachea. The following case is borrowed from Laennec :
* Professor Corvisart, wishing to pay surprise visits to a
certain department of the Clinical Hospital, went there one
evening at an unusual hour. He entered the porter's lodge,
and found this individual digesting his dinner, with which
he had taken too much to drink. The man was surprised,
and felt sick, but made a violent effort to restrain vomiting.
He fell to the ground and expired. When the body was
opened, the bronchi, trachea, and larynx were found full of
half-digested food.*
Gentlemen, whether or not an individual has made such
a bacchic repast is of little consequence. He feels that he
must be sick, though he wishes not to vomit because he is
in the presence of his superior, or of someone before whom
he would be ashamed to do so. He strives by a violent
effort not to expel the food which is thrown up his oesophagus
into his throat. The chymous mass enters the trachea, and
he dies, asphyxiated.
In order to understand the readiness and the force with
which foreign bodies may enter the trachea and bronchi, I
will mention to you the case of a sewerman, who fell in the
sewer of the Rue Rochechouart with his face in the trench
of the sewer, and whose trachea M. Descourt found to be
stuffed with sewage sediment, as if rammed in by a ramrod,
and in the midst of this mass was a pebble as large as a
haricot bean, which had been made to enter there by a
strong effort of inspiration. Further evidence is afforded by
those new-born infants who are thrown into privies and fall
into semi-solid faecal matter; they make efforts at inspiration,
and thus introduce this matter to the finest extremities of
the bronchial ramifications. When a section is made of
their lungs at the autopsy, and pressure is applied, little
threads like pieces of vermicelli are squeezed out, the excre-
mentitious nature of which it is easy to recognize.
* Laennec, ' Auscultation mediate,' third edition, tome i., p. 259.
14
2IO SUDDEN DEATH
C. Lesions of the Thyroid Body. — The trachea and
bronchi may be compressed from without by a morbid con-
dition, which sometimes occasions sudden death. This
disease is hypertrophy of the thyroid gland. It is true
that, in cases of very large suffocating goitres, attention is
aroused, and the accidents which may happen are foreseen.
But goitres may lead to sudden death although they are
quite small, and do not give rise to stridulous breathing or
to attacks of dyspnoea ; in women, whether pregnant or not,
haemorrhages may take place in cysts of the thyroid body,
and prove rapidly fatal.
[A comparatively slight enlargement of the middle lobe is
much more dangerous than a much larger swelling of the
lateral lobes.]
D. Lesions of the Mediastinum. — Tuberculosis of the
bronchial glands may also bring about sudden death.
Cases may present themselves in several forms :
1. The existence of tuberculous glands around the bronchi
is not easy to recognize ; sudden death happens more fre-
quently in these cases than in others. Remember what
you see in a strumous child whose cervical glands, for
example, are swollen : it seems to you at first that these
glands are enlarged ; they are really small. It is the sur-
rounding tissue which is oedematous and swollen, and its
congestion gives the gland its enormous appearance. It is
the same with the bronchial glands. The nodular mass
compresses the trachea, and if the process takes place in
youths or in children, whose trachea and bronchi are very
soft, the pressure may be so great that death occurs in an
attack of suffocation in the course of two or three hours.
It is very difficult in such a case to make a precise diagnosis.
Auscultation reveals nothing of importance, and percussion
alone can give you a clue.
2. In the second period, when there have been repeated
attacks of inflammation of the peri-glandular cellular tissue,
it is no longer soft and yielding, but becomes hard and
resistant ; it continues to contract, and thus constricts the
trachea and bronchi. The bronchial glands themselves are
hard and degenerated, sometimes containing calcareous de-
I
LESIONS OF THE RESPIRATORY SYSTEM 211
posits. They may be expelled after having perforated the
trachea. Fritz, one of my fellow-assistants in the hospital,
had to perform tracheotomy one day, on an emergency,
upon the daughter of the director of the hospital to
which he was attached ; this little girl was stifled and very
nearly asphyxiated, when Fritz withdrew from the trachea
a calcareous body which was nothing but a bronchial gland.
Under the influence of this compression bronchial spasm
is produced, followed by fatal syncope. An autopsy will
immediately disclose the cause of death in such a case.
[Several cases are to be found in English medical peri-
odicals during recent years of sudden asphyxia from ulcera-
tion of caseous mediastinal glands into the trachea and
bronchi. Unfortunately, they have all been fatal hitherto.
Instances are to be found recorded by Westcott,* Kidd,-f*
Goodhart,i Hastings.,§ Ord,|| and others. The patients
were all children, varying in age from 2 J to 13 years.
Some of them were plump and healthy-looking, and
previous illness had been unsuspected ; in others, warn-
ing had been given for some length of time beforehand
by attacks of dyspnoea, strident cough or obstinate bron-
chitis. The discharge of the caseous glands into the air-
passages took place quite suddenly, sometimes even during
sleep : intense dyspnoea arose at once, often with screaming
and coughing, and the patient usually died in a few minutes.
In one case tracheotomy was performed, with temporary
relief, but the child died in half an hour. In this case
a plug of caseous matter from a broken-down gland was
found in one bronchus. In all cases a group of enlarged
caseous bronchial glands was found, and the ulceration had
taken place either into a bronchus or into the trachea just
above the bifurcation. In some instances the presence of
miliary tubercles in the lungs is mentioned.]
Rilliet and Barthez have stated in their book that the
large bloodvessels may be opened by the ulceration into
* British Medical Journal^ March 12, 1881, p. 386.
I ' Transactions of the Pathological Society of London,' February, 1885.
X British Medical Journal, February 28, 1885, p. 435.
§ Ibid., March i, 1890, p. 497.
II Lancet, January 5, 1889, p. 37.
14 — 2
212 SUDDEN DEATH
them of bronchial glands which have become hard and
cretaceous. This may possibly occur, but at any rate it is
very rare, and I have not seen it mentioned by any one
except these two authors.
Sudden death has been observed in cancer of the medias-
tinum. I have only met with one such case, and it gave rise
to medico-legal inquiry.
An attendant at the Necker Hospital was accused of
having strangled a patient who was restless in his bed.
The autopsy disclosed the fact that this individual, on
whose body no trace whatever of violence could be de-
tected, had an enormous mediastinal cancer three inches in
diameter; this cancer compressed the trachea so as to
completely flatten it.
With regard to this, allow me, by way of parenthesis,
to put you on your guard against accusations against
hospital attendants, which are nearly always made at
random. I remember a case which occurred in the St.
Anne Asylum. A lunatic, who was somewhat less mad
than the rest, was employed there in helping to keep the
books of the establishment. One day, while turning over
the leaves of the register, he came across the name of
a deceased patient with this note appended : * Internal
strangulation.'
The madman plied his imagination, and persuaded him-
self that this patient had been strangled by one of the
house-physicians. He made formal accusation to the police,
so that the law took the matter up ; exhumation was
ordered, and at the autopsy intestinal strangulation was
found, which had caused death.
Gentlemen, we may smile when we read of such cases :
they are very difficult to clear up, and they cause the
medical expert the greatest annoyance.
II. LESIONS OF THE LUNGS.
A. Pulmonary Congestion.— Pure, ideal pulmonary con-
gestion, without any primary or concomitant disease, is very
exceptional. We shall have to speak of sunstroke and heat-
stroke in this connexion.
LESIONS OF THE RESPIRATORY SYSTEM 213
I think that the cases of idiopathic pulmonary congestion
reported by different authors as having caused sudden death
should be accepted with caution. Hourmann relates that a
young man went to a ball after partaking of a heavy dinner,
and suddenly fell down dead. He adds that the heart was
very large.
Dr. Fortassin, who had advanced cardiac disease, retired
to bed ; in the night rattling was heard in his throat ; his
friends ran to his side, but he died. At the autopsy his
lungs were found to be like two bags of blood ; the right
lung was extensively lacerated, and the pleural cavity was
full of blood.
This case is not one of idiopathic pulmonary congestion,
but of an accidental complication of heart disease, which
seems to have caused death.
The same remark applies to the following case, related by
Ollivier of Angers :
A man was in arrears with his rent ; in an interview with
his landlord a somewhat violent dispute took place, and the
man died suddenly. At the autopsy it was found that he
had adherent pericardium.
M. Verneuil has related several cases of death from pul-
monary congestion in the course of erysipelas ; Devilliers,
in the puerperal state. Houde wrote his inaugural thesis
on the frequency of pulmonary congestion in articular
rheumatism. These are, in my opinion, examples of
secondary pulmonary congestion.
I believe that pulmonary congestion sufficiently intense
to induce sudden death, without any concomitant disease,
is extremely rare, and that an autopsy will always reveal
the disease which has determined the pulmonary congestion.
On one occasion, at the Morgue, I came to the conclusion
that death was due to pulmonary congestion. Both lungs
were really gorged with blood, but the bronchi were the seat
of considerable dilatation — being large enough to hold
pigeons' eggs placed in a row ; between the dilated
bronchi the pulmonar}^ tissue was in the condition of
chronic pnuemonia.
When there is a less extensive disease of the lungs,
214 SUDDEN DEATH
there may be a violent congestion around this lesion —
quite out of proportion to the importance of the lesion
itself; still, the primary disease exists.
We have nowadays quite given up using the phrase
* fluxion to the chest'; we use the term 'pneumonia'
instead. * Fluxion ' has disappeared from our vocabulary,
and, in fact, nothing can be seen of it post-mortem; but,
nevertheless, it is an accompaniment of some diseases, and
constitutes a source of danger to life.
As a consequence of tuberculosis or of renal or cardiac
disease, pulmonary congestion may occur, and may bring
about sudden death, but it is not idiopathic.
B. Pneumonia. — I come now to sudden death in
pneumonia.
Gentlemen, when we hear for the first time of sudden
death in a case of pneumonia, we feel as much astonishment
as when we are told of sudden death in abscess of the brain ;
and yet pneumonia may, under certain circumstances, run
its course in a latent manner, and only be recognized post-
mortem. Hourmann and Dechambre were the first to give
a systematic account of sudden death in pneumonia, while
they v^ere house-physicians at the Salpetriere. At that
time science was dominated by the views of Morgagni on
morbid anatomy ; every one endeavoured to classify, define,
and catalogue diseases ; sudden death in pneumonia was put
down to cerebral congestion. Hourmann and Dechambre
noticed that female inmates of the Salpetriere would some-
times die suddenly under singular conditions ; for instance,
they might have taken their breakfast and be walking in the
garden or sitting on a bench talking to their companions,
and all at once fall down dead. Post-mortem, these gentle-
men found extensive pneumonia that must have existed for
several days, and yet had given rise to no symptoms. We
understand' these cases better now. Charcot has described
them well, and has proved that not only is there no rise of
temperature in such patients, but that the temperature is
even subnormal.
I do not wish to discuss the question of the absence of
fever and of other symptoms ; I am standing on medico-
LESIONS OF THE RESPIRATORY SYSTEM 215
legal ground. You will sometimes meet with cases of
pneumonia — even suppurative pneumonia — that have de-
veloped in an entirely latent manner in old people, in
alcoholic subjects, or in those persons who are midway
between health and disease — pregnant women, for example
(Ollivier d'Angers). The circumstances which call for
judicial inquiry are always the same : an individual, who did
not seem ill previously, dies suddenly, under suspicious,
perhaps tragic, conditions. Here is an example :
A woman, 66 years of age, was found in her room with
gurgling in her throat ; and a plug of linen lay between her
lips : she died without being able to give any explanation of
her condition, and her body was removed to the Morgue
for the purpose of an autopsy being performed upon it.
Quite a romance had been constructed on the incidents
of this case. The porter remembered that a man had
accompanied this woman to her room, and had left the
house shortly after ; he was able to describe this man, who
was identified and arrested.
This woman had a perforation of the arch of the palate ;
upon investigation, it was proved that she was accustomed
to plug this aperture with a linen tampon. The autopsy
demonstrated that she was suffering from pneumonia, and
that the tampon had become displaced and wedged be-
tween her teeth, either in her delirium or in the agony of
death.
Accidents such as that which complicated this case call
forth the interference of the officers of the court.
Some years ago there was brought to the Morgue the body
of a hump-back, which had been found in the Seine and had
not been identified. The hair was as black as possible, and
none of the teeth were wanting, though they were somewhat
worn down; these two facts made us think that the
individual was about 60 years of age. At the autopsy we
found pneumonia of the apex. This individual, whose hair
and teeth were so well preserved, was an alcoholic subject,
who had thrown himself into the Seine in an attack of
delirium in the course of pneumonia.
It was found on making inquiry that he was 80 years of
2i6 SUDDEN DEATH
age. I quote this case incidentally to impress on you that
we have no certain criterion of the age of any individual
whose case we may have to examine. Say simply that the
individual appeared to be of such or such an age.
[Chronic pneumonia may occasionally end in sudden death —
for example, by haemoptysis, though this is rare. The follow-
ing case is, however, an instance : A middle-aged man was
admitted to the St. Marylebone Infirmary suffering from
this complaint. He was weak and pale, but not emaciated
or hectic, and there was moderate dyspnoea, enough to
prevent active employment : there was consolidation of the
upper parts of the lungs, cough, and rather abundant
expectoration. He remained much the same for three or
four months, when he was suddenly seized, early one
morning, with very abundant haemoptysis, the first time it
had ever occurred, and this caused immediately fatal
syncope, or probably asphyxia.
Post-mortem. — The pericardium was adherent ; the heart
somewhat hypertrophied and dilated. Each pleura was
extremely thick and almost cartilaginous, and was universally
adherent. The upper lobe of the right lung was greatly
condensed and contracted, nearly airless, and composed of
a coarse framework of pigmented fibrous tissue, excavated
near the apex by a few small smooth cavities. The left
lung was in a state of advanced fibroid induration, airless
throughout, consisting of hard, tough, pigmented fibrous
tissue : the bronchial tubes of the upper lobes were either
obliterated or dilated. The trachea, bronchi, oesophagus,
and stomach contained coagulated blood.]
C. Capillary Bronchitis. — Capillary bronchitis may cause
death under somewhat different conditions. I shall not
speak here of the form which is met with in childhood, but
shall come to that later on ; I shall only deal with it now in
so far as it attacks youths, adults, and old people.
The term ' suffocating catarrh ' is a very appropriate one
for this condition ; it admirably characterizes the patho-
logical condition to which it is applied. It supervenes in
old people from exposure to cold. In most cases it does
not give rise to any medico-legal investigation ; in others an
LESIONS OF THE RESPIRATORY SYSTEM 217
inquest is called for. Under certain conditions adults may-
be affected. During the siege of Paris, I lost 150 soldiers
or * Gardes-Mobiles ' at the Javal ambulance station, from
capillary bronchitis. It was intensely cold in December,
and you know that many of these unfortunate men had
their feet frozen, with formation of eschars ; they were also
insufficiently fed. These young soldiers guarded the trenches
at night. They were cold and were overcome with dizziness,
so that they had the appearance of being drunk. They had
to be led to the ambulance ; they could not even undress, but
fell all of a heap on their beds and went to sleep. At the
end of five or six hours they died, with their mouths full of
froth, the product of bronchial over-secretion.
M. Ranvier, who held an appointment at the Val-de-
Grace Hospital, at the same time met with precisely similar
cases.
According to the information which we managed to
collect, these men had been attacked first with aphonia and
bronchitis, and they suffered from general exhaustion. On
post-mortem examination, we always found the bronchial
tubes filled with froth and the lungs scattered with black
apoplectic foci, varying in size from that of a hazel-nut to
that of a walnut. These phenomena, which were met with
in soldiers who were merely suffering from a catarrh, were
repeated in an identical form in January in some of their
comrades, when an epidemic of measles was raging in their
ranks.
It is as well that you should know of these cases ; in
winter we often read in the newspapers, when the weather
is very cold in Alsace-Lorraine, the north of France, or else-
where, that an individual — a carrier, for example — has been
found dead on the roadside. You may be asked for your
opinion as a medical expert. Remember that the presence
of froth in the bronchi, subpleural ecchymoses, and pulmo-
nary apoplexies may be the effect of intense cold, and so
the hypothesis of crime may be dissipated. Children used
to be told, and quite rightly, not to drink cold water while
in a perspiration. I saw, at Ste. Barbe, two young people
die in an identical manner after drinking water drawn from
2i8 SUDDEN DEATH
the pump when they had been playing at prisoner's base.
In these cases the cold did not act upon the external surface
of the body, but by reflex action on the lungs by means of
the pneumogastric. In such cases as these you will have to
decide as to the responsibility of the principals — head-
masters of schools or directors of institutions ; there is
no fault that they can be reproached with, except that of
allowing their pupils to have access to a tap of water.
[Chevers remarks, probably with entire justice, that the
danger of imbibing cold drinks when heated depends much
more on the quantity than the temperature of the liquid
drunk. A small quantity of cold water would be harmless,
but a very large quantity, rapidly swallowed to quench thirst,
might be dangerous.]
Capillary bronchitis offers a further point of interest. It
may happen as a result of an accident which is called * night-
man's asphyxia.'
I have notes of three cases which happened in two acci-
dents of this kind. You know, Gentlemen, what is meant
by ' nightman's asphyxia.' A workman goes down into a
cesspool that has previously been opened ; he gives a few
blows with his pickaxe and suddenly falls down. Remember
that the workmen are supposed to wear a belt to which a
rope is fastened ; but workmen will not comply with regula-
tions, even those which are expressly framed to ensure their
safety while engaged in their work.
When a cesspool is emptied, it is generally deemed suffi-
cient to empty it partially, i.e., to remove the liquid and
semi-liquid matter. After this process has been repeated
several times, the faecal matters form a thick, stratified, hard
and resistant crust at the bottom of the pit, which has to be
broken up with a pickaxe and removed with a shovel. This
procedure is styled ' putting the finishing touch.'
In the Rue St. Dominique, a nightman was about to
undertake the cleaning out of a cesspool ; while he was
breaking up the solid faecal crust, he was exposed to the gas
which was given off (I do not know the composition of this
gas, but it does not seem to me to be simply sulphuretted
hydrogen), then he staggered and fell. His comrades
LESIONS OF THE RESPIRATORY SYSTEM 219
shouted to him to come up, and one of them descended into
the cesspool to fetch him, but he fell down also. These two
workmen were brought up again, and the one who had fallen
first was the first to be restored to life, by means of artificial
respiration — a method which I need not describe in detail
here.
In the second accident, the same series of events occurred,
but this time only one workman suffered.
Well, Gentlemen, in these three cases the workmen took
their places in the cart after they had recovered, lit their
pipes, and returned home ; they ate their dinner, went to
bed, and in a few hours they died of capillary bronchitis.
What has the medical jurist to do with such cases as
these ? He may be consulted because the insurance com-
panies refuse to pay the claims. The company admits
having assured the workman against accident, but it de-
clares that it is not responsible here, inasmuch as the
workman died in bed, and not while working in the cesspool,
and that between the time of the accident and the com-
mencement of the catarrh several hours had elapsed, during
which the man appeared to be in good health.
I had some difficulty in getting the responsibility of
the insurance company acknowledged in these cases. I suc-
ceeded because the two accidents happened within a few
weeks of each other, because I was directed to conduct the
medico-legal investigation in all three cases, and because I
had to deliver my reports to the same magistrates, so that I
could more easily persuade them to share my conviction.
D. Pulmonary Phthisis. — Pulmonary phthisis may be a
cause of sudden death ; I have already spoken to you of
cases of this kind when dealing with thrombosis, embolism
and profuse haemoptysis. But besides ordinary phthisis we
may have acute tuberculosis.
You will sometimes have to deal with cases in which
persons are accused of a crime because someone has died
in their presence, in circumstances which the law regards as
suspicious. And you will find, at the autopsy, that the lungs
of the so-called victim are studded with tubercular granula-
tions. A young tripe-seller, 20 years of age, was busy pre-
220 SUDDEN DEATH
paring some tripe for a customer at his stall in the market.
The customer was stretching out his hand to take the tripe
which the dealer was handing to him, when at the same
moment the latter fell backwards, striking his head against
the edge of a table, and his blood streamed out. The buyer
hastened to procure assistance ; but his actions gave rise
to the idea that there had been a struggle. The police
stepped in, and the customer was arrested, while the body of
the tripe-seller — for he was dead — was conveyed to the
Morgue. At the autopsy I ascertained that both lungs were
stuffed with tubercle ; they even stood upright on the slab.
At the inquest evidence was given that the tripe-seller, who
was addicted to alcohol, had been at work all the preceding
night. No one in his vicinity had ever heard him cough; no
one, not even he himself, suspected that he was tuberculous.
Alcoholism was the principal factor in the latent course
pursued by the tuberculosis. Remember, then, that tuber-
cular phthisis may run its course without manifesting any
symptom.
Shall I relate another case to you ? A child, 12 years old,
whom his master had struck on the head with a ruler, died
suddenly. The master was accused of having caused the
child's death. Post-mortem, the lungs and meninges were
found full of granulations. It is evident that the master had
no right to strike the child with the ruler, but this slight
blow had nothing whatever to do with the production of the
pulmonary and meningeal lesions.
Is it possible for sudden death to occur in double pneumo-
thorax ?
Bricheteau has reported two such cases.* M. Duguet has
recorded a third. These are the only cases that I know of.
E. Cancer of the Lung. — This is a painful affection of
slow progress, and is accompanied by attacks of suffocation,
and by sputum of characteristic colour. I only know of one
case of sudden death from this disease which has given occa-
sion for an inquest.
The accused person in this case was a chemist, who had
given two pills to a gentleman who had consulted him, and
* Bricheteau, ' Clinique medicale.'
1
LESIONS OF THE RESPIRATORY SYSTEM 221
who had died suddenly after swallowing the pills. The
chemist was prosecuted for illegal practice of medicine, and
for making a mistake in the drugs he had sold. The autops}^
having revealed the existence of cancer in the lung of the
deceased, the prosecution was abandoned.
F. Emphysema of the Lungs. — Piedagnel wrote his
inaugural thesis on sudden death in pulmonary emphy-
sema. He collected the eports of thirty cases, which were
published not long ago. I should like to make the same
remarks with reference to emphysema that I did in the case
of pulmonary congestion. I do not believe that emphy-
sema alone, apart from any other lesion, can lead to sudden
death, any more than simple pulmonary congestion can
do so.
G. Pleurisy. — Of all pulmonary affections, pleurisy causes
the greatest number of sudden and unforeseen deaths. They
frequently occasion medico-legal investigations. These cases
of sudden death may be divided into two categories, accord-
ing to the process by which death is brought about : one of
these has been well described by Aran, physician to the St.
Antoine Hospital ; the existence of the other has been
demonstrated by a large number of observers.
Aran was struck by this case : A young man, aged 25, came
to his consulting-room one day quite out of breath. He
called himself an * arthritic,' and ascribed his symptoms of
oppressed breathing to that diathesis. Aran made him
undress, examined his chest, and ascertained the presence of
pleuritic effusion reaching up to the middle of the infraspinous
fossa. He told the patient to get home and go to bed, and,
as the latter consented to have paracentesis performed, he
would come and perform it immediately.
At the very moment that Aran reached the house the
patient died.
[A very similar case is reported by Sir W. H. Broadbent.*
A gentleman, aged 24, of very phthisical family, had a large
pleuritic effusion on the right side, which was increasing
rapidly: there was dulness all over the side, passing across
the middle line of the sternum. Respiration was free, but
* 'Transactions of the Clinical Society, London,' March 2, 1878.
222 SUDDEN DEATH
attended by effort and expression of distress on the face, but
there were no paroxysms of dyspnoea. The patient had
been able to lie down at night, and was lying down when
seen ; his pulse was good. Paracentesis was proposed for
the following day, and after some hesitation the patient
consented. He awoke next morning at six o'clock, feeling
comfortable, but immediately afterwards was seized with
severe dyspnoea. After some delay, his medical attendant
was sent for, who arrived at ten o'clock and found the
patient dead.
In this case the symptoms were ordinary ; removal of
fluid was urged, not from apprehension of immediate danger,
but because the effusion was increasing rapidly, and dyspnoea
would . ensue. No post-mortem examination was allowed.
Death was probably due to thrombosis of the pulmonary
veins.]
There are cases of latent pleurisy, where the effusion takes
place gradually, where there is only slight shortness of
breath, without severe attacks of suffocation, which are the
most frequent causes of sudden death. I have seen thirty
such cases at the Morgue since 1876.
Besides these cases of pleurisy with very abundant sero-
fibrinous effusion, there are others with less fluid, sometimes
purulent, and involving the diaphragm, which cause sudden
death.
The pathogeny of this form of sudden death has given rise
to lengthy discussion. It has been ascribed to displacement
of the heart, the theory being that, when the apex of the
heart is displaced to the right by effusion on the left side,
the heart is so twisted thereby that its action is interfered
with, and that sudden death may result from this abnormal
condition. Now, pleuritic effusion is at least as common on
the right side as on the left.
Torsion of the aorta has also been credited with causing
the disaster, but without any more reason.
Embolism has also been mentioned. Two cases might
appear to corroborate this view. The first is that of Dr.
Wood, an American. He relates that an individual
became suddenly hemiplegic and aphasic in the course
LESIONS OF THE RESPIRATORY SYSTEM 223
of an attack of pleurisy, from embolism of the middle
cerebral artery. The second case is that of M. Vallin,*
who reports a case which is identical with Dr. Wood's.
In both cases the embolus came from the pulmonary
veins ; the clot which had been broken off entered the left
side of the heart, passed into the arterial system, and blocked
the middle cerebral artery. These cases therefore confirm
the theory, which is possibly correct. But can this sole
explanation be applied to all cases of sudden death in
pleurisy ? That is a very different matter.
Gentlemen, when one lung is no longer able to perform
its work, the other is obliged to carry on the whole of the
lesser circulation. The quantity of blood that is necessary
to maintain circulation has, therefore, only one lung at its
disposal, and this organ has almost double work to perform;
suppose, then, that from any cause the circulation of blood
in the healthy lung is obstructed, hypersemia or congestion
must follow, which may cause sudden death : post-mortem in
such cases, apoplectic nodules are found. I do not main-
tain that this is the sole cause of sudden death in pleurisy,
but I am sure that it is one of the causes, since I have found
in many instances, post-mortem, that the healthy lung is con-
gested and full of apoplectic foci.
Woillezf has reported some cases of sudden death occur-
ring in the course of pleurisy. Read these reports over
again, and you will find in his accounts of the post-mortem
appearances, which are described with the great care charac-
teristic of Louis's pupils, the exact lesions that I have pointed
out to you.
They have not struck Woillez in the same light, however,
nor has he attached more importance to the discovery of
apoplectic foci in a healthy lung.
Lastly, in some cases there is, along with the effusion,
fatty degeneration of the heart, adherent pericardium, etc. ;
we are entitled to regard these lesions as contributing to
bring about sudden death.
From the point of view of forensic medicine, the questions
* Vallin, Soc. med. des Hop.^ 1871, and Gaz. hebd. de Med.
t Woillez, 'Traite des Maladies des Voies respiratoires.'
224 SUDDEN DEATH
are often embarrassing. Answer them for yourselves in the
following instance :
A policeman arrested a man : the latter resisted, and
aimed a blow with his fist at the chest of the officer, who
fell down dead ; witnesses saw the blow struck, and the
arrested man admitted having delivered it.
On opening the thorax, a considerable amount of pleuritic
effusion was found, compressing the right lung. The officer
was therefore in danger of sudden death at the moment
when he was making the arrest. Was it, therefore, justifiable
to say that the blow had caused death ? At any rate, it was
only the exciting cause.
Sudden death may happen during the operation of para-
centesis thoracis; it is less common nowadays than formerly,
when fewer precautions were taken about the operation.
While I was house-physician I had one day to assist one of
my masters in performing paracentesis : the patient was a
wealthy banker, and four professors of the Faculty were
present at his bedside ; a number of basins were in readiness
to receive the fluid that was to be drawn off. The needle
was entered, but without result ; the puncture was repeated
twice more, but still without any success ; and at the end of
a quarter of an hour the physicians went away without one
of the basins having been wetted. In six hours the patient
suddenly began to expectorate a large quantity of albuminous
fluid, and died.
Legroux, Marotte, and others have expressed the opinion
that death during paracentesis is due to syncope. The
patient is usually seated on his bed ; in proportion as the
pleuritic fluid escapes there is a rush of blood towards the
lungs, and syncope follows from cerebral anaemia. This is
possible.
[A case of fatal syncope following paracentesis thoracis is
reported by the same physician.* A man, aged 62, complained
of shortness of breath and occasional attacks of dyspnoea.
Fluid was found in the left side of his chest. After five days'
rest, paracentesis was performed : 80 ounces of serum were
removed, but without forcible suction ; there was no pain or
* Transactions of the Clinical Society, London, October 23, 1876.
LESIONS OF THE RESPIRATORY SYSTEM 225
fainting ; the heart came back nearly to its normal position,
but a considerable amount of fluid remained in the chest.
The man seemed to be relieved and to be doing well, though
he had the usual cough. He had his tea, and about half an
hour afterwards, three and a half hours after the operation,
was noticed to be very quiet, and was then found to be
dead.
Post-mortem. — There was no evident thrombosis of the
pulmonary veins or arteries. The right lung was normal ;
the extreme base of the left lung had not expanded. The
upper part of the lung contained air, and there was much
froth in the bronchial tubes. The heart was large, pale,
flaccid, and twisted to the left on the great vessels at the
base ; the right side was empty.
In a severe case of pleurisy, with effusion on the right
side, that I attended several years ago, paracentesis was
performed twice, with great relief on each occasion, but the
patient died suddenly in an attack of dyspnoea, thirty hours
after the second operation. No post-mortem examination
was allowed, but I suspected thrombosis of the pulmonary
vessels.]
Since we have had more perfect instruments, and as we
can repeat the aspirations from time to time, we do not com-
pletely evacuate the cavity, and we no longer exhaust it by
removing all the effused fluid. When the proper point is
exceeded and an excess of liquid is withdrawn, considerable
pulmonary congestion ensues, and as a consequence there is
bronchial over-secretion, just as in ' suffocating catarrh '; it
is, however, much more albuminous, doubtless owing to
exudation of blood serum into the aveoli of the lung.
M. Terrillon has made a study of these cases ;* he has
collected about thirty of them, all nearly identical. The
individual on whom paracentesis is performed is seized with
a spasmodic cough ; the operation is not proceeded with ;
the patient is put to bed. On feeling his pulse, there is
nothing to give warning of any accident. An hour after the
* Terrillon, ' De I'Expectoration albumineuse apr^s la Thoracent^se.'
Th^se inaug. Paris, 1873.
15
226 SUDDEN DEATH
patient coughs up an extraordinary amount of liquid from his
bronchial tubes, and dies suffocated.
[Dr. S. West contributed a paper* on this subject to the
Clinical Society, and arrived at similar conclusions, viz., that
serous expectoration after paracentesis is due to cedema of
the lungs resulting from rapid filling of the bloodvessels in
the newly-distended lungs, with consequent exudation.
Fatal cases, he supposes, must be attended by some per-
manent condition, such as obstruction of the pulmonary
veins, or perhaps of the lymphatics.]
Such accidents scarcely ever happen now, since the opera-
tion is not pushed so far now as it used to be. However,
they do occur occasionally, and the responsibility of the
physician or surgeon will be called in question. In cases of
the sort, I shall always remain faithful to the rule that it is
wise to leave some fluid behind in the pleural cavity, but I
should not think it a serious error if the physician should go
a little farther. It depends on an estimation of the nature
of the case. The amount of fluid in the pleura cannot be
known exactly ; it is easy to make a mistake. Any one who
declares that there are 5 pints effused may only find ij or
2 pints, while another who believes that there is only an
insignificant effusion may be astonished at having to
withdraw 3J or 5 pints. It seems to me, therefore, quite
unjustifiable to hold a fellow-practitioner responsible for an
error of this kind.
Accidents of another kind have been described by
Raynaud and myself. They may take place while washing
out the pleural cavity, or during the injection of iodine, etc.
In such circumstances epileptiform convulsions may occur,
but I do not think that they have ever caused sudden death.
Moreover, they do not seem to be met with now that the
operation of paracentesis is performed with greater skill and
precision.
[A fatal case of convulsions following the injection of an
empyema cavity has been recorded by Dr. Cayley.] f
H. Rupture of the Diaphragm.— I ought to say a few
* 'Transactions of the Clinical Society, London,' April 10, 1896.
t /did., vol. X.
LESIONS OF THE RESPIRATORY SYSTEM 227
words to you about rupture of the diaphragm. It is neces-
sary that you should know that it may exist. How is it
produced ? It is very difficult to say exactly, partly because
it is an extremely rare condition^ partly because it is very
difficult to ascertain whether or not there has been a con-
genital hernia. In cases of sudden death, with or without
violence, a portion of the abdominal viscera may be found
intruding in the pleural cavity ; it is not always easy to say
what was the exact state of the organs that existed before
the final accident. M. Duguet* has recorded 17 cases of
rupture of the diaphragm, and I would advise you to read
his very interesting memoir, discussion of which now would
detain us too long.
[I. Compression of the Chest — Tight-lacing. — Readers
of Dr. John Brown's * Horse Subsecivae ' t will remember
*Jeems the Doorkeeper,' who used zealously to render
assistance to the girls who fainted in church, by * ripping
up ' their stays with his knife, the laces * cracking like bow-
strings.' Such a condition is generally trivial enough, like
the ordinary hysterical fainting of women ; but, apparently,
fatal suffocation sometimes proceeds from this cause. One
instance of fatal syncope from wearing tight clothes is
mentioned by Winslow.]: The sex of the victim is not
mentioned, but it may probably be guessed.
Another case, upon which an inquest was held, and in
which death was ascribed to this cause by the medical man
who attended the patient and gave evidence, happened in
recent years. § A servant girl, aged 22, went on Novem-
ber 14, 1896, to see a procession of motor-cars start in
London for Brighton. She got pinned in the crowd and
was with difficulty extricated by her companion. She then
said: * Take me away, I feel stifled!' On reaching home,
she felt tired and worn out, and took a bath to refresh her-
self ; but while doing so her head suddenly sank down and
she expired. A post-mortem examination was made, and it
* Duguet, ' De la Hernie diaphragmatique congdnitale.' Th^se de
doctoral. Paris, 1866.
t 'John Leech and Other Papers,' 1882.
% Lancet^ November 21, 1840.
§ Morning Post^ November 20, 1896.
15— 2
228
SUDDEN DEATH
was stated in the medical evidence that the girl was very
stout, and that death was due to having been too tightly
laced, which brought on syncope ; this condition was aggra-
vated by crushing in the crowd. This opinion is probably
correct ; but in this case, as in most of a similar nature, the
cause of death is complex ; the impure air of the crowd may
also have had something to do with it.
A very similar case happened still more recently, in 1901.
A female servant, somewhat stout in figure, and wearing
tight stays, fell dead while hurrying along the street one
evening. Death was found to be due to syncope, brought
on by tight-lacing.]
LECTURE V.
MODIFICATIONS OF VASCULAR TENSION : THEIR ACTION
AS AUXILIARY CAUSES, OR AS EFFICIENT CAUSES
(WHEN IN EXCESS).
Gentlemen, — Certain influences play an important part in
the causation of sudden death. Their mode of action is to
produce changes in vascular tension. With your per-
mission, I will distinguish between their modes of operation
as follows :
I. AUXILIARY CAUSES : EFFORT, COLD, HEAT.
Many persons think that heat and cold are the two prime
factors of sudden death. This is true to a certain extent.
Heat and cold frequently determine sudden death in those
who are the subjects of some lesion which places them in a
position of physical inferiority and prevents them from suc-
cessfully resisting such influences. But, as a rule, heat and
cold only act as contributory causes.
There are other cases where, apart from any concomitant
lesion, heat or cold may determine sudden death. Post-
mortein you will only find healthy organs, and the problem
you have to solve will be difficult.
When these influences are exerted in an accessory capacity,
we may sum them all up in the same formula : they bring
about some modification in vascular tension. They com-
prise effort, the process of digestion, cold, and heat.
You know what effort signifies. The muscles of the chest
are contracted ; respiration is performed by the diaphragm
230 SUDDEN DEATH
only ; all the viscera within the chest are as motionless as
possible, in order that the individual may have a firm basis
from which his muscles may act. See what happens in
coughing : the walls of the chest are fixed ; the diaphragm
alone acts ; the body becomes stiff ; vascular tension is
increased ; the veins swell ; the face gets red. If there is
any locus minoris resistentice in the circulatory system, e.g.y a
miliary aneurysm in the brain, it may burst, and its rupture
may cause sudden death. Cases of this sort have been
noticed during parturition, in the fits of whooping-cough, in
defaecation, and even during coitus.
[Death during, and as a consequence of, coitus is rare,
and, as far as I am aware, h^s not been known to occur in a
perfectly healthy individual. A few cases that are on record
may be briefly mentioned. The two following are related by
Mr. Linnecar,* and death was due to rupture of the basilar
artery in each case : (i) A man, aged 38, tall and spare, fell
dead by his wife's side during intercourse. (2) A full plethoric
man, aged 60, suddenly fell dead during intercourse. The
three following cases are narrated by Inman ; but, unfortu-
nately, nothing is said about a post-mortem examination in
any of them : (i) A man who had suffered great loss of blood
from a wound. (2) During transient improvement in a case
of phthisis. (3) A man, weak from diabetes, got up from
his marriage-bed, only to return to it, and died before
evening.]
While the process of digestion is going on, there is equally
an increase of vascular tension. It has been noticed that
cerebral haemorrhage often takes place after a meal, especi-
ally if much has been taken to drink. By drinking two or
three pints of liquid, which is not an exaggerated amount, the
vascular tension is raised, and a vessel may give way before
the kidneys have had time to dispose of the surplus by secre-
tion of urine, thus restoring the tension to its normal degree.
As to variations of temperature, it is certain that sudden
death is most frequent during the winter months.
When sudden death is due to the influence of heat or cold,
the mechanism by which death is produced is not the same
* Lancet^ April 24, 1841.
MODIFICATIONS OF VASCULAR TENSION 231
in both cases. Understand, Gentlemen, that I am only speak-
ing now of such temperatures as we meet with in France.
Under the action of somewhat intense heat, the capillaries
dilate, the skin gets red and covered with perspiration. The
dilatation of the capillaries lowers the vascular tension ; the
pulse remains regular, but is more frequent. When the
vascular dilatation is considerable, and the heart is weakened
by any cause whatever — in persons suffering from aortic
incompetence, for example — it may produce fatal syncope.
The action of cold shows itself in the contrary way. The
capillaries contract instead of dilating ; intra-vascular tension
is increased ; the pulse is less frequent. It causes a reflux
of blood to the central organs, and if any vessel is weakened
it will burst. This is what happens in those who suffer from
aneurysm, particularly miliary aneurysm.
In both cases heat and cold only act as auxiliaries to some
pre-existing cause.
II. EFFICIENT CAUSES : COLD. HEAT.
These agents may be, in a certain number of cases, the
sole factors of death. They may become efficient causes by
their excess. A body is found by the roadside : what is the
cause of death ? Nothing but d, post-mortem examination will
supply you with facts which will enable you to decide whether
death may be due to heat or to cold. You ought to be able
to deliver a reasoned opinion, and, in order to do this, you
should know first of all that an excessive temperature is
not indispensable. Heat and cold may kill without the
thermometer registering abnormal temperatures.
A. Heat. — Let us first consider death due to heat alone.
It has been said that it may be due to sunstroke or heat-
stroke ; there is no great difference between them. Of
course, I exclude that trifling effect of insolation which is
common in our climate, and which shows itself by erythema
of the skin, and is devoid of danger.
We know but little of sunstroke in France ; but it is very
frequent in America. In New York it kills 20 or 30 persons
every year. There are more victims of sunstroke in New
York than in any other city in the world.
232 SUDDEN DEATH
[In the year igoi the annual * heat-wave ' was especially
severe, lasting and extensive. The heat remained excessive
for a fortnight without intermission ; and though the maximum
shade temperature in the city of New York did not exceed
98° or 99° F., the humidity, etc., of the atmosphere made it
extremely oppressive. On July 2 there were 225 deaths in
New York, and 250 horses fell dead in the streets also.
During the week ending July 7 there were 989 deaths
altogether from the heat ; and, of course, many more were
affected with heat apoplexy in milder forms. Many other
cities of the United States were affected in like manner to
a greater or less degree ; in some places the maximum shade
temperature was several degrees higher, but its pernicious
effects were not as great as in New York. After the sub-
sidence of the first * wave ' of heat, there was a recurrence
a few days later, but of less intensity.]
In heatstroke, on the contrary, it is not the solar radiation
which kills. People are found dead in the shade of a wood
or under a tent, while the thermometer registers 97° F. in
the shade. The heat is a moist one.
In sunstroke the symptoms resemble those of meningitis.
In persons thus struck we meet with delirium, cerebral dis-
turbance (which were formerly designated ' frenzy,' or
* phrenitis ')> and sometimes vomiting. Claude Bernard^
and M. Vallin have experimented on this subject, but their
results were not very decisive. CI. Bernard shut animals up
in boxes, only the head being outside the apparatus, and
exposed to the sun. The animals subjected to these experi-
ments showed symptoms like those of meningitis after a
certain time ; but an animal placed in these conditions can-
not move — its body, confined in a box, cannot liberate the
heat which is stored up in it. It is no longer in the same
situation as an animal that is free to move about as it likes,
and the results of the experiments to which they were sub-
mitted ought to be accepted with great reserve.
Heatstroke is very prevalent in India ; it is from that
country that the descriptions of it come. In France we
had our first opportunity of studying it about 1866, and the
* Claude Bernard, * Leqons sur la Chaleur animale.' Paris, 1876.
1
MODIFICATIONS OF VASCULAR TENSION 233
earliest cases that were met with were misunderstood. At
that time the Suez Canal was nearly finished, and the ships
began to bring back to Europe the labourers and soldiers
who had served in the East. On board several of these
ships some of the passengers suffered from a singular form
of illness. These individuals, who were, moreover, in an
excessively hot atmopshere (104° F. in the shade), spent the
day in their cabins. Some of them, who had been in good
health hitherto, were seized, on leaving the tabl'e, with
attacks of delirium and frenzy ; they wished to jump over-
board, and they died speedily.
These phenomena were regarded as attacks of pernicious
fever supervening in persons who had lived in hot climates,
and who had formerly suffered from intermittent fever there.
This was the explanation given by M. Texier. It has had to
be abandoned. We are now convinced that the attacks were
only cases of heatstroke, and it is now found necessary to
take negroes as stokers on board ships passing through the
Red Sea, for none but they can resist the intensity of the
heat which prevails in the stokehole.
[Those persons are most liable to sunstroke who are work-
ing very hard while exposed to the full heat of the sun. In
the most severe cases, death may occur very rapidly.
Lieutenant-Colonel J. K. Trotter* mentions the case of his
companion. Captain McK., who had previously suffered from
fever and hard work, and was new to the country. He died
of heat apoplexy in half an hour. Also Osier says that ' death
may be almost instantaneous, the victims falling as if struck
upon the head.']
Besides these fatal cases which take place in distant
regions, we had, even in Paris, in 1877, some sad cases
which may help to elucidate the nature of the disorder.
When the review of July 14 was over, the troops were dis-
banded, and returned to their cantonments. Some regiments
retired to the woods of St. Cloud or Vaucresson. The men
were disposed to rest themselves there, and many were
seized with genuine heatstroke. Dr. Pioche, who was then
a military surgeon, has contributed a complete account of
* 'The Niger Sources,' London, 1898.
234
SUDDEN DEATH
these cases. He relates that no sooner had the men re-
moved their knapsacks than they fell down panting, with]
their faces flushed and anxious, and some of them died. It]
is a curious fact that the non-commissioned officers especially]
were selected as victims.
The question of clothing has very much to do with the
production of heatstroke. During the Chinese War, two
battalions took part in the military operations from the
beginning of the campaign. The men of one of these bat-
talions still wore the cloth uniform which they had worn in
Europe ; those of the other battalion had been supplied with
the colonial dress. Among the latter no accident was met
with ; among the former, on the contrary, the heat made
numerous victims. In all other respects they were equally
exposed.
People may die of heatstroke in a conflagration. This
fact was proved to us when the Opera Comique was burnt.
I am well aware that the production of carbonic oxide must
be taken into account in such conditions. But the lungs
cannot long withstand the introduction of air heated to
104° or 122° F., even if this air contains no carbonic oxide.
Dr. Speck* has reported the following case : A girl com-
plained of rheumatic pains. She was put to bed, and ten
loaves of bread fresh from the oven were placed around her.
At the end of three hours, the unfortunate girl was dead.
She had succumbed to the hot vapours exhaled by the
loaves of bread.
In connexion with such examples as these, those fatal
accidents should be considered which may suddenly befall
individuals in a vapour bath. You may be called upon to
make medico-legal investigations in cases of this kind.
Without speaking to you of that woman who was found
dead in a bath-room, the temperature of which was 187° F.,
and where the steam-jet remained open, there are less
extreme cases, where the temperature is not too high, but
where the individuals who suffer have not been able to
endure it long. I do not know whether these individuals
had any constitutional defect, which is the main factor, or, at
* ' Cas de Mort par la Chaltur' (Ann. d^Hyg.^ 1876, tome xlvi., p. 561).
MODIFICATIONS OF VASCULAR TENSION 235
any rate, a potent predisposing cause, of sudden death ; but
I know that under any circumstances vapour baths, with a
temperature of 158° to 185° F., give rise to accidents so
frequently that I do not dare to recommend them.
What is the modus operandi of heat when it determines
•death in these conditions, i.e., in India, or in the stokehole
of a ship ? When the heat becomes considerable, the
capillaries of the skin and of the lungs dilate ; intravascular
tension is lowered, and the skin is bathed in perspiration.
While the skin perspires, the lungs eliminate a still larger
amount of water. Observe, Gentlemen, that when an in-
dividual suffering from pneumonia or typhoid fever has a
dry tongue, it is because he no longer eliminates watery
vapour by his lungs.
The organism gives off watery vapour as a defence against
the heat. But when the external air is saturated with
moisture, the organism can continue the struggle no longer,
the lungs can no longer eliminate water, the beats of the
heart increase in frequency, its sounds become indistinct,
and it stops ; while the axillary temperature runs up to
104° F., or even 113° F. ; the individual is literally baked,
and he dies.
The process is identical with that in a porous earthenware
carafe ; the water in the interior of the vessel is chilled by
the evaporation of that which percolates to the outer surface.
When the atmosphere is dry, and the body is kept more or
less in motion, much higher temperatures can be borne than
in a confined place where the heat is moist.
The lesions found post-mortem are those of pulmonary con-
;gestion. Hestrez has very fairly compared the lungs to two
bags of blood ; the bronchi are full of froth. The blood
remains black, though in contact with air and oxygen ; it no
longer becomes arterial, therefore the corpuscles must have
undergone a profound alteration. It is very important for
the medical jurist to be aware of this fact, because it is
always possible at an autopsy, except after certain forms of
poisoning, or when putrefaction is already advanced, to re-
store the red colour to the blood. In this case it is no
longer possible to do so.
236
SUDDEN DEATH
The nervous system suffers severely. Vallin has insisted
that these patients are insensible. They have headache,
become delirious, then comatose, and die. The pupils are con-
tracted at first, but dilate widely in the last moments of life.
In 1844, during the conquest of Algeria, General Bugeaud,
who led a column of 3,000 soldiers, was exposed to an ex-
treme temperature ; he lost 200 men, eleven of whom com-
mitted suicide in the space of three hours. Ideas of suicide
are, as a matter of fact, common in individuals suffering
from heatstroke, especially if they are alcoholic subjects.
Gentlemen, when the temperature of a muscle is raised,
certain phenomena are observed which I ought to bring
to your notice ; they have been shown very clearly by
M. Marey's registering apparatus. When this instrument
is attached to a frog's thigh, the animal's muscles are
tapped several times, and the contraction which follows
each tap is marked on the register ; in proportion as the
muscle is warmed, the curve diminishes in amplitude, and
soon becomes a straight line, and although the taps are
repeated, the line remains horizontal. Kiihne of Heidelberg
has explained the phenomenon by the coagulation of myosin.
Others have ascertained the presence of lactic acid in the
muscles of the frog, just as in over-driven animals. M. Vallin
observes that, in animals exposed to the full heat of the sun's
rays, the heart stops in systole ; if the animal is killed im-
mediately, M. Vallin finds the left side of the heart so hard
as to deserve the epithet ' ligneous.'
As regards the secretions, there are only two which offer
any point of interest : at the commencement of heatstroke,
perspiration is profuse, then it stops ; the urine, on the con-
trary, is scanty at first, but becomes abundant (polyuria) when
the skin no longer acts. Morehead has pointed out the
frequency and intensity of this desire to urinate. Gubler states
that he has found albumen and sugar in cases of this class.
I should find myself in considerable difficulties, Gentle-
men, if I were obliged to give an opinion, founded simply
on post-mortem examination, on the cause of death in a
medico-legal investigation of a fatal case of heatstroke.
These cases happen more often in the provinces than in
MODIFICATIONS OF VASCULAR TENSION
237
Paris. Do not forget to inquire under what circumstances
the person died ; find out whether he had been eating or
drinking ; go and examine for yourself the wood in which
the body was found ; ascertain the temperature, the force
and direction of the wind, the moisture of the air, etc., on
the day when death occurred. These details are of impor-
tance, for examination of the body will only afford presumptive
evidence.
B. Cold. — Death from cold is more common than that
from heat. In Russia cold kills about 700 persons annually.
M. Lacassagne* estimates that we lose in France on an
average 200 men and 50 women annually from cold.
This proportion is easily explained : the occupations ot
men expose them more than women to external cold.
An experiment of Magendie's explains in a very suggestive
way the mechanism of death from cold. He shut up a rabbit
in a cage, the temperature of which was maintained at 32° F. ;
in five minutes the temperature of the rabbit had fallen 5J°;
in a quarter of an hour it had fallen 11°; and in 40 minutes
it had fallen 36°, and the animal died. It is easy to under-
stand why this happens. Under the influence of cold the
capillaries contract and vascular tension is increased. As
the resistance augments, the action of the heart becomes
slower. As long as the peripheral capillaries are contracted
the body does not cool much, for the blood does not reach
the surface, and thus part with its heat by radiation ; but
when the contractile force of the capillaries is exhausted,
they dilate, blood rushes to the surface, and gives up a great
deal of its heat.
You know that when you make snowballs your hands are
cold at first, but afterwards become red and warm, the
capillaries being dilated. It is the same with the cold
douche. The jet of cold water makes the capillaries con-
tract ; they should not dilate until the douche is over, in
order that it may prove beneficial. But if the individual
becomes warm under the douche, to use the douchers' ex-
pression— ie., if the capillaries, which were at first contracted,
dilate while still exposed to the jet of cold water — he turns
* Lacassagne, ' Prdcis de Medicine judiciaire.' Paris, 1886.
238
SUDDEN DEATH
blue, the blood, chilled by the cold water, returns cold t<
the internal organs, and the situation becomes perilous.
When the cold is intense, frost-bite may occur ; the nose,
eyelids and ears are usually the first portions of the body to
suffer. But these are local lesions, which are quite distinct
from our present subject.
Our physiological resources against cold are limited.
When the degree of cold is slight, we walk more briskly ;
we feel exhilarated ; we inhale more oxygen and exhale
more carbonic acid.
It is no longer so when the cold is intense. In death by
cold it seems as if combustion is arrested ; the blood re-
mains crimson ; it no longer contains carbonic acid, and it
has lost its coagulability. The chemical changes in the
body are therefore very much disturbed.
[At low temperatures the haemoglobin of the blood fails to
give up oxygen to the tissues.]
What is the action of cold upon the nervous system ? If
the exposure to cold has been of long duration, the indi-
vidual has no recollection of what has passed ; there is
amnesia (which has been well described by M. Motet*).
At the outset there may be delirium, there is often a pro-
pensity towards suicide, and always a tendency to sleep ; sen-
sibility is deadened (remember that the application of cold
was at one time used to procure local anaesthesia in petty
operations, such as that of ingrowing toe-nail) ; sight is dim ;
according to Gmelin, the retina is pale and the lens some-
times frozen. The vaso-motor system is also affected.
Weir Mitchell placed a bladder of ice along the course of
the ulnar nerve ; the hand became cold, then the capillaries
dilated, and it grew red, just as after section of the great
sympathetic.
The muscles contract under the influence of slight cold ;
remember the movements of the cremaster and the desire to
pass urine, which you can prove experimentally on yourselves.
When the cold is keen, the muscular contractions last longer,
and finally stop ; Marey's recording instrument has made
"^ Motet, 'Intoxication par I'Oxide de Carbone, auto-observation'
{Ann. d'Hyg.y 1894, tome xxxi., p. 258).
MODIFICATIONS OF VASCULAR TENSION 239
this clear. The muscular fibres no longer contract volun-
tarily ; the individual cannot walk, and is obliged to stop ;
he becomes stiff, and the action of his heart ceases. The
urine, which is abundant at first, is suppressed at last ; the
skin remains dry, and there is no perspiration.
Larrey has given a masterly description of death from cold
in his account of the retreat from Russia ; I cannot resist
the temptation of reading a few lines of it to you :
* We were all in such a state of prostration and torpor
that we could scarcely recognize one another ; we marched
in gloomy silence. The organ of vision and the muscular
strength were weakened so that it was difficult to proceed,
and even to maintain one's equilibrium. The individual
thus affected fell at the feet of his companions, who did not
turn their eyes to look at him. Although I was one of the
most robust men in the army, it was with the greatest diffi-
culty that I managed to reach Wilna. On my arrival at
that town, I had no more strength or courage left ; I was
ready to fall to rise no more, like so many other poor
wretches who had perished before my eyes. . . . The road
from Miedzeski to Wilna was covered with corpses. Death
in these poor creatures was preceded by pallor of the face, a
sort of idiocy, difficulty of speech, and by weakness, or even
a total loss, of sight. In this condition some of them marched
for a while, guided by their comrades or friends ; muscular
action grew perceptibly weaker, the individuals staggered as
if they were drunk; weakness increased steadily until the
man fell — a certain sign of the total extinction of life. . . .
They were immediately struck by painful torpor, then passed
into a state of lethargic drowsiness, and in a few minutes
their burdensome existence was over.'
Similar cases were observed on the ship Tegethoff, and
have been described by Payer and Weyprecht while winter-
ing in the ice at a temperature of 58° F. When the men left
their cabin to go out, they were sometimes exposed to a differ-
ence of 126° or 130° F. ; but as it was possible to keep the
cabin warm, they were able to withstand these violent changes.
I have told you, and I repeat, that sudden death may be
produced without the external temperature being extraordin-
540 . SUDDEN DEATH
arily low. It has been observed even with the thermometer
at 32°, 30°, or 28° F., when the wind is very strong. This is
a very important fact to know in forensic medicine.
In 1845, General Levasseur, after receiving a repulse, led
his troops to Setif. This is the retreat which is known as
* The retreat of Bou Thaleb ' ; it occupied forty-eight hours,
during which the thermometer did not fall below 32° F. But
the wind blew with such force that the men could not light a
fire, and consequently could not prepare their soup. Out of
2,800 soldiers commanded by General Levasseur, 208 died in
forty-eight hours, and when the column arrived at Setif, 521
entered the hospital. The never-abating wind, together with
inanition and the despondency which always attends retreat,
had made these soldiers less able to resist cold than they
would have been under other circumstances.
The medico-legal questions connected with death from
cold are not numerous ; it is necessary to take into account
the intensity of the cold, the force of the wind, and the
length of time that the individual has been exposed to their
influence. An adult resists cold tolerably well, because of
the size of his body, provided, at any rate, that he is not an
alcoholic subject, and that he does not enter a wine-shop or
tavern on the way. Alcohol, which dilates the capillaries,
promotes the action of cold. Here is an instance, which
took place in Russia : The thermometer was about 18° or
ig° F., and the fete to celebrate the distribution of spirit
licences was being held in a certain town. Potemkin gave
a supply of alcohol for gratuitous distribution in the square
of the town ; 1,500 to 1,800 persons died of cold.
In the country, when an individual is found benumbed
with cold or frozen, it is not allowed to pour brandy down
his throat, but he is laid on a manure-heap or in an oven
used for baking bread ; empiricism is thus in agreement with
the teachings of science, and has long ago found a means of
combating the disastrous effects of cold.
Inanition, of course, aggravates the effects of cold. It is
a singular thing that lunatics are unaffected by it ; they do
not complain of cold, and they resist it better than their
attendants.
MODIFICATIONS OF VASCULAR TENSION 241
[This applies chiefly to lunatics in a state of excitement ;
in a condition of melancholia or dementia, where the vital
processes are languid and depressed, cold is highly dangerous,
and apt to prove fatal by producing bronchitis.]
New-born children are exposed to great dangers from
chills ; they are not protected by the mass of their body, and
they generate only a small amount of heat. They are most
exposed on the occasion when they are taken into the
country in what is called the ' nurse's convoy.' When the
passengers alight from the railway carriage, after a journey
that has lasted some hours, some poor little infant is often
found to be dead already, or else dying, and about to finish his
days in the vehicle — appropriately called * purgatory ' — which
is to take him to the village which was his destination. Some-
times the chill of which these nurslings die is purposely con-
trived. The plan is very simple, and the medical jurist will
have great difficulty in proving it. The door and window
are both left open ; the infant is suspended from a nail in a
current of air, and the result is only such as might be fore-
told. If the medical jurist intervenes, he finds the signs of
pulmonary congestion, with mucus and froth in the bronchi.
What conclusions can safely be drawn from such data ?
Chills are also the most frequent causes of death as a result
of baby-shows.
With regard to old people, the law intervenes in cases of
sequestration. You know that in country places the father
and mother often give their property to their children, in
order that the latter may provide for themselves, on condition
that they shall be comfortably boarded and lodged as long as
they live. The children are sometimes ungrateful ; the old
father is sometimes half starved ; he is consigned to a damp,
cold room, and dies of pulmonary catarrh. A medico-legal
investigation is in most cases fruitless.
16
LECTURE VI.
SUDDEN DEATH DUE TO LESIONS OF THE DIGESTIVE
SYSTEM.
Gentlemen, — Lesions of the oesophagus, stomach and
intestines may cause sudden and suspicious death. Certain
diseases of the pharynx may do the sanae.
I. LESIONS OF THE PHARYNX.
I shall perhaps astonish you. Gentlemen, by saying that
sudden death may supervene in the course of simple pharyn-
gitis, or erythematous sore throat. An autopsy throws no
light on these very puzzling cases. I do not know of many
cases of the kind, it is true, but those which I am able to
relate to you are typical :
It is some years since I met with an event of this kind.
I was asked to attend a young medical student who was
dresser to M. Cusco ; he had just had an attack of syncope.
As he was suffering from a slight sore throat in the evening,
I went to see him again on the following day with M. Cusco.
M. Cusco, who was at the time paying much attention to
laryngoscopy, examined his pupil's larynx, and found neither
oedema nor even redness there. The young man had another
attack of syncope, but revived : he had a third during the
night, and recovered again. He asked M. Cusco's permission
to spend a little time with his family, and in a fortnight
wrote to ask for extension of leave. He caught a fresh chill
while he was staying with his relatives, pharyngitis returned,
and he died in an attack of syncope. This fact, which I
I
LESIONS OF THE DIGESTIVE SYSTEM 243
believed for a long while to be a solitary instance, surprised
me much.
In 1874 I was called in a great hurry to see a girl who
was suffering from a slight sore throat, and who, I was told,
had had an attack of syncope. When I arrived, as speedily
as possible, she was dead.
Finally, not very long ago, I received a pitiful letter from
a young provincial physician, who believed he was to be
blamed for a fatal accident which had befallen one of his
patients, and he begged for my opinion.
This physician had been summoned one night to the
suburbs of the small town where he practised to attend a
girl who complained of a sore throat. The throat was
somewhat red ; there was some gastric disturbance, but
there were no grave symptoms, and considering the hour of
the night, and the distance from any druggist, the physician
did not insist on the administration of an emetic, which he
intended to prescribe on the following day. When he
returned the next day, the girl was dead. I reassured my
fellow-practitioner, and replied that the administration of an
emetic would not have altered the situation.
[In such cases as these one's first idea is naturally to
suspect the existence of diphtheria, which may be fatal
suddenly at an early stage, either by cardiac paralysis or by
very rapid spreading of the false membrane down the air-
passages. Such a question may be settled now more easily
than formerly, by means of a bacteriological examination,
or a careful post-mortem examination, if death has occurred,
may determine the point. An ordinary attack of sore throat
may also be suddenly fatal from oedema, perhaps with spasm,
of the glottis. Such a case is described by Dr. F. Robinson*
as follows : Private J. McF., a healthy soldier, aged 21, and
of three years' service, entered the hospital on September 25,
having been ill for the last three days with sore throat. Both
tonsils were swollen, especially the right, and the uvula was
oedematous. There was a tolerably free passage, and liquid
food was taken without difficulty. There was no dyspnoea
* ' Transactions of the Pathological Society of London,' vol. xxiii.,
p. 234.
16 — 2
244 SUDDEN DEATH
or cough, or any symptom of laryngitis. The man felt rather
weak, and his skin was cool. Next day, in the evening, he
seemed in no way worse ; but, as he complained of having
had no sleep during his illness, * haust. hydrochloral,' 3ss.,
was ordered. About two hours afterwards Dr. Robinson
was sent for hurriedly, and found the patient dead. He had
taken the medicine ten minutes before, swallowing it easily,
but immediately afterwards said he felt choking ; he then
put his finger in his mouth to try and relieve his breathing,
drank some water, gave a few gasps, and expired. Tracheo-
tomy and artificial respiration were tried without success.
Post-mortem, — There was great oedema of the glottis and
infiltration of the adjacent tissues, one of the vocal cords
being embedded in it ; the epiglottis was greatly thickened
and rigid, and apparently incapable of protecting the air-
passages. The heart was somewhat pale and fatty.
The writer remarks that the cause of death was not clear.
It was not due to the wrong medicine or to an overdose.
Probably drinking it had caused spasm of the glottis. If
that were the case, however, tracheotomy might have been
expected to give relief.]
Simple sore throat may, therefore, provide us with a very
disagreeable surprise, and as the redness disappears after
death, we are not entitled to conclude that no sore throat
has existed because no trace of it is to be found at the
autopsy. What is the nature of these accidents ? In my
opinion it resembles laryngeal spasm, or the inhibition which
results from a blow, although a slight one, over the larynx.
Remember, in this connexion, that case which I have already
narrated to you of the maid of honour, Mme. Adelaide, who
died suddenly, at the moment when a Danish physician was
applying a drop of ammonia to her pharynx.
Closely allied to these pharyngeal phenomena, which we
must ascribe to spasm or inhibition until we get a better
classification, there are others in which sudden death is the
effect of material causes.
When an individual swallows hard and compact sub-
stances, or when he eats gluttonously, and the food which
he stuffs into his throat blocks the entrance of his larynx,
m
LESIONS OF THE DIGESTIVE SYSTEM 245
he dies suddenly choked. Accidents of this sort are not
uncommon among general paralytics, and I ask you to bear
this hability in mind.
[An inmate of an asylum suffering from chronic epileptic
insanity was seized with a fit while eating his dinner, sitting
at table with many other patients. He immediately choked,
and was dead before medical assistance arrived.
Post-mortem. — A large plug of meat, like a cork, was found
occupying the glottis, and filled the larynx below the vocal
cords.
An inquest was held at Gloucester* on a boy, aged 6, who
went home one day saying that he had been eating horse-
beans, and was found to be choking. He was sent to a
doctor, but collapsed on the way, and died.
Post-mortem. — Thirty-nine horse-beans were found in his
stomach, and one was sticking in his larynx.
Among the curious objects which have accidentally caused
suffocation in this way one or two may be mentioned. A
man was exhibiting the feat of placing a biUiard ball in his
mouth and closing his teeth. He had often done so before, but
this time it became impacted in his throat, and neither he
nor his companions could remove it, and he died before
medical aid could arrive.
It would hardly be thought possible for a person to be
choked by a live fish, yet several such cases are on record,
some being mentioned by Chevers.-(- The fish have either
entered the mouths of Indian natives while bathing, or have
slipped in while being held between the teeth after being
caught.]
II. LESIONS OF THE (ESOPHAGUS.
I come now to lesions of the oesophagus. We meet with
cases here, Gentlemen, which are often singular, sometimes
inexplicable, and which may give rise to suspicion of poison-
ing. It was with this in view that M. LetuUe reported two
cases of sudden death due to dilatation of the oesophagus,
with small superficial ulcerations in one case, but which
were absent in the other. The autopsy did not reveal the
* The Tifnes, September 3, 1897. t Op. df., p. 618.
J46 SUDDEN DEATH
cause of the dilatation in either of them. We know,
besides, that in stricture of the oesophagus there may be
an accumulation of food in the pouch above the stricture,
which may cause sudden death by pressure.
At this very moment a great stir is being made in some
of the newspapers about the supposed poisoning of the
Comte de Chambord. You know that, when the Comte de
Chambord was taken ill, several eminent physicians, includ-
ing Vulpian, were summoned to Frohsdorf. The physicians
who met at the patient's bedside agreed in the diagnosis of
cancer of the stomach. After a temporary improvement,
the patient's condition grew worse and he died.
Post-mortem. — No cancer was found at all ; only superficial
ulcerations, with a few deeper ones, were found in the oeso-
phagus. Vulpian, with characteristic honesty, did not hesitate
to declare, not only that he had made a mistake in pro-
nouncing that the case was one of cancer, but also that he
could not state what was the cause of the ulceration of the
oesophagus. By that time rumours of poisoning were going
about ; then no more was heard about it. For some weeks
this rumour has been revived again, and it is openly stated
in certain circles that the Comte de Chambord was poisoned.
None of the persons who make this assertion could state,
any more than I could, what poison is capable of producing
these lesions.
Gentlemen, lesions that we did not expect to find are
often met with in making autopsies ; lesions are also met
with which are not described in any nosological scheme,
lesions which we cannot classify at all. These are matters
which surprise us, I admit, but they do not justify us in
expressing a suspicion of poisoning. It is certain that when
this happens in the case of a person of princely rank, or of
a political notability, the imagination is prone to exaggerate
everything, and to find something extraordinary in what
would only have been looked on as natural in a member of
the middle class. If you survey the history of France, your
attention will often be arrested by similar cases, and a great
number of princes and princesses, who were believed to have
been poisoned, really died a natural death.
LESIONS OF THE DIGESTIVE SYSTEM 247
[Another rare and somewhat obscure condition which
causes rapid, if not sudden, death, and which may give rise
to suspicion as to the cause, is rupture of the apparently
healthy oesophagus. A collection of seventeen such cases,
all ending fatally, and usually in a few hours, has been pub-
lished by Dr. McWeeney.* The affection occurs almost
always in men about the prime of Hfe, and the subjects
have often been addicted to alcoholic excess. The accident
seems always to occur during the act of vomiting and to be
provoked thereby. The lesion is a vertical slit in the lower
end of the tube near the diaphragm. Death is brought
about, of course, by escape of the contents of the stomach
into the pleural cavities. Authorities differ as to the pre-
disposing causes of the accident, but most probably there is
some softening of the coats of the gullet, brought about by
chronic inflammation, or, perhaps, by regurgitation and
partial digestion of the living tissues. It is hardly likely
that even violent retching could burst the walls of the tube
if its walls were perfectly sound.]
III. LESIONS OF THE STOMACH.
Before entering upon the study of the lesions of the
stomach which may cause sudden death, let us first settle
two incidental questions — sudden death from indigestion,
and death in dyspeptic coma.
Can a person die suddenly from indigestion ? (Notice that
I am not speaking here of children ; I shall deal with them
later on.) All authors reply in the affirmative. Well,
Gentlemen, I have read all the cases which they have
recorded, but I have not met with a single case in which
pre-existing lesions in other organs than the stomach were
not sufficient to account for death ; in most cases the
patient had some renal affection, or was convalescent from
typhoid fever.
Such was the case of the lad which Dr. Martelt has
reported : the boy was convalescent from a mild attack of
typhoid fever, and was allowed to walk about the ward as he
* The Lancet^ July 21, 1900, p. 158.
t Martel, Gaz. hebdom.^ 1877, p. 605.
248 SUDDEN DEATH
pleased, when one day, after breakfast, he had an attack of
syncope, and died so rapidly that he was dead before the
arrival of the house-physician, though the latter had been
summoned at once. An autopsy was made ; all the organs
were healthy, but the stomach was distended by a mass of
haricot beans not yet acted upon by the gastric juice. This
lad, who had been subjected to a strict regimen during his
fever, acquired an exaggerated appetite, as convalescents
commonly do ; he had obtained an extra supply of this
indigestible food from his comrades, and had swallowed it
hastily to avoid being detected.
If this lad had eaten these beans in his ordinary state of
health, he might have had an attack of indigestion, but he
would not have died.
[Inman mentions two such cases* : (i) Miss R., aged i8,
of a very delicate constitution, had an attack of epidemic
influenza, for which the sole treatment had been a dose of
salts. While still weak she ate a solid, hearty meal. It
was too much, and she died immediately afterwards. (2) A
stout man had passed the crisis of an attack of fever, and
was recovering ; his appetite was so great that he not only
devoured his own allowance of food, but went round the
ward to eat up what the other patients had left of their
dinner. He died the moment he regained his own bed.]
Tardieu only quotes one case, and it is hardly conclusive :
An individual, who was, as the report says, somewhat out
of health, went to a druggist, who gave him four purgative
pills. He swallowed only two of these before retiring to
rest ; in the night he was seized with vomiting and died.
The druggist was accused of having poisoned his customer.
The two remaining pills were found and submitted to
analysis, but they contained no suspicious substance. The
autopsy revealed no organic disease.
The druggist who sold the pills was accused of having
poisoned the patient, but an analysis of two pills that
remained disclosed nothing suspicious. For my own part,
I believe that indigestion will in the very near future be
erased from the list of causes of sudden death.
* Op. cit., p. 234.
LESIONS OF THE DIGESTIVE SYSTEM 249
[An inquest was held lately* on a case in which death
apparently resulted simply from over-eating. It bears a
close resemblance to that of the lad who died of surfeit and
cerebral haemorrhage referred to on p. 166. A boy, aged g,
had been on a Band of Hope excursion one day, and partook
freely of refreshment in the form of ginger-beer, apples,
nuts, chocolate, three bottles of ginger ale and some sherbet-
and-water, after which he had his tea. He died at 2 o'clock
next morning. According to the medical evidence, he died
from collapse due to acute gastro-enteritis. As none of the
items of food were likely to be poisonous, death must
probably be assigned to the quantity consumed.
The influence of a full meal in provoking rapidly fatal
pericarditis has been already alluded to.]
Dyspeptic coma has been studied in Germany especially ; I
have only met with two cases, neither of which was fatal.
It is analogous to diabetic coma ; but there is no sugar in
the urine. It has been profoundly studied by Kussmaul,
and hence has received the name of * Kussmaul's group
of symptoms.' The name connotes a group of symptoms
which I will describe to you briefly. Suppose that an
individual in good health, who may or may not have suffered
from dyspepsia formerly, is suddenly seized with somnolence,
at first slight, but rapidly deepening into coma, and with a
peculiar form of dyspnoea characterized by deep and regular,
but often accelerated, respiratory movements. The tempera-
ture is more often lowered than raised, and the breath has
a characteristic odour like that of apples or over-ripe fruit,
and the urine is reddened by the addition of perchloride of
iron.
It has been thought that these phenomena are due to
auto-intoxication by acetone, liberated by intestinal fermen-
tation. Acetone actually has an odour like that of ripe
fruit, and the addition of perchloride of iron produces a red
colour when it is present in the urine.
But Senator, Riess, and Litten have detected acetone
when there has been no coma ; they have, moreover, insisted
on the fact that Kussmaul's group of symptoms is met with
* Daz'ly Mai7, August 24, 1 897.
250 SUDDEN DEATH
in the course of various diseases, such as pernicious
anaemia, diseases of the liver and kidneys, chronic catarrh of
the bladder, certain eruptive diseases, etc.
We ought, therefore, to ask ourselves whether it is not
one of these diseases which is the cause of death, rather
than dyspeptic coma, which we will regard, if you please,
merely as an exceptional occurrence.
We ought to place by the side of Kussmaul's disease the
sulphuretted hydrogen dyspepsia of children, which has
been described by Senator, Cantani and Stefano. I have
no personal experience of it.
Simple ulcer of the stomach is a very common cause of
sudden death. The round «/c^r, which has only been well
known since Cruveilhier's time,* is not a disease that has
only appeared in modern times.
Madame, sister-in-law to Louis XIV., whose funeral
oration was delivered by Bossuet, appears to have died of
simpler ulcer of the stomach. The symptoms which her
disease presented, its sudden gravity and tragical ending,
immediately gave rise in the minds of contemporaries to
the idea of poisoning.
Nowadays we are familiar with the characters of ulcer
of the stomach, and it would seem to be difficult to make a
blunder.
However, one of the first medico-legal cases with which
I had to do was one of this kind. Mme. Lerondeau, a
woman living in a suburb of Versailles, was accused of
having poisoned her husband. He had complained to
several of his neighbours of not feeling well one morning,
and died the same day, after taking some sorrel soup
which his wife had prepared for him. I do not know
whether the husband and wife had been living on bad
terms together, but anyhow the law intervened ; the woman
was arrested, and a post-mortem examination was ordered.
The analytical chemist found a small quantity of oxalic acid
in the stomach ; the medical jurist discovered on the mucous
membrane of the stomach, and minutely described, six small
ulcers near the pylorus. He did not think that these were
* Cruveilhier, ' Anatomic pathologique.' Paris, 183032.
LESIONS OF THE DIGESTIVE SYSTEM 251
simple gastric ulcers, but asserted that they were caused by-
oxalic acid that had been put into the soup, and Mme.
Lerondeau was sentenced to imprisonment with hard labour.
Owing to a flaw in the proceedings, the sentence was
annulled, and the case was transferred from the Court of
Versailles to that of Paris. Mme. Lerondeau's counsel
applied to Wurtz, Vulpian, and Bergeron. Vulpian examined
the specimen, and found that the lesions had all the appear-
ances of simple gastric ulcer. Wurtz has shown, in a
remarkable memoir, that when the mucous membrane is in
a catarrhal state, the digestion even of a piece of bread gives
rise to the formation of oxalic acid, even to a more consider-
able amount than that found by the chemist at Versailles in
M. Lerondeau's stomach. The Attorney- General abandoned
the prosecution.
It is not very difficult. Gentlemen, when we discover an
ulcer of the stomach, to determine whether it has been
caused by some caustic substance or by natural inflam-
matory processes. In the simple ulcer you will always
find the characteristic projecting margin and smooth
base, which cannot deceive you. When an individual has
swallowed sulphuric or hydrochloric acid, there are erosions,
perforations, and lesions of all kinds.
A simple, round gastric ulcer may develop in a latent
manner, without producing any marked functional dis-
turbance. It can, therefore, easily be understood how a
suspicion of poisoning may arise in the mind of some
relative or friend of the deceased. This suspicion is evinced
more frequently — I will even say that it is constant — when a
person dies of perforation of the stomach with symptoms of
peritonitis.
It might be thought that an individual in whom perfora-
tion has suddenly occurred ought always to present the
characteristic signs of peritonitis, but it is not so ; he may
become collapsed, and present symptoms like those of
cholera.
Leudet of Rouen* has related the following case: While
he was house-physician at the Hotel-Dieu, a man walked
* Leudet, * Clinique mddicale.' Paris, 1874.
252 SUDDEN DEATH
abruptly out of a public-house facing the hospital, hol(fing
his hand to his abdomen, suffering acute pain, and exclaim-
ing: 'They have poisoned me!' The man was taken to
the Hotel-Dieu, while the crowd, believing what he said,
proceeded to sack the public-house. The man died. Leudet
made an autopsy, and discovered perforation of the stomach
by a simple ulcer, and commencing peritonitis.
When the simple ulcer is undergoing cicatrization, and
the patient is getting better, the intolerable pain after eat-
ing having disappeared, and a strict milk diet being no
longer persisted in, he is sometimes tempted to eat more
than is good for him, and the consequences may be most
disastrous.
While I was Aran's house-physician at the St. Antoine
Hospital, a man was under his care suffering from simple
ulcer of the stomach, which was healing, and he had
abandoned a strict milk diet. It was spring-time, and the
man was walking about the hospital yard. He went to the
porter's lodge, bought an apple-tart, and ate it in the yard.
He was immediately seized with vertigo, fell down, was
carried indoors, was put to bed, and soon died. At the
autopsy the cicatrix was found to be torn, and the organ
was distended with gases which had penetrated beneath the
mucous membrane of the stomach, so that the walls seemed
to be inflated.
Since the time of Hunter and Cruveilhier, post-mortem
ulceration of the stomach has been recognized as a fact ; it
is attributed to the action of gastric juice upon a portion
of the wall of the stomach which has lost its epithelium or
undergone some other lesion. All that I know of these
ulcers is obtained from the writings of authors ; I have never
had any opportunity of seeing them, but I have twice seen
a post-mortem ulceration under similar conditions, as a result
of poisoning by a non-caustic substance. In both cases the
poison was strychnine ; one was a case of suicide, the other
of accidental poisoning.
Let us take this case : A boy went to a druggist to ask for
poison wherewith to get rid of his cat, as he was tired of the
animal. The druggist, whom it was impossible to identify,
1
LESIONS OF THE DIGESTIVE SYSTEM
253
handed him a packet of strychnine. The boy went home,
altered his mind, and deposited the poison in his desk.
Then he thought he would like to see what the powder
tasted like, so he moistened his finger, dipped it in the
powder, and tasted it, though he spat most of it out again
(he was able to state this), and he died in well-marked
strychnine convulsions. Post-mortem, I found the stomach
small, containing about 2 oz. of blackish liquid ; in the
fundus there was a circular perforation i^ inches in diameter,
and at a distance of |^ inch from this was another perforation
about \ inch in diameter. The mucous membrane seemed
to have undergone digestion. The spleen was a soft pulp.
Experiments on animals show that the introduction of a
certain quantity of strychnine into the stomach considerably
increases the secretion of gastric juice ; perhaps that is the
way (I only offer the suggestion) that strychnine acts in
certain affections of the stomach.
[Of course, perforation of a gastric ulcer does not always
cause rapid death by setting up acute peritonitis. If the
base of the ulcer is adherent to the liver, the ulcer may
burrow into that organ. Or if the perforation takes place
posteriorly into the lesser cavity of the peritoneum, a sub-
diaphragmatic abscess may form, which may last for a
considerable time before the patient is relieved by operation
or dies of exhaustion. Again, a gastric ulcer has been
known to perforate the diaphragm into the pericardium,
setting up pericarditis.
A gastric ulcer, previously latent, may also cause rapid
death by opening a bloodvessel in the walls of the stomach,
causing excessive hsematemesis, the cause of which cannot
be ascertained without a post-mortem examination.]
When you are making an autopsy, and find a perforation
of the stomach, you will have to make a differential diagnosis
between simple gastric ulcer, poisoning, and the ingestion of
some caustic substance.
I will quote one other case to you before ending the
account of sudden death from diseases of the stomach. A
Paris physician, who was well known in the theatrical world,
had suffered for a long time from dyspepsia. He married a
254 SUDDEN DEATH
very pretty and elegant young wife ; he was also accustomed
to administer morphine injections to himself. The rumour
went about among his friends and the public that his wife
would be only too pleased to be rid of her husband. He
died. His friends insisted on a medico-legal post-mortem
examination, but they were not satisfied with the result of it.
They then examined the numerous volumes in which the
deceased had written day by day for more than twenty years
his impressions and details of his sufferings. Fortunately
for his young widow, her husband's notes and the opinions
of the physicians whom he had consulted agreed with the
results of the autopsy, and the proceedings were stayed.
The autopsy had brought to light an enormous dilatation of
the stomach, the larger curvature measuring 30 inches, the
smaller 19 inches ; the food could not easily pass out of the
stomach, for the pylorus, which was situated in the right
iliac fossa, was connected to the rest of the intestine by
means of the duodenum, which was curved like a swan's
neck. There was a formidable accumulation of liquid con-
taining detritus of food in the stomach ; the colon was filled
with scybala as large as one's fist.
IV. LESIONS OF THE INTESTINES.
Medico-legal intervention is much more frequent in simple
ulcerations of the duodenum. M. Aloncle* has collected 39
cases. Since then M. Bucquoy has published a certain
number, and the total number of cases on record amounts
to 100.
A distinguishing feature of simple ulcer of the duodenum
is that its existence is quite unknown both to the patient and
to those around him. In ulcer of the stomach there are
pain, vomiting and haemorrhage ; ulcer of the duodenum
gives rise to no symptoms. Moreover, sudden death, in the
medico-legal sense, is comparatively more frequent in the
latter than in the former.
A well-built youth, about 20 years of age, was brought to
the Piti6 Hospital. He complained of acute pain, and kept
* Aloncle, 'De I'Ulcere perforant du Duodenum.' These de Paris, 1883.
LESIONS OF THE DIGESTIVE SYSTEM 255
his hands pressed on his abdomen ; he had been very well
during the day, but at 7 p.m. he was seized with atrocious
pain in the abdomen, seemingly situated between the
stomach and liver. He soon became collapsed, and died at
5 a.m. He presented symptoms like those of cholera —
aphonia, suppression of urine, etc. The autopsy showed that
this young man had a simple ulcer of the duodenum ; it was
evidently of long standing, being surrounded by a rim
like that of a simple round ulcer of the stomach. The
intestine was perforated, and food had entered the peritoneal
cavity ; the peritoneal cavity contained 2^ pints of yellowish
fluid.
Ulcers of the duodenum are situated in the first part
of that segment of the bowel, and by preference on its free
surface.
I know of only one case of perforating ulcer of the
jejunum.
Intestinal ulceration may be caused by dysentery, tuber-
culosis, cancer, or typhoid fever. Medico-legal intervention
is sometimes demanded by the relatives of the deceased in
such cases.
I remember the following case : A girl belonging to a very
honourable family was attacked with typhoid fever, and
stated in her delirium that she had been violated, giving full
details and quoting names. She died, and her parents,
recollecting the deHrious statements made by their daughter,
insisted on an autopsy being made. The girl had ulceration
of the ileum, and was a virgin. Whether or not an attempt
on her chastity had been made, I do not know, but at any
rate the act of violation had not been completed.
All these ulcers may give rise to intestinal haemorrhage,
which may produce syncope. Death may result from it,
and we ought always to bear the possibility in mind.
M. Lancereaux has, within the last few years, thrown light
upon a subject that was already known, but which had been
imperfectly studied before ; I refer to embolism of the
mesenteric artery, which may give rise to intestinal ulcera-
tion and haemorrhage. Finally, we sometimes meet with
persons who have died of intestinal haemorrhage, although
256 SUDDEN DEATH
it is impossible to discover the vessel that has given way.
This fact has been established by Gendrin and Trousseau.
Much importance has lately been attached to a special
form of ulceration which takes place in the vermiform
appendix. This perforation is rapidly followed by grave
symptoms, which remind one of those of cholera, and are
more like those of poisoning than those of peritonitis ; there
are abdominal distension and vomiting, and the surface
becomes cold. Reginald Fitz was the first to describe this
disease ; it is important for the practical physician as well
as for the medical jurist to know of it.
Never in your practice pronounce the word ' poisoning,'
unless you are sure of your diagnosis ; if it has once
escaped your lips, and reached the ears of the patient's
relatives, they will not be able to think of anything else !
Before uttering a word of suspicion, think over all the
phenomena of perforation which I have briefly described to
you ; it is a diagnosis which you will have to make, though
it is not always very easy to establish.
[Dr. P. Apostolides, of Greece, narrated* two cases of
fatal acute peritonitis due to the perforation of healthy
intestines by ascarides. In one case the aperture was situated
in the lower part of the jejunum ; in the other, in the upper
part of the ascending colon.
It is well known that lunatics will kill themselves by injury
to their intestines by various miscellaneous objects that they
have swallowed, but the following case of the so-called
* human ostrich * is decidedly peculiar : An inquest was held
on the body of O. W., aged 42, who got his living by visiting
public-houses at night and swallowing all kinds of things for
a reward. He never came home sober. He would eat bread
and cheese and pickles, and then devour the saucer ; he would
also frequently swallow coins, chains, etc. At the last, he had
not been well for three days, and walked to the Whitechapel
Infirmary, where he was admitted looking very ill, but was
removed to the London Hospital. He was thought to be
suffering from intestinal obstruction, and an operation was
performed, from which he did not recover.
* The Lance/y May 7, 1898.
LESIONS OF THE DIGESTIVE SYSTEM 257
Post-mortem. — 25 pieces of cork, 20 pieces of tinfoil, a lead
bullet, a piece of string 18 inches long with corks attached,
8 pennies, a piece of leather g inches long with a hook at
each end, several pipe-stems, and a piece of newspaper were
found in his intestines. A piece of tinfoil and one of the
hooks had perforated the bowel, and had set up fatal peri-
tonitis.]
Hindrance to the passage of the contents of the intestine may
be of long standing or may develop abruptly. In both cases
it may give rise to sudden and suspicious death. When it
is abrupt, there is internal strangulation. A small hernia,
unknown to the subject of it, may be strangulated at the
moment of its formation ; its existence can only be proved
post-mortem, because liquids have been able to pass along the
intestine during the lifetime of the patient ; strangulation
has not been complete ; the symptoms presented by the
patient — diarrhoea, vomiting, and coldness of the surface
— have led to the belief that the case is one of poisoning.
Such cases happen by the thousand.
[The chief guide in the diagnosis of intestinal obstruction
from irritant poisoning is the absence of purging in the
former; it is usually constant and appears speedily in the
latter.
The case is recorded by Mr. Rake* of a strong man who
died in two hours from volvulus of the transverse colon.
In operations for intestinal obstruction, the contents of the
alimentary canal may regurgitate into the air-passages while
the patient is under the influence of the anaesthetic, and he
may thus choke.]
In simple intestinal obstruction medico-legal intervention is
sometimes required. Let me give you an example :
Towards the end of the Empire, an old lady was seized
with uncontrollable vomiting. As she had occupied a con-
spicuous social position and had been intimately connected
with one of the Bonaparte family, it was thought that she
had been poisoned. The physicians who attended her
advised a consultation. At the time when the consultation
was to take place, the old lady was sitting on her zinc
* The Lancet^ April 29, 1889.
17
258 SUDDEN DEATH
toilet-pail, and suddenly a curious noise was heard, the
nature of which was not evident at the moment ; she had
just passed an enormous gall-stone, which is now exhibited
in Dupuytren's museum ; this calculus had blocked the
intestine. Naturally all suspicion of poisoning was dispelled ;
the lady recovered and returned to America, where she died
recently more than 80 years of age.
Forensic medicine may also have to deal with cases of
simple constipation ; in one case nearly 30 oz. of faeces were
found in the intestine. M. Socquet has removed from
the large intestine 17J lbs. of faecal matter.
A great inventor, who had amassed a large fortune, but
whose name I shall not mention, habitually suffered from
obstinate constipation ; he soothed his pain with chloroform.
One day he received a visit from two friends who were not
so well off, and after their departure he was found dead on
the sofa ; his brother, with whom he had not lived on the
best of terms, suspected that he had been murdered by
these friends ; the bottle of chloroform and a folded cloth
had been found by the side of the body. The law
intervened, and an autopsy was ordered. I found the
intestine loaded with very hard faeces. The autopsy could
not reveal to us how he came by his death. Whether he
had put himself to sleep for ever by means of chloroform,
or whether he had been put to sleep by his friends, I cannot
say ; but it is always a difficult matter to send a person to
sleep by means of chloroform if he does not wish to be
anaesthetized. Before speaking to you of the curious
phenomena and complications which long-continued consti-
pation sometimes produces, allow me to point out to you
the singular fact that malformations of the anus may give
rise to sudden death. A little girl, 8 years of age, died with
symptoms of poisoning. The body was sent to the Morgue
ior post-mortem examination. The child had an imperforate
anus ; defaecation had been performed by means of a small
fistulous communication between the rectum and vagina, a
little below the hymen ; this fistula had been blocked by
hard faeces ; an enormous accumulation had formed in the
rectum, which measured nearly 5 inches in diameter. There
I
LESIONS OF THE DIGESTIVE SYSTEM 259
was also arrest of development of the uterus. This little
girl had lived up to that age without any of the family sus-
pecting that her bowels were not relieved in the usual
manner. She died of intestinal obstruction, the symptoms
of which were actually taken for those of poisoning.
These cases of death due to intestinal mischief are very
interesting, and they are closely connected with certain
pathological problems that are now receiving attention.
M. Vibert has related the following case, which is of great
medico-legal interest because of the situation occupied by
the victim, and because of the disputes which might arise
after his death as to the payment of a claim for life
assurance :
A young medical man, aged 23, who practised in the
suburbs of Paris, went to lunch one day at his brother's
house in Paris ; he was in the habit of taking injections of
morphine ; in the morning he was indisposed owing to an
attack of abdominal pain and diarrhoea ; he was unable to
eat any luncheon, and, as his sufferings increased, he de-
termined to return home ; he died in the water-closet used
by the station-master, on his arrival at the station where he
ntended to alight. As Dr. X.'s brother knew that Dr. X.
had insured his life, he went to the public prosecutor and
stated to him very straightforwardly that he had been asked
whether his brother's death might not be due to some
unforeseen cause, viz., suicide by an over-dose of morphine.
All the inhabitants of the little town where Dr. X. practised
were convinced that suicide had taken place.
In case an autopsy confirmed this supposition, M. X.
determined to renounce his claim upon the insurance office.
A medico-legal autopsy was performed by M. Vibert, and it
was ascertained that there was a tubular stricture of the
descending colon commencing a little way above the sigmoid
flexure, and 7 inches in length ; the wall of the stricture
was indurated and thickened, and presented a layer of
dense fibrous tissue about ^V ii^ch in thickness beneath the
mucous membrane ; the intestine was somewhat dilated
above the stricture, and there was a small quantity of faeces
there. M. Vibert concluded that death was due to natural
17 — 2
26o SUDDEN DEATH
causes, there being no evidence of the presence of any
poison.
Since then we have made four autopsies of the same kind
at the Morgue. What is the cause of death under such
conditions? It is identical with that which I previously
described to you under the title of dyspeptic coma. M.
Bouchard has proved the existence of ptomaines in faeces,
and in all such cases special forms of fermentation may lead
to auto-intoxication, as in this case. The anomalous feature
of these cases of poisioning is that they occur in some
instances, but are absent in others. All these novel facts are
of great interest to the medical jurist, and he ought to bear
them in mind when he is conducting his investigations.
To what cause should these strictures be assigned ? As a
general rule, when inquiries are made of the relatives and
friends of the deceased, and information is obtained as to
the previous history, the disease can be traced to a neglected
attack of dysentery; cicatrices result which steadily con-
tract.
V. LESIONS OF THE LIVER.
I come now to the consideration of those lesions of the
liver which may occasion sudden and suspicious death.
These, Gentlemen, include a certain number of special
cases ; but you will be of the same opinion as myself when
you listen to an enumeration of all the diseases of the liver ;
and you will agree that any one of them may lead to sudden
death under conditions which would suggest to one's mind
the possibility of poisoning.
Take malignant jaundice, for example ; you know its
characters, and are well aware of the yellow colour which
rapidly invades the face and the whole body of a person who
seemed well previously.
To my knowledge, the law has stepped in in two fatal
cases because phosphorus -poisoning was suspected, and
those individuals were prosecuted to whose advantage it
was for the death to take place. In another instance,
where there also was malignant jaundice, the individual
who died suddenly had been taking part in a discussion
LESIONS OF THE DIGESTIVE SYSTEM 261
shortly before. His neighbours, who had noticed that his
skin had become yellow in a very short time, spread the
report that his death was due to a violent paroxysm of
anger to which he had been provoked, and that bile had
become mixed with his blood. As there had been a dis-
pute, the officers of the court took the matter up, thinking
that the deceased had perhaps received blows which would
occasion death. The man was found to have acute atrophy
of the liver, which was quite sufficient to cause jaundice
and account for death.
Finally, Gentlemen, I shall give you the particulars of
a very interesting medico-legal autopsy, for the case on
which this inquest was held gave rise also to an accusa-
tion of attempt to procure abortion. The case was that of
a female of 35 to 40 years of age, who was a servant to a
medical man. She suffered from atrophic cirrhosis of the
liver, and had become debilitated in consequence of the
disease. Her abdomen grew large, and this was noticed
by her neighbours. She was seized with syncope one even-
ing, and died the same night. As she had had epistaxis
at the moment of syncope, blood was found on her sheets,
pillow, and chemise. The porter of the house at once
accused the medical man of attempting to procure abortion
on his servant. The body was carried to the Morgue, and
I made an autopsy. The woman was not pregnant, but
she had eighteen or twenty pints of fluid in the peritoneal
cavity ; her liver presented the typical characters of cirrhosis.
[A sudden fatal termination may occur in cirrhosis of the
liver from haematemesis ; this event may even take place
quite early in the disease. It is due to rupture of a vein in
the coats of the stomach or of a varicose plexus at the lower
end of the oesophagus.]
Sudden death due to gall-stones is a rare event. Portal*
quotes two cases. Dr. Durand-Fardel and Curry each
record one. Charcot"!* speaks of syncope sometimes occur-
ring in the course of biliary colic.
* Portal, ' Observations sur la Nature et le Traitement des Maladies
du Foie,' p. 170. Paris, 1813.
t Durand-Fardel, ' Maladies des Vieillards.' Paris, 1854.
262 SUDDEN DEATH
I myself can relate to you the following case : A young
woman, 25 or 30 years of age, active, and of good con-
stitution, forewoman in a feather manufactory in the Rue
du Caire, had an appointment at Lagny. As she was
afraid of missing the train, she ran to the Eastern Railway
station ; but when she reached the Place de Strasbourg
she found that she had several minutes to spare, and went
into a caf^, where she drank some currant syrup with
seltzer-water, and having paid for it, she took her ticket
and entered the carriage. The train had only just started,
when she was seized with horribly painful colic, and said
to her fellow-travellers in the compartment : * I have been
poisoned in the caf^; I do not know what it was that I
have just been drinking.' At last she reached Lagny,
where she was met by her friends ; but as her pain kept
getting worse, they took her to a hotel near the station.
A physician who was called in haste reassured them, and
told them that the patient was suffering from biliary colic.
The pains increased, however, and the young woman died
in the night. The event caused considerable sensation at
the hotel ; inquiries were made, and some astonishment
w^as expressed when the circumstances were ascertained
under which she had left Paris. The superintendent of
police intervened, and the body was sent to the Morgue,
where a post-mortem examination was made.
Post-mortem. — The bile - duct contained a good - sized
calculus, and there were many more in the gall-bladder.
The most curious feature observed at the autopsy was the
fact that the lumen of the duodenum was completely
obstructed. There was collateral oedema of the coats of
the intestine, the mucous membrane being raised to such
a degree as to make an absolutely resistant tube.
[A closely similar case is recorded by Dr. T. V. Crossby,*
where a woman, aged 55, living alone, who was previously
unknown to the writer, was taken ill one day, and at night
roused the neighbours, complaining of violent pain in the
abdomen and chest ; she vomited and died before the
medical man arrived. The case was almost mistaken for
* The Lance f, July 3, 1897.
1
LESIONS OF THE DIGESTIVE SYSTEM 263
one of irritant poisoning. A bottle half full of brandy and
other empty bottles were found, but no irritant poison was
present and none of the vomit was preserved.
Post-mortem. — A biliary calculus was found in the bile-duct.
It is perhaps worthy of note that the error of overlooking
jaundice is all the more easily made when the case is first
seen, as happened in the above instance, at night, for the
icteric tinge is hardly distinguishable by gaslight. A man
was admitted one evening into the St. Marylebone Infirmary
suffering from constant vomiting, and in a state of great
exhaustion. He was examined carefully soon after he was
put to bed, but no definite lesion could be detected. He died
the same night.
On making the autopsy next day, his skin was seen to be
of a deep lemon tint from obstructive jaundice ; this had
been invisible on his admission. The cause of death was
found to be chronic hepatitis.
In a case observed by myself, fatal syncope happened
during an attack of biliary colic.
Post-mortem. — A gall-stone of considerable size was found
lying in the duodenum, and evidently had recently passed.
The liver presented numerous small nodules of cancer.]
Allow me, in connexion with this subject, to make a
short incursion into the domain of clinical medicine. When
examining patients suffering from biliary colic, there is
often found dulness on percussion over the region of the
liver, and the question is raised whether this is caused by
a distended gall-bladder or Spigelian lobe. I am inclined
to believe, judging from the result of this autopsy, that this
dulness is sometimes due to distension of the duodenum.
This case is almost unique, and it is very interesting. How
could sudden death take place without perforation, or any
other grave anatomical lesions ? Death is certainly due to
stoppage of the heart, determined by a reflex inhibition
due to excitation of the pneumogastric filaments distributed
over the liver.
Ruptures of the gall-bladder and biliary ducts are possible.
I have never met with a case where the passage of a cal-
culus has caused a rupture or laceration, and thus brought
264 SUDDEN DEATH
J
about an escape of bile into the peritoneal cavity. I believe
that when these lesions occur they are due to some other
cause ; thus, ulceration of the gall-bladder may take place
in typhoid fever, for example. In other instances the presence
of a gall-stone may set up inflammation of the gall-bladder ;
but then adhesions form between the peritoneum, the gall-
bladder, and the intestine, and ulceration, if it happens at
all, does not give rise to a perforation into the peritoneal
cavity, but into the intestine, and there is not the same
danger.
Hydatid cysts of the liver may burst into the peritoneal
cavity. When the cysts are large, their existence is usually
well known to the physician and the patient's friends, if
not to the patient himself. But if no one knows of their
existence, what will happen ? The patient may die suddenly
in profound collapse. He will not present the symptoms
of acute peritonitis, although there is inflammation of the
peritoneum. He will die with choleraic symptoms, and if
death supervenes under conditions that are at all peculiar,
the law will intervene, and an autopsy will be ordered.
Tardieu records the following case : A husband surprised
his wife in flagrante delicto of committing adultery. A violent
scene took place between the three actors in the drama, and
the husband ran to find the superintendent of police. On
his return he found his wife unconscious and collapsed,
and she died in the course of three hours with choleraic
symptoms : diarrhoea, vomiting, suppression of urine, etc.
How could any one beheve, in spite of the denial of the
husband and lover, that no violence had been inflicted ?
A medico-legal autopsy was ordered, and death was found
to be due to the rupture of a hydatid cyst into the peri-
toneal cavity. Was the rupture due to an act of violence ?
The body showed no trace of it, and probably there had
been none.
VI. LESIONS OF THE SPLEEN.
Lesions of the spleen do not often give rise to medico-
legal intervention in our own country, but in those lands
LESIONS OF THE DIGESTIVE SYSTEM 265
where malarial fevers prevail it is quite otherwise. The
spleen may burst as a result of very great violence, such as
a crush of the body or a fall from a height.
A man took his mother-in-law for a drive in a tilbury.
The tilbury was overturned in such an unlucky manner that
the man fell on the top of his mother-in-law, and the latter
died almost immediately. The man escaped unhurt. There
was a medico-legal investigation, because of the circum-
stances in which the accident took place. At the autopsy,
the spleen was found to be ruptured.
The spleen may also be ruptured during the straining of
childbirth, especially when labour is difficult.
[Sir J. Y. Simpson records three fatal cases of rupture of
the spleen during pregnancy, parturition, and the puerperal
state respectively ; in the last case it followed some unusual
exertion a week or two after delivery. Dr. Whitney* relates
the case of a woman, aged 38, eight months advanced in her
ninth pregnancy, who had enjoyed excellent health hitherto.
After eating a hearty supper she was seized in the night with
violent pain in the region of the stomach, and soon with
convulsions, supposed to be puerperal. She died in a few
hours, and at the autopsy it was found that labour had not
begun, but that there was a laceration of the spleen, from
which 4 or 5 pints of dark and still fluid blood had escaped.
The spleen was little if at all enlarged, and the torn part
had the colour and consistence of currant jelly.
Another case is related which took place in Austria.f A
woman, six months advanced in pregnancy, was assaulted
by a drunken husband and became collapsed. The abdomen
was opened, and the spleen was found to be ruptured so
as to have caused abundant haemorrhage. The organ was
removed, and the woman recovered.
Spontaneous rupture may also occur in the enlarged spleen
of leucocythsemia, with fatal haemorrhage, and sometimes
the viscus may rupture at the seat of an infarct, possibly
setting up peritonitis.
* Boston Medical and Surgical Journal^ October i, 1868, dcndi Medical
Times and Gazette^ November 28, 1868, p. 621.
t Medical Press and Circular^ November 2, 1898.
266 SUDDEN DEATH
Wardell* cites a case related by Traube and Cohnheim,]
where haemorrhage took place from rupture of a group ofl
dilated veins of the spleen. He goes on to say that rupture
has been known to take place during the last stage of an
ague, and in cholera, and in relapsing fever ; and mentions
a case which occurred in the practice of Dr. Deville, of
Harrogate, in which a man convalescent from continued
fever was seized suddenly with acute pain in the left hypo-
chondrium, and he rapidly became collapsed and died. At
the autopsy the spleen was found extremely friable, and
there was a fissure parallel and anterior to the hilum, from
which the splenic pulp extruded.]
In warm climates — in countries where intermittent fever
prevails — the spleen of those individuals who have undergone
frequent attacks of malarial fever becomes hard, and it also
becomes extraordinarily fragile. Dr. Pellereau, who practised
in the Isle of Bourbon, has published the result of seventeen
medico-legal autopsies, in which he shows that the spleen may
be ruptured by very slight violence; he relates, for example,
the history of an individual who was running across some
fields, and was struck lightly in the splenic region by the
branch of a cactus that he brushed against in passing. This
injury, if it deserves the name, caused a rupture of the
spleen and fatal haemorrhage into the peritoneal cavity.
I myself have been consulted about a similar case :
A gentleman, occupying a very good social position in the
department of Charente-Inferieure, was accused of killing
one of his friends in the course of a dispute. There had
actually been a little scuffling, in the course of which the
friend had been pushed against a writing-table, but with so
little force that he paid no attention to it, and made no
complaint about it at the moment. He returned home, and
when he arrived there he became ill. He rapidly became
blanched, and died. A medico-legal autopsy was ordered.
The medical jurist who made it found the spleen ruptured,
and concluded that the dead man's friend was to blame.
He stated, however, that the spleen was hard, but not much
enlarged.
* Reynolds' * System of Medicine,' vol. v.
LESIONS OF THE DIGESTIVE SYSTEM 267
When the physician drew up his report, he had, however,
only consulted the works of European authors, who do not,
or, rather, who did not, mention the special fragility of the
spleen in persons who have inhabited warm climates, and
have had attacks of intermittent fever there. I remembered
this fact when I was called upon to make a further report,
and I learnt that the deceased had formerly been a naval
officer, who had been invalided in consequence of frequent
attacks of malarial fever, which made his continuance in
the service quite impossible. The proceedings were stayed.
[Chevers states* that rupture of the spleen is common in
India. The subjects of the accident generally live in
remarkably unhealthy localities, and have been, either at the
time or recently, suffering from intermittent fever. The con-
dition of the spleen, which renders it liable to rupture, is
usually that of engorgement, which makes its substance
friable, and its size is more or less increased ; on the other
hand, the organ may be indurated, either large or small, and
give way from brittleness. Though the fatal result is usually
brought about by some degree of violence, even though this
may be very slight, yet cases of spontaneous rupture in inter-
mittent fever are on record. One is related by Chevers
from his own experience. Cases of rupture of the spleen
occasionally recover, but certainly not when the haemorrhage
has been great.
Of thirteen cases reported by Pellereau,t five were spon-
taneous, and eight were due to a trifling accident.]
VII. LESIONS OF THE PANCREAS.
We shall pass rapidly, Gentlemen, over lesions of the
pancreas. Even if we understood something of its functions,
we do not know much about its pathology. In the autopsies
that I have made, I have sometimes found haemorrhages in
the pancreas. As death was due in these cases either to
pulmonary congestion or, as in the case of the young woman
that I related to you a little while ago, to biliary colic, I am
forced to believe that pancreatic haemorrhage is a concomi-
tant, and not an essential lesion.
* Op. ciL, p. 457, t Ann, d'Hyg., 1882.
268 SUDDEN DEATH
1
[Inflammation and other diseases of the pancreas have
for a very long time had a place in medical text-books, but
the descriptions have been based mainly on the rare lesions
of the organ found post-mortem ; little or nothing was known
of any definite symptoms sufficiently marked to constitute a
recognizable disease.
Within the last few years some advance has been made,
and considerable attention has been called to the subject
since Fritz delivered the Middleton-Goldsmith lecture* upon
it, basing his description on a number of cases that he had
collected from medical literature. His conclusions were
that acute pancreatitis is a distinct disease, and not so
very rare, that may be plainly recognized, marked by a con-
stant set of symptoms — vomiting, tenderness, constipation,
collapse, etc. — and almost invariably ending in death after
running a short and uniform course.
Post-mortem. — Signs of acute inflammatory changes are
found in the pancreas, often with small or large haemorrhages
in the organ, and with patches of * fat necrosis ' in neighbour-
ing portions of the subperitoneal tissues. Cases of pancreatic
haemorrhage have been described by some writers as a
separate disease, but it is probably only a variety of the
above.
The nature and cause of the disease are unknown. In
this negative respect it is like acute atrophy of the liver,
which it resembles in some other of its features also.
Clinically, the disease is important, because it is apt to
be confounded with intestinal obstruction, and with subacute
peritonitis ; also because it almost invariably ends in death
in the course of three or four days at most. Sometimes
the first stages of the disease are so slight that the final
collapse is the first symptom to which attention is called,
and death is practically sudden, and it may give rise to
the idea of poisoning.
Two cases of the sort have been published :
I. By Dr. Harris, of Boston, U.S.A. f A working-woman,
aged 35, was found on a doorstep, complaining that she was
* New York Medical Record, 1889.
t British Medical Journal^ March 8, 1890, p. 564.
LESIONS OF THE DIGESTIVE SYSTEM 269
very ill. She had been at an employment agency a few
hours before, seeking work. A smell of alcohol was noticed
in her breath, and she was removed, as a case of drunken-
ness, in a patrol waggon to the police-station. On her
arrival there she was found dead.
Post-mortem. — Besides some oedema and extravasation in
the bases of the lungs, there was haemorrhage into the
splenic end of the pancreas, with a small effusion into the
surrounding subperitoneal tissue.
2. An inquest was held* on the body of A. F., ward-
master in the Government Civil Hospital, Hong-Kong, who
was found dead in his quarters. Dr. Atkinson had been
summoned to him, but found him dead on the sofa.
Post-mortem. — There was acute inflammation of the
stomach and pancreas, with a large haemorrhage into the
head of the latter. Nineteen grains of chloral and J grain
of morphia were found in the stomach. He could not
probably have taken more than J drachm of chloral. The
cause of death was said to be syncope in acute gastritis
and pancreatitis, possibly accelerated by a medicinal dose of
chloral.]
VIII. LESIONS OF THE SUPRARENAL CAPSULES.
I shall not speak at any greater length on this subject.
M. Letulle has related two cases of sudden death in cachectic
individuals, and in the autopsy on each he found advanced
tuberculization of the suprarenal capsules.
[This case seems to have been one of Addison's disease,
which is known to cause very rapid death occasionally, and
may thus lead to an inquest]
I shall not add any more to what I have already said in
the course of these lectures about lesions of the peritoneum.
Remember only that, from the medico-legal point of view,
there are fatal — even rapidly fatal — forms of peritonitis,
which do not present the usual symptoms of peritonitis.
These cases of peritonitis, on the contrary, give rise to
* The Lancet, April 30, 1898, p. 1207, quoting the Hong-Kong Weekly
Press.
270 SUDDEN DEATH
phenomena which we can only call choleraic, such as sup-
pression of urine, aphonia, vomiting, diarrhoea, and collapse.
The same may happen in tuberculosis and cancer of the
peritoneum.
IX. CORPULENCY.
[Though corpulency is not in itself an immediate cause of
sudden death, yet it deserves to be mentioned in this con-
nexion, as it sometimes leads in a direct manner to such an
accident. Kirsch* gives statistics of the relative frequency
of the various modes in which sudden death may happen
from such a cause. Out of nineteen cases in corpulent
persons, there was acute congestion of the lungs in twelve,
cerebral haemorrhage in six, rupture of the heart in one.
The pulmonary congestion arose from paralysis of the left
ventricle, the right acting normally. Apoplexy is due to
arterio-sclerosis, which is very common in corpulency.
Rupture of the heart is due to degeneration and overwork
of the left ventricle. Death is really due to failure of heart-
power, and generally immediately follows violent exertion,
or excess of eating or drinking. Stout persons are very
liable under such conditions to fatal syncope, and it occurs;
in them at an earlier age than in others. It is dangerous
for very stout persons to attempt too great exercise, such as
up-hill walking, when enjoying a holiday, especially after a
comfortable meal.]
* British Medical Journal^ May 15, 1886, p. 938.
LECTURE VII.
SUDDEN DEATH CAUSED BY LESIONS OF THE FEMALE
GENITAL ORGANS.
Gentlemen, — It might appear reasonable to divide this
chapter into two sections, one relating to lesions of the
genital organs in pregnant women, the other relating to
lesions of the same organs in women who are not pregnant^
This plan would lead to numberless repetitions.
A. VAGINAL EXAMINATION.
Allow me to draw your earnest attention to a very impor-
tant point. You may be exposed in certain cases to sus-
picions which may cast discredit upon you and compromise
your reputation.
In a woman, whether pregnant or not, who has lesions of
the uterus or its appendages — fibroid tumours, for example
— simple vaginal examination, such as a physician makes
daily in his consulting-room, may cause sudden death.
I remember that, when I was house-physician, I was one
evening with my colleague, Chas. Martin, in Gosselin's
wards, by the side of a bed in which was lying a woman,
on whom he had to make a vaginal examination. He made
the examination, and then went to wash his hands. The
woman died suddenly, without M. Martin, who was washing
his hands at the end of the ward, or even myself, who was
by the bedside, being able to render any aid, however quick
we might have been. Post-mortem we only found a fibroid
tumour. All the organs were healthy. When I exhibited
272 SUDDEN DEATH
the specimens at a meeting of the Anatomical Society,
Dr. Barth related to the society three or four similar cases
that had occurred in his own practice.
Some years later Lorain published the following case :
A girl, i6 years of age, who had contracted gonorrhoea,
although she had the signs of virginity, was admitted under
his care. Lorain himself administered an injection through
the orifice of the hymen, by means of a syringe with wings.
The operation was very simple, and the introduction of the
tube of the syringe could not cause any injury. At the fourth
injection the girl died suddenly.
Twice within my own knowledge it has happened that
women have died in the consulting-room of a physician
who had simply made a vaginal examination. You see what
would be the consequences of an accident of this sort : the
physician is obliged to give notice to the superintendent of
police that there is a corpse in his house ; a romance, a
legend, is quickly invented ; if the deceased woman was
pregnant, and if she had said to her neighbours that she
regretted her condition, the physician will be accused of
having attempted to procure abortion. Tardieu * has very
justly compared these sudden deaths with those which take
place in abortion.
In country places the physician will be in a very awkward
situation in the presence of such rumours and of the public
hostility, which will not always be allayed even when the
result of the autopsy is made known, and he will often have
great difficulty in recovering his reputation after such attacks
have been made upon it.
Simple vaginal examination may also have another conse-
quence.
M. Tarnier stated in the Court of Assizes that women
have twice come to him in order to submit to such an
examination, and have aborted the same evening, and yet
neither of them wished for abortion to take place.
This is an extremely interesting chapter from the point of
view of medical responsibility. If we ask ourselves to what
* Tardieu, ' Etude mddico-legale sur I'Avortement,' 4* edition. Paris,
1881.
I
I
LESIONS OF THE FEMALE GENITAL ORGANS 273
cause these sudden deaths are to be attributed, what I have
already said to you concerning inhibition and the following
remark will enable you to explain the process.
Superficial lesions sometimes suffice to bring on palpita-
tion or intermission of the pulse even in robust, though very
nervous, women, without any lesion of the heart ; cauter-
ization of a small ulcer on the cervix of the uterus will make
this palpitation and intermission cease. Is not that a proof
of the intimate relation that exists between the innervation
of the genital organs and that of the heart.
B. EXTRA-UTERINE GESTATION.
Sudden death may supervene in the course of extra-
uterine gestation. This gestation may be interstitial or
tubal. It seldom reaches the normal term. Sometimes
the foetus does not die until pregnancy is far advanced ; it
may remain for a time in the true pelvis, and be then
discharged in fragments.
Whatever may be the course of events in extra-uterine
gestation, suppose a woman is the subject of it, in what
circumstances will the intervention of the law be called for ?
Allow me, Gentlemen, to recall to you a case that I
referred to when I was speaking to you of the tension of
gases produced by putrefaction {vide p. 97).
A celebrated actress came to Paris with her maid and two
American travelling companions, who did not know a word
of French. They went for a walk in the Bois de Boulogne.
During the walk the actress felt unwell ; she was taken to
the Pr^-Catelan, where she drank a glass of milk ; as she
became worse, she was obliged to stop at the Armenonville
Pavilion, where she died. I told you that an Englishman
of high social position had time to reach Paris before the
autopsy ; he found me at the Morgue, and the first words
that he said to me were, * It is not possible for this woman
to be pregnant ; I have very good reason to be certain.' I
acquiesced. The actress had a three-months tubal pregnancy,
and the foetal cyst had ruptured into the peritoneal cavity ;
the young woman had therefore died of intra-peritoneal
haemorrhage. I told the English lord that she had died of
18
274 SUDDEN DEATH
rupture of the veins of the ovarian plexus into the peritoneal
cavity ; the precise cause of death I only stated in my official
report.
The public, who were much excited about the death of
this distinguished actress, learnt from the journals of the
day, which pride themselves on being well informed, that I
attributed the mishap to the fact that the young woman had ^^
drunk a glass of cold milk at the Pre-Catelan. "^^^
I will quote a second case to you : ^^^
A young physician, who took his degree in 1884, set up
in practice in Paris, and took into his service a maid,
24 years of age. One evening he went out after dinner,
and when he returned from his walk he found a mob in
front of his door, and the hall-porter was in a great state
of excitement. The maid was dying of loss of blood, and
expired soon after. The young physician was immediately
accused of having treated his maid as if she were his
mistress, and of having attempted to procure abortion. The
body was removed to the Morgue, and the autopsy revealed
the existence of a tubal pregnancy of three months' duration,
with rupture of the foetal cyst into the peritoneal cavity.
The unfortunate doctor, in spite of the conclusions of my
report, was obliged to leave that quarter and set up in
another part of Paris, a long way from his former residence.
Gentlemen, you are young ; allow me to give you a piece
of advice : when a physician is young and unmarried, he
ought only to take into his service females who are plain
and who have passed the canonical age.
[Occasionally a tubal gestation cyst ruptures at a very
early period, when the existence of pregnancy is quite
uncertain. Under such circumstances, the cause of the
alarming symptoms is very difficult to recognize.]
C. RETRO-UTERINE HEMATOCELE.
Besides these tubal or abnormal pregnancies, apart even
from pregnancy at all, death may take place from haemor-
rhage into the peritoneal cavity. Bernutz has applied the
term ' haematocele ' to such conditions.
Here is an example which is all the more interesting be-
LESIONS OF THE FEMALE GENITAL ORGANS 275
cause the patient recovered, and I was able to follow up the
case for a long time afterwards : A lady was taking up her
quarters in a new lodging, and was standing on a pair of
steps ; though she was not making any violent effort, she
was taken ill and I was sent for ; I found her completely
bloodless, though not losing blood by any external orifice.
My assistant and I took it in turn to stay near the patient,
spending four whole days thus, and giving her an injection
of caffeine or of ether every ten minutes. The woman was
unconscious, scarcely alive. Thanks to the teaching of my
master, Bernutz, I recognized the existence of a pelvic
haematocele, although the most careful exploration did not
yield any evidence of it. It was only on the third day, when
it had become encysted, owing to the formation of false
membranes due to peritoneal irritation, that it became
possible to confirm the truth of the diagnosis.
Cases of this kind do not always pursue such a fortunate
course. They may sometimes give rise to sudden death.
Gallard asserted that hsematoceles were always due to
rupture of a foetal cyst in an extra-uterine gestation, and
that careful search would always detect a corpus luteum,
which would reveal the nature of the disease.
Virchow attributes the formation of haematoceles to the
rupture of extremely fragile and highly vascular false mem-
branes, similar to those of pachymeningitis, consecutive to
an attack of inflammation of the peritoneal pouches. The
origin of such conditions really matters very little, so long
as we recognize their existence.
D. RUPTURE OF THE UTERUS.
In natural pregnancy the uterus may sometimes rupture in
the second month, under the influence of a strain or slight
violence. I have never met with an accident of the kind,
but Moynier has reported a case.
E. VULVO-VAGINAL VARICES.
In certain women, most often during the second or third
pregnancy, vulvo-vaginal varices, sometimes of considerable
size, may be met with. They are even found in primiparse.
18—2
276 SUDDEN DEATH
These varicose clusters may be almost imperceptible ; in
some cases they may attain the size of the foetal head. These
varices may burst as a result of an effort during delivery, or
even apart from delivery. The blood escapes externally,
and the woman may die of haemorrhage.
I once had to perform a medico-legal autopsy at the
Morgue, together with MM. Tarnier and Champetier (of
Ribes), on the body of a woman who was suspected of
having procured abortion ; we did not, however, find any
evidence of abortion, but a considerable bundle of vaginal
varices ; nevertheless, it was impossible to discover the
opening from which the blood had flowed.
This is not an isolated instance. When a woman dies
under these conditions, the laceration of the varicose vein
is no longer discoverable, because the varices are no longer
distended by liquid ; it would be necessary to inject the
varicose cluster in a way that might be possible in the post-
mortem theatre, but this would not be an easy matter in a
medico-legal autopsy, where, when there is a suspicion of
abortion, we examine the uterus, its appendages, and the
placenta (if it exists), before thinking of varicose veins in
the vulva and vagina. At any rate, I do not know of a
single medico-legal autopsy in which the orifice by which
blood has escaped has been found in a cluster of varicose
veins.
When rupture of these varicose veins takes place during
delivery, at the moment when the foetal head passes, it is
impossible to be in any doubt as to the nature and cause
of the haemorrhage. But it is otherwise when the rupture
takes place before labour begins.
There may be sudden and suspicious deaths during de-
livery. Moynier has reported cases of rupture of the utero-
ovarian plexus, but this is very rare.
F. SYNCOPE.
Here is another accident, which is more frequent. When
a woman is confined, she may have an attack of syncope.
The fact is certain. When the birth is secret, and espe-
cially in cases of infanticide, the accused woman always
J
LESIONS OF THE FEMALE GENITAL ORGANS 277
says that she became unconscious and did not know what
was happening, and that when she recovered her senses
she found the child dead between her thighs.
At the assizes, the judge will ask you if such attacks of
syncope are common ; they are possible, but they are not
frequent under normal conditions. I was much surprised
to read in a lengthy memoir by Freyer, a distinguished
obstetrician of Berlin, that out of 165 confinements he had
met with 34 cases of syncope. Dr. Freyer expresses no
astonishment at this proportion ; he appears to consider it
natural, and he does not relate the circumstances in which
these syncopal attacks took place. There is an enormous
difference, in this matter, between our experience in France
and that which Freyer describes.
Moreover, statistics are not of much importance ; the
interest to us lies in the conditions under which syncope
may present itself.
Is syncope more common among women who are confined
in secret ? Perhaps. These women, of course, do not wish
anybody to know of their delivery ; they have determination
enough to suppress all cries and groans ; it may be that the
very excess of pain may bring on syncope in them.
This is probably the most frequent mode by which syncope
is produced in those women who are confined secretly ; yet
this syncope may also be determined by an attack of
haemorrhage or some other obstetrical accident, since there
is no competent person present to prevent or check it.
G. CHLOROFORM.
You know that of late years it has been customary to
administer chloroform during labour. Obstetrical anaes-
thesia is not so deep as surgical anaesthesia, I admit. Yet
there have been deaths to deplore. Ought these deaths to
be attributed to chloroform ? Is it not possible for syncope
to come on in women who are under the influence of chloro-
form just as in those who are not ? I point out to you the
possibility of these accidents, for they may give rise to very
embarrassing problems ; the responsibility of the physician
278 SUDDEN DEATH
or midwife may be questioned, and you may be called upon
to decide the question.
A certain number of sudden deaths after confinement, and
sometimes in pregnancy (for the pathogeny is the same), are
attributable to venous thrombosis and embolism. I shall
not repeat what I have already said on this subject, while
studying with you the lesions of the circulatory system. In
pregnant women, thrombosis of the veins of the lower ex-
tremities and of the vena cava may take place before
confinement ; the straining of the woman during the act of
parturition may dislodge the clot, which is then precipitated
into the circulatory stream.
Finally, sudden deaths have been observed due to abscess
of the ovary, 53 hours after delivery ; but I do not lay much
stress upon this.
LECTURE VIII.
SUDDEN DEATH IN FEVERS.
Gentlemen, — There are certain fevers in which death may
occur in a sudden and somewhat unexpected manner, and
therefore give rise to medico-legal intervention.
You know what intermittent fever is. Gentlemen, with its
pernicious forms — algid, comatose, and choleraic.
You are aware that an attack may be pernicious from the
very beginning, without the patient having had any attacks
of fever previously ; that algidity may show itself along with
the initial rigor — i.e.^ in the first stage ; that the comatose
form usually appears at the end of the second stage; and that
the choleraic phenomena present themselves in the sweating
stage.
These different forms of attack may, however, be mixed
up, and become ' subintrant,' and there are all sorts of ways
in which it is possible for death to take place under suspicious
circumstances at any period of the disease. Death may
occur in the first attack ; it may occur in the first stage with
as much likelihood as in the second or third.
In those countries where pernicious fever is rare, attacks
of this class are nearly always misinterpreted. From the
medico-legal point of view, the medical jurist intervenes all
the more frequently in fatal cases of pernicious fever, in pro-
portion to their rarity, because public opinion does not
know to what cause to assign them ; i.e., in countries where
cases of intermittent fever are fewest, medico-legal interven-
tion is at its maximum, and in countries where such fever is
prevalent, medico-legal intervention is at its minimum.
28o SUDDEN DEATH
In the hgemorrhagic forms of certain exanthemata, such as
small-pox and scarlet fever, death may happen suddenly,
especially in pregnant women. When the haemorrhagic form
of the disease has not been recognized, the medical jurist
may be directed to make an autopsy.
I shall not enumerate here the causes which may lead to
sudden death in fevers or infective diseases, either during
their course or during convalescence. We have drawn
attention to them already when studying myocarditis, endo-
carditis, thrombosis, embolism, syncope, etc.
You will find them set forth at length in systematic
treatises.
[A few of these are worthy of a little attention, however,
as difficulties may present themselves in the case of some of
them ; and in others, where sudden death may be expected
to occur occasionally, the mode of death is as yet somewhat
obscure, and requires to be cleared up by further observations.
Anthrax may sometimes prove fatal in a very short time,
even in twelve hours,* almost before the patient has had time
to know that he is ill. As the disease is not an epidemic one,
such an occurrence might prove puzzling, unless the occupa-
tion of the patient be borne in mind ; for nearly all these
cases happen in persons employed as wool-sorters in factories ;
though others who have to handle infected hides may be
attacked — a postman recently died in this way.
There are two forms : internal anthrax or wool-sorter's
disease, and external anthrax or malignant pustule. The
former only can give rise to perplexity, as the effects of the
latter are visible. Speaking of malignant pustule. Dr. Ross,
of New South Wales, says :t * I have attended several cases
in the extreme heat of summer, in which the patients have
died within twelve or fourteen hours after having contracted
the poison, or from the time they were first inoculated.' Thus,
the disease may be more quickly fatal than plague itself.
* The poison may enter by the pulmonary or alimentary
mucous membrane, but usually by inoculation through a
* Allbutt, ' System of Medicine,' vol.'ii.
t The Lancet, April 13, 1898, p. 1213. ^
SUDDEN DEATH IN FEVERS 281
cut, abrasion or scratch of the skin. Those on the face and
neck are the most virulent.'
Mumps. — This is usually a trifling disease, but has been
known to end in sudden death. Accurate post-mortem
examinations have seldom been made, but in one case*
sudden death was found to be due to thrombosis of the heart
and embolism of one of the arteries at the base of the brain.
Diphtheria. — No other acute disease presents so great a
liability to sudden death. It should be looked on as a
possibility in every case, even the mildest, and the patient's
relatives should consequently be always warned. The heart
particularly should be regularly examined for any indication
of an approaching catastrophe. The common mode of death
in this disease is by extension of the false membrane into the
air- passages, blocking the larynx, trachea or bronchi : nearly
always this is gradually fatal, so that there is abundance of
warning ; but occasionally death may occur very abruptly.
Choking is not unknown as a cause of death, probably from
paralysis of the pharynx ; Dr. Hale White has recorded a
casef in which tea entered the air-passages. A case of
food obstructing the glottis has already been mentioned
(p. 208). The more insidious forms of sudden death take
place through the nervous system and heart. One of them
has been well known for many years, and is certainly due
to implication of the vagus, and occurs at a somewhat late
period of the disease, usually associated with some other
signs of paralysis. In this class of cases the heart becomes
slower day by day, till the pulse may be only 20 or 30 per
minute ; and then death invariably ensues. But in some
cases the heart may be preternaturally rapid. Sir W. Jenner
mentions a case in which the pulse was 140 five minutes
before death. This probably depends on the following con-
ditions. The most sudden cases of all are met with in the
acute stage of the disease, before the end of the second week.
The attack may be mild or severe, as far as the throat is
concerned, and the pulse may be rapid, slow, or irregular
and weak. There is usually very little warning, or even none
* Gillet, Gaz. des Hopitaux de Paris^ 1873, P- 1156.
t ' Transactions of the Clinical Society of London,' February, 1894.
282 SUDDEN DEATH
at all ; the patient may become languid, and usually vomits ;
he becomes collapised, and may die immediately, or after
remaining prostrate for a few hours. I saw such a case in
October, 1897. A female child, aged 5, had an attack of
diphtheria, with extensive deposit of false membrane on the
throat, which did not, however, extend to the larynx. The
local and general symptoms improved steadily, and about
the end of the second week nearly all the false membrane
had disappeared, the pulse, being normal almost till the
last. The child was rather light-headed one night ; in the
morning some petechial spots were noticed on the lower part
of the abdomen and thighs, and vomiting took place once or
twice. The child died suddenly that afternoon, while lying
quietly in bed. No post-mortem examination was allowed.
I also met with another such case a few years before. A
child, suffering from diphtheria in an early stage, was taken
up by its father into his arms and died immediately, though
there had been no dyspnoea. In this class of cases the cause
of death is probably myocarditis, though the condition is as
yet not very well understood : there is degeneration of the
muscular fibres, due either to an inflammatory process or to
simple fatty or granular degeneration. They have been
described by Gee* and by Goodall and Washbourn.f Clots
in the heart have also been looked upon as a cause of sudden
death in this disease, especially by Sir B. W. Richardson. J
Dr. Robinson Beverley§ describes two such cases, in one
of which a careful post-mortem examination was made, and an
ante-mortem clot was found in the right ventricle ; but in this
case there had been gradual and extreme slowing of the heart,
and possibly the clot was deposited simply in consequence
of the slow circulation of the blood, due to the imperfect
cardiac action ; and this explanation would probably apply to
all cases of cardiac thrombosis.
Acute Rheumatism. — Besides rapidly fatal cases from
hyperpyrexia, or excessive effusion in pericarditis, several
* Allbutt, ' System of Medicine,' vol. i., p. 738.
t 'Manual of Infectious Diseases,' 1896, p. 132.
X * Transactions of the Medical Society of London,' November 1 1, 1872.
§ 'Transactions of the Clinical Society of London,' January, 1880.
SUDDEN DEATH IN FEVERS 283
instances are on record of death from myocarditis, some-
times very sudden. In some of these cases there is much
fever and constitutional disturbance ; in others these
symptoms are almost absent. Dr. Bristowe described two
cases* in females: in one of these syncope took place in
the course of articular rheumatism, without any cardiac
mischief having been detected ; in the other, with the
ordinary symptoms of acute rheumatism, including a high
but not excessive temperature, death took place suddenly at
the end of a few days.
Post-mortem, — In the former no cardiac lesion whatever
was detected ; in the other there was some fatty degeneration
of the heart, but no pericarditis.
Another case, in which myocarditis was recognised during
life and confirmed after death, and which died suddenly,
was described by Dr. Herringham.f
Typhoid Fever. — Occasionally death may be speedy, as
well as unexpected, from perforation of an ulcer in the
* ambulatory form.' Haemorrhage also, if very severe, may
be rapidly fatal. It occurred in December, 1899, in a
patient of mine, who was doing well otherwise, though he
had impaired his chance of recovery by undertaking a
voyage from West Australia to South Australia after the
commencement of the illness. Tremendous haemorrhage
came on suddenly, the blood soaking through everything on
the bed, and death occurred within three or four hours from
the onset of this complication. Sudden death may also
occur from rapid or instantaneous heart failure, usually
about the third week ; the symptoms are those of syncope,
and a post-mortem examination does not always reveal any
cause in the texture of the heart.
Plague. — At the beginning and height of a severe epidemic
of this disease, it has been noted by Sydenham and others
that it is not uncommon for persons to be struck down even
while going about and engaged in their business, and to die
speedily, without any other manifestation than the appear-
ance of purple petechial spots on the skin.]
* 'Transactions of the Clinical Society of London,' January, 1880.
t Ibid., i8q8.
LECTURE IX.
SUDDEN DEATH DUE TO HEMOPHILIA.
Gentlemen, — I come now to sudden and suspicious death
due to humoral changes ; I use this term in a somewhat elastic
sense, so as to include haemophilia, diabetes, uraemia, and
alcoholism.
Hcemophilia is a rare affection, and on that account does
not often give occasion for medico-legal intervention. But
when this is required, the medical jurist will find himself
beset with very great difficulties.
Haemophilia may occur in isolated cases, or it may run
through families.
When a bloodvessel is opened in one of these subjects, it
is almost impossible to arrest the haemorrhage. When a
man who is the subject of haemophilia dies of haemorrhage,
would it have been possible to stop that haemorrhage ?
You see that the question of responsibility crops up at
once : there is the responsibility of the druggist to whom the
man, who has just become unconscious, is carried, and the
responsibility of the physician who has been called in to
render first aid. The example that I am going to cite
to you. Gentlemen, will enable you, I think, to form an
opinion.
Thirty years ago, a youth, 14 or 15 years of age, neither of
whose parents was the subject of haemophilia, fell down in
the Rue de I'Odeon and cut his lip, causing haemorrhage.
The lad was taken to his parents' house, which was in the
same street, and they sent for me. In spite of my long-
SUDDEN DEATH DUE TO HEMOPHILIA 285
continued efforts, I found it impossible to stop the haemor-
rhage ; I sent for my master, Dr. P. Lorain, who was no
more successful. "We summoned Nelaton and Gosselin to a
consultation, but the haemorrhage could not be arrested, and
the lad died in the night.
Eighteen months afterwards. Gentlemen, this lad's sister
was married. On her bridal night haemorrhage ensued in
consequence of the rupture of the hymen ; she died twelve
hours after, without any of the physicians or surgeons who
were collected round her bed being able to check the
haemorrhage. How does forensic medicine come to inter-
vene in these cases of sudden death in haemophilia ? I have
had personally to deal with two such cases, and in almost
identical circumstances.
A young man went to his barber, who combined the pro-
fession of dentist with that of hairdresser. After having cut
the hair or the beard of his customer, the barber, noticing
that he had a decayed tooth, persuaded him to have it
extracted. He extracted the tooth, and haemorrhage took
place. Remember that at that time the practice of dentistry
was free, and that the law which regulates it at the present
time did not then exist. The barber, not knowing how to
stop the haemorrhage, took his customer to a chemist, who
applied plugs of perchloride of iron, but in vain. The patient
was then carried to St. Antoine Hospital, where he died.
Was the barber-dentist responsible for the young man's
death ? The widow brought an action against him for
damages, and at that point I was commissioned as an expert.
Was the young man the subject of haemophilia? Perhaps
he was, but he was not aware of it ; no more was the barber.
The father, mother, and brother of the deceased were still
living, and we could not discover any trace of the disease in
them.
In the second case, on the contrary, a very celebrated
dentist, who possessed many qualifications and diplomas,
was involved. A young woman who was about to be married
was taken to him. He examined her teeth and recommended
the extraction of a stump; the stump was removed, and
haemorrhage immediately followed, which it was quite im-
286 SUDDEN DEATH
possible to stop, and the young woman died. The dentist,
it seems, had lost his head somewhat when this accident
took place. He went away repeating :
' Oh, my God ! it is I who have killed her 1 it is I who ^^
have killed her!'
The family, whose suspicions were aroused by these im-
prudent words, on the advice of a physician who did not
think of its being a case of haemophilia, and who expressed
the opinion that * powerful ' haemostatics should have been
used, brought an action against the dentist.
I had to be very reserved in my conclusions, for, in spite
of the absence of any hereditary taint, it was not demon-
strated that the girl was not the subject of haemophilia.
[A typical case was the subject of an inquest at the
Southwark Coroner's Court a few years ago.* A little boy,
aged 3, the son of a fireman, was playing with other children
at an imaginary fire-extinction, holding a piece of string to
represent the hose. He came into collision with another
boy, and his nose began to bled, and continued to do so until
a medical man arrived and plugged his nostrils. The boy
died next morning.
It turned out that the haemophilic tendency was in the
family; the boy himself had narrowly escaped bleeding to
death during a slight operation, and his brother, aged 9,
nearly died in school from loss of blood caused by the
extraction of a tooth.]
The great danger of haemophilia is that neither the subjects
of it nor those in habitual intercourse with them are aware
of the fact. The slightest injury may induce a catastrophe
in them.
* The Times, 1897.
LECTURE X.
SUDDEN DEATH IN DIABETES.
Gentlemen, — Diabetes is the disease of all others which
runs the longest course without its subject being aware of it,
whatever may be the quantity of sugar voided in twenty-four
hours. The ordinary diabetic is a man who has a good
stomach and digestion, who appears to be in good health up
to the moment at which he enters upon what may be called
the * pathological period,' which is revealed by a succession
of boils, loss of teeth, ocular troubles, etc. The common
belief is that the diabetic passes much urine, but sometimes
this is not the case at all, and at other times the patient
scarcely notices it. He drinks more, perhaps, than other
people, therefore it seems only natural to him to make water
more freely and more frequently ; moreover, if the quantity
of urine passed increases little by little every day, there is
not sufficient difference between one day and another to
attraction his attention. Diabetes may develop in an entirely
latent manner. I am persuaded that a few years hence
clinical observers will be able to break up the group, which
is at present regarded as homogeneous. For my own part,
I have never met with two cases of diabetes that are abso-
lutely alike. In one class of cases the patients are fat, in
another class thin ; there is diabetes with excess of urea,
and diabetes without such ; but classification according to
these varieties does not afford a solid basis for forming
a prognosis. The only form of diabetes which I would
actually separate from the main group is that which results
28 8 SUDDEN DEATH
from an injury — a railway accident, for example — and which
has been specially studied by M. Richardiere and myself.*
This form is more curable than the rest, and in none of
these cases did we meet with accidents such as those that I
am going to point out to you.
Certain individuals, whom no one suspected of being the
subjects of glycosuria (this is important, for it alone explains
the intervention of the medical jurist), may be carried off
very rapidly by a great variety of accidents. They may die
of pulmonary complications, such as the * fulminating pneu-
monia ' of Bouchardat. This form of pneumonia is only
detected 24 or 36 hours before death takes place. It may
develop with extreme rapidity, something like the pneumonia
of the aged, but it is accompanied, however, by symptoms
of reaction which make it evident that the patient is ill 24
or 36 hours before he dies.
They may die from some complication of a wound or surgical
operation. You know that before the introduction of anti-
septic dressings surgeons hesitated before operating on a
diabetic. Gosselin did not care even to open a boil in such
subjects. Since the claims of antisepsis have become estab-
lished, it has been shown that rapid death in such cases is
only due to an intensive culture of streptococci and staphylo-
cocci; but it is true, nevertheless, that diabetes renders the
healing of a wound much more difficult.
A wholesale mercer of the Rue de Rivoli slightly abraded
the skin over the crest of the tibia in falling over a footstool.
He was carefully treated by his usual medical attendant, who
called in Trelat to a consultation, as the wound did not heal.
The medical attendant being taken ill, I was asked to take
his place. I was then house-physician to Aran, and the
urine was systematically examined in all the patients under
his care. I therefore examined my patient's urine, and
found that it contained sugar. The next day but one, the
brother (a notary) and sister of my patient begged me to
examine their urine also. I found that they were passing
from goo to 1,200 grains of sugar per diem. All these three
* Brouardel et Richardiere, ' Du Diabete traumatique au Point de Vue
des Expertises mddico-l^gales ' {Ann. (THyg.^ 1888, tome xk., p. 204).
IN DIABETES 289
persons lived for more than 20 years without ever experi-
encing any disorder that might be attributed to diabetes.
My patient in particular died only two years ago ; he sur-
vived 32 years after the occurrence of the above-mentioned
trifling accident, and he would never have known that he had
diabetes but for that wound being so slow in healing.
And notwithstanding the great advantages which anti-
septic treatment bestows on our patients, it should always
be ascertained, before undertaking an operation, whether or
not they suffer from diabetes. Death may take place in an
unforeseen manner in diabetes. The form which most often
gives rise to suspicion, medico-legally speaking, is that which
is called * diabetic coma.'
All observers agree in saying that coma sets in after a
phase characterized by loss of appetite, dyspepsia, constipa-
tion, vomiting, pinched face, and feeble pulse, indicating
gastro-intestinal disturbance. These symptoms might suggest
peritonitis, but for the absence of pain and fever. There is
also a peculiar form of dyspnoea, marked by ample, regular
and slow respiratory movements. This dyspeptic period
lasts from 36 to 48 hours ; then the patient becomes coma-
tose ; the temperature in the axilla falls to 95°, and there is
loss of consciousness. The comatose phase lasts from 24 to
36 hours. You see that the entire process lasts 4 or 5 days
altogether.
The above is a picture of diabetic coma as it was first
described. Then exceptions were discovered ; cases of
diabetic coma were met with which were comatose from the
first, the abdominal stage being quite absent. These cases
are often difficult to interpret, and they may easily give rise
to suspicion. This does not apply to those persons who
know that they are diabetic, and whose history is well known
in towns like Vichy or Carlsbad, where they spend season
after season. These patients pursue a course of treatment ;
but as they are, or think they are, in good health, they make
excursions, go to the Casino, do not husband their strength,
or sometimes they overdo their treatment because they have
not consulted their physician, or have ceased to see him.
They suddenly fall into a state of coma. Such cases as
19
290 SUDDEN DEATH
these have been well studied by Cyr,* a physician at Vichy,
who died a few years ago.
Cyr has described another variety, of which I myself have
seen three examples. A diabetic, as a result of over-work,
of preoccupation, or of cerebral excitement, becomes
mentally disturbed. His character is changed : he becomes
morose and difficult to live with, and at length talks in
an incoherent manner, which I can only compare to the
babbling of individuals in the first stage of anaesthesia from
chloroform ; then headache and giddiness supervene, and
the individual suddenly becomes comatose. Cyr has never
observed convulsions.
If any member of the patient's family or any of his
acquaintances know that he is diabetic, there will be no
medico-legal difficulty. But if no one was aware of it,
suspicions of poisoning may arise, whether or not there may
have been dyspeptic troubles before the comatose period is
established.
A medico-legal autopsy will be ordered, but it will be
without result ; the medical jurist will not find any lesions
on which conclusions can be based. His only chance is to
find urine in the bladder, and sugar in that urine ; unfortu-
nately, the bladder is most often empty. In case of poison-
ing, as a general rule, the autopsy is not performed
immediately after death ; in most cases exhumation has to
be performed. The difficulties of research will then be all
the greater, and even if liquid is found in the bladder, its
composition will have undergone alteration, and may con-
tain sugar no longer, although it might have done so during
life.
[Pepper observesf that if a post-mortem examination of a
case of diabetic coma be made while the body is still fresh,
the organs, and especially the brain, may exhale the charac-
teristic odour.]
The medico-legal difficulties. Gentlemen, are therefore very
great, and the problem is very difficult to solve.
If we are to believe Colin and Parrot, the quantity of
^ Cyr, 'Traits pratique des Maladies du Foie.' Paris, 1887.
t * Lectures on Practical Legal Medicine,' the Lancet, 1887.
IN DIABETES 291
urine passed during coma is diminished to such a degree
that Parrot has been tempted to speak of ' anuria ' ; thus, the
diabetic seems to die at the moment when excretion of urine
ceases.
Another form of sudden death in diabetes has been
described, due to syncope or atrophy of the heart. Two
English physicians, Dickinson and Scott, are the principal
writers who have laid stress on this form. In the autopsies
on diabetics that I have made, I have found the heart fatty,
but never atrophied.
19 — 2
LECTURE XI.
SUDDEN DEATH DUE TO THE KIDNEYS.
A. UREMIA— AUTO-INTOXICATION.
Gentlemen, — Death due to the kidneys is the most frequent
form of sudden death. Let me say at once that the renal
lesion is not always the only factor ; there is often a com-
bination of causes, and for this reason the mechanism of
this kind of sudden death is difficult to determine. But
from the point of view with which we are concerned at
present, it is necessary to remind you that the kidney is the
great emunctory of toxines and of all foreign products which
pass through the system, entering the blood and being dis-
charged from it without assimilation. Death supervenes
when poisons manufactured in the system, or unwholesome
food that has been ingested, can no longer be adequately
removed by the diseased kidneys. The individual is there-
fore poisoned either by his food or by poisons which are
generated within his own body, i.e., auto-intoxication.
When we study the kidney in childhood, in the adult, and
in old age, we see that the size of the gland in proportion to
the rest of the body is not constant. In the child the kidney
is of enormous size, in the adult it is less, and it is atrophied
in old age.
Take the kidney of an adult. You know its shape ; you
know that it consists of cortex and medulla, and that it is
provided with a hilum, in which are the pelvis and calyces
surrounded with a padding of fat. In old age the hilum
enlarges and becomes loaded with fat, while the cortex
SUDDEN DEATH DUE TO THE KIDNEYS 293
shrinks, so that the senile kidney is contracted in two direc-
tions.
It may therefore be said, from an anatomical point of
view, that the essential part of the kidney diminishes with
age.
From the physiological point of view, we know that a dose
of iodide of potassium given at the same time to a child, to
an adult, and to an old man, appears more quickly in the
urine of the child than in that of the adult, and more quickly
in that of the adult than in that of the old man.
Ten years ago I made the following experiment in my
own house. I took a young man, aged 20 (he had not yet
drawn lots for the conscription), who was my servant, an
adult, myself (I was 45 years of age, and I consider that
my kidneys were then those of an adult), and my mother,
aged 70.
We each took 15 grains of salicylic acid, dissolved in half
a bottle of wine and water, in the course of the day. In my
servant, the salicylic acid appeared in the urine an hour
after breakfast ; in myself, only in the evening, after I had
drunk all the half-bottle ; in my miother, not until the third
day. On the following day the servant no longer had any
salicylic acid in his urine ; in -myself the elimination lasted
for four days ; it lasted nine days in my mother. The gra-
dation is therefore closely related to age.
An important fact follows from this, from the point of
view of poisoning by substances swallowed in small daily
doses, and I will add that it is a fact of which there is
actual proof. Observe that my mother, my servant, and
myself had healthy kidneys. But how many people are
there whose kidneys are affected as a result of some former
disease, e.g., of nephritis from scarlet fever, rheumatism,
pregnancy, etc. These persons have kidneys which are older
than they themselves are ; their renal lesion may have been
completely cured, yet in spite of that they may be subject to
the most serious accidents. Let me give you an instance :
A pupil of the Monge school, about 13 years of age, was
knocked about by his companions, and struck his loin against
the corner of a desk. He returned home, and passed blood
294 SUDDEN DEATH
with his urine. A surgeon and I were called in, and we
thought there was a contusion with rupture of the kidney.
The boy got well. Eighteen months afterwards he suffered
from an attack of jaundice, which seemed to be only simple
catarrhal jaundice; however, it rapidly assumed the malig-
nant form ; albuminuria appeared on the seventh day, there
was almost complete suppression of urine, and the boy died.
Remember, then, that an individual who has suffered from
damaged kidneys, although all signs of the mischief have
disappeared for a long time, is exposed to grave dangers if
he catches any infective or eruptive fever. Even influenza
may be the cause of these accidents ; I can cite two cases
to you bearing on the matter.
The subject of the first case was a deputy ; that of the
second a hospital physician. They had both fought in the
war of 1870-71, one in the army of the Loire, the other in
Bourbaki's army. Both had suffered during that period
from nephritis induced by exposure to cold, but they had
completely recovered from it. They suffered from influenza
four years ago ; in spite of the mildness of the influenza,
they showed symptoms of cerebral disturbance, with
anxiety, loss of memory, etc. They recovered ; but these
unusual complications must be attributed, not solely to the
influenza, but to the fact that this disease occurred in per-
sons suffering from renal inadequacy.
Here is another case, to which I have already referred
with some fulness :
A retail poultry-woman in the market, who had a fine
stuffed turkey remaining on her hands, invited her relatives
and friends to come and help her eat it ; all who partook of
this turkey became ill ; the stuffing, which was no longer
very fresh, contained toxic alkaloids. The woman alone,
who had not eaten more than her guests, died, because she
had diseased, and therefore inadequate, kidneys. She could
not eliminate the toxic substances which she had swallowed.
It is not necessary, however, that the substances swallowed
should be of a poisonous nature. A journalist, after a copious
repast, went to a house of ill-fame in the Rue Tiquetonne ;
he was already somewhat intoxicated ; nevertheless, he
DUE TO THE KIDNEYS 295
treated all the inmates of the establishment to champagne,
and finally went upstairs with one of them. When he was
in bed he defsecated as he lay there. The woman was dis-
gusted, and slipped away, leaving him by himself. Next
morning, when the door of the room was opened, the man
was found lying dead on the floor at the foot of the bed
with his left side covered with bruises. Naturally, the
superintendent of police intervened ; the body was removed
to the Morgue, and an autopsy was made. The kidneys
were contracted and older than their possessor (he was
44 years of age). The champagne that he had drunk had
intoxicated him because he could not eliminate it. He had
died of urgemic convulsions.
Why does the kidney suddenly cease to perform its
excretory functions ? Because the organ is irritated and
congested, and consequently there is less urine secreted.
Therefore, when we have to prescribe a diuretic, we should
choose one which is free from irritating properties.
I am not speaking here of invalids, but of those persons
who excrete a few grains of albumen daily.
The same is true of arterio-sclerosis and of cardiac
affections ; there is indeed a very close relation between
the heart and the kidney. The question has been under
discussion for a long time in Germany. Traube has shown
that any renal mischief will determine increase of arterial
tension, so that the left ventricle becomes hypertrophied,
and thus constitutes a genuine cardiac affection.
It matters little to us, Gentlemen, to know whether the
disease of the heart has preceded that of the kidneys, or
vice versa. When the heart is diseased, the kidneys are
congested, and they can no longer eliminate the offending
substances which they ought to remove from the system.
Suppose that you have to make an autopsy on a person
who has died under such conditions. It is necessary to
seek for albumen in the urine. This search ought to be
made, but it would be rash to draw positive conclusions
from it. There are, indeed, urasmic patients who pass no
albumen. Besides, albumen is always found in the urine
of a person who has been dead 48 hours. To assure them-
296 SUDDEN DEATH
selves of this fact, MM. Ogier and Vibert took the bladder
from a corpse at the Morgue, emptied it, filled it with water,
and hung it up in the laboratory ; in a few hours' time this
water contained albumen. When putrefaction begins, albu-
men is formed. The discovery of albumen, therefore, does
not prove that albumen was present during life.
Pathological anatomy might help us to answer the ques-
tion. Unfortunately, when we make an autopsy in a case
of this kind, we have too often to regret that it is done too
late ; for, in the first place, the kidneys occupy a dependent
position in the body, and therefore become infiltrated by
exudation from the blood, and their texture is altered
thereby. Death from uraemia may, under certain circum-
stances, be attributed to poisoning. Now, medico-legal
autopsies, when there is a suspicion of poisoning, are most
often made after exhumation ; thus, the kidneys are putrefied,
and there is not much to be learnt from a minute examina-
tion of them.
What then. Gentlemen, are the forms of uraemia from
which individuals die who have diseased kidneys, and whose
rapid death appears suspicious ?
There is first of all the bronchitic form. The patient is
suddenly seized with dyspnoea and pulmonary oedema, with
abundant secretion of bronchial froth, which forms a button
round the nostrils and mouth after death, just as in bodies
that have been drowned. He dies suffocated by bronchial
froth. When we meet with this form, the kidneys in most
cases are not contracted, but are the seat of desquamative
nephritis. Sometimes cardiac disease co-exists and in-
tensifies the amount of oedema. Dr. Lesser, of Breslau,
who was formerly Casper's assistant, has paid special
attention to sudden death. Out of seventy-five cases which
he attributes to this group of phenomena, and in which he
finds renal lesions, he only credits the kidneys with seven-
teen cases of sudden death, there being in these no disease
of the heart. For my own part, I believe that the kidneys
play a much more considerable part in the production of
sudden death than Lesser assigns to them, even when
there is some cardiac affection present. It is the kidney
I
DUE TO THE KIDNEYS 297
which regulates the amount of liquid discharged from the
body, and which sometimes does not permit the removal or
poisonous substances at all.
The g astro 'intestinal form is characterized by coldness of
the surface, vomiting, and diarrhoea ; in short, by choleraic
phenomena. It gives rise to the idea of arsenical poisoning.
The disturbance of the gastro-intestinal functions no longer
permits the food to undergo the normal transformations in
the alimentary canal. Dangerous fermentations are set up.
It is from this form that individuals often die, whose
kidneys are structurally altered, and who eat tainted or
indigestible food which they can no longer assimilate or
get rid of in the normal way.
The comatose form gives rise to the idea of opium-poison-
ing. A magistrate was cross-questioning in his court a
man who had been arrested shortly before. The man sud-
denly became comatose and died. He had albuminuria.
Coma in this albuminuric subject was probably determined
by the mental emotion caused by his arrest and examination.
If this accident had happened in a private house, instead
of in a magistrate's court in the presence of a magistrate,
officials, and poHce, all working in broad daylight, poison-
ing might have been suspected, and a medico-legal in-
vestigation would have had to be made.
The convulsive form chiefly seizes upon those persons
who drink to excess, and especially those who are addicted
to certain kinds of liquor, such as absinthe, arrack, and all
those which contain essences. M. Magnan has described
epileptic fits which are met with especially in those
alcoholic subjects whose favourite drinks are liqueurs, etc.
We shall return to the subject of the kidneys of alcohohc
subjects presently.
The fulminating form has been noticed for a long time.
It is that form which suddenly strikes an individual, so
that he falls down and dies in a few minutes or an hour.
M. Alfred Fournier* published the first characteristic case.
It had been recognized in England some years before.
An individual was taken ill in the street, went to a chemist's
■* Alf. Fournier, ' Des Formes de I'Uraemie.' These d'agregation.
298 SUDDEN DEATH
shop, and received a draught. He immediately fell dead on
the threshold as if struck by lightning. The passers-by
fancied that the man had been poisoned by the chemist, so
they set to work and smashed everything in his shop. The
body was removed by the police, and a judicial autopsy
was ordered. Lesions of Bright's disease, which was already
well known, were found in the kidneys, and this explained
the sudden death.
From what I have already told you. Gentlemen, do not
forget that forensic medicine is more closely concerned
with uraemia than with any other cause of sudden death,
and that it is often difficult to make a certain diagnosis
from the results of an autopsy. Remember that the kidney
no longer eliminates the substances which it is its function
to excrete. Death happens, therefore, by auto-intoxication,
and this auto-intoxication has been attributed to the in-
complete excretion of urea. It is true that urea is found
in the blood, but at the same time the kidney no longer
eliminates ptomaines and leucomaines, which contribute in
a large measure to poison the system. Remember that
certain substances, such as salicylic acid for example, taken
in small doses daily, are imperfectly excreted, and accumu-
late within and poison the system, while a single large dose
would have had no ill effects. Acetate of lead is another
such substance. You know that in dysentery as much as
22^ grains can be administered in one enema without any
risk ; but if one-thirtieth part of this dose is given daily for
a month, symptoms of poisoning will be produced.
Lead-poisoning may induce convulsive or delirious symp-
toms. When, about 1864, MM. OUivier, Cornil, Fritz, and
Ranvier made their researches into lead-poisoning, which
they confirmed by experiments on animals, they studied the
state of the kidneys in this condition with great care, and
found interstitial nephritis. The kidney was no longer the
perfect filter that it ought to be.
Your responsibility in regard to these accidents may be
called in question under other circumstances. An individual
may have albuminuria of which he may be ignorant. It
may be unattended by oedema or by any functional disturb-
DUE TO THE KIDNEYS 299
ance, and you yourself will be unaware of it, unless you
systematically examine the urine of all your patients for
albumen.
M. Bouchard has related this case : While he was acting
for Professor Bouillaud at the Charite Hospital, a woman
was admitted under his care suffering from syphilis, and for
whom he prescribed mercurial pills. When this woman had
taken one pill, she was seized with severe stomatitis and
terrible ursemic symptoms. M. Bouchard examined the
urine, and found albumen in it. The kidneys were unsound,
and thus the mercury was not eliminated.
In 1877 I was consulted about an identical case. The
brother of one of my pupils was a cavalry officer, and a
student at the Military School. This young soldier was
covered with boils. I was invited to see him, and I ascer-
tained that he had no albumen or sugar in his urine. Some
days afterwards he contracted a hard chancre, followed by
roseola, and after the administration of a single mercurial
pill he suddenly became collapsed. The urine was examined
at once, and showed an enormous proportion of albumen —
34 grains per ounce of dried albumen. You will find this
case reported at length by M. Descoust.*
A consultation was held, and, in spite of my advice, the
administration of mercury was prescribed afresh. The
officer had only taken two mercurial pills, when he became
affected with stomatitis, which lasted five months. The use
of mercury had to be discontinued. The affection of the
kidneys was cured, however. Three or four years after, this
officer was sent to Tunis, and there he contracted typhoid
fever with renal complications, which caused his death,
because his renal filter had not returned to its absolutely
normal condition.
[Pepper mentionsf two fatal cases of enteritis from the
vaginal injection post-partimi of corrosive sublimate solution
of the strength of uoVir to toVo> where grave renal disease
existed. Profuse diarrhoea occurred.
* Descoust, ' De I'Albuminurie survenant dans le Cours des Accidents
secondaires de la Syphilis.' These, Paris, 1878.
t ' Lectures oij Practical Legal Medicine,' the Lancet, 1887.
300 , SUDDEN DEATH
Post-mortem. — The small and large intestines were actively
inflamed. Thousands of haemorrhagic patches, a few minute
ulcers, and some lymph were found on the mucous surfaces.
There was slight general peritonitis, especially over the middle
of the colon, where the process was most intense.]
Other causes may lead to similar results, without the
kidneys being primarily affected.
When I was Aran's house-physician, an old woman who
seemed much exhausted was admitted under my care. She
became comatose one evening, and died in the night. When
I reported the fact to my chief the next morning, he said to
me, * That woman had cancer of the uterus.' This proved
to be the case. Cancer of the cervix uteri may invade the
fundus of the bladder. When it reaches a certain size it
blocks up the orifices of the ureters, and thus causes retention
of the urine in the kidneys and their ducts. Evacuation of
fluids which ought to be excreted is impossible, and may
sometimes lead to hydronephrosis and uraemic poisoning.
The same complications may follow stricture of the urethra,
prostatitis, stone in the bladder, etc.
[Sir S. Baker states* that * it is a curious fact, that a shot
through the kidneys of any creature occasions almost instan-
taneous death, and the animal falls immediately, as though
shot through the neck ; this proves the terrible shock to the|
system, as the body is smitten with a total paralysis.' I
quote this, as the author referred to is usually reliable,
though I am not aware that the fact has been noticed by
any other sportsman, or that an}^ such observations have
been made in the human subject.]
B. GOUT.
I think I ought to place sudden death in gout by the side
of sudden death from diabetes and of that from renal com-
plications.
Old authors used to say that sudden death in gout was
due to visceral metastases.
Since Garrod clearly established the distinction between
rheumatism and gout, English authors have observed more
■^ 'Wild Beasts and their Ways,' vol. i., p, 370.
DUE TO THE KIDNEYS 301
and more attentively the state of the kidneys in the autopsies
they perform, and they have described the ' gouty kidney,'
which they sometimes confound with the senile kidney.
English physicians have more opportunities than we have of
studying gout. The consumption of beer, and especially of
porter, seems to explain its frequency. In France we scarcely
ever see the phenomena of gout in hospitals, except in
association with lead-poisoning, and outside the hospital we
only see it among the richest of our patients.
Gouty metastases, of which the old authors speak, are of
different sorts. There is first of all serotis apoplexy, i.e.,
abundant serous effusion into the meshes of the pia mater
and into the ventricles. Then there is gout rising into the
lungs. This consists of symptoms analogous to those which
I described to you under the heading of pulmonary oedema
and capillary bronchitis. The individual dies, suffocated by
his bronchial froth, as Piorry said. Finally we have choleraic
intestinal symptoms. This form is one of the classical mani-
festations of uraemia.
Gentlemen, in passing under review the 150 cases of gouty
metastasis that I have been able to collect from the writings
of authors, I have nearly always found that some renal lesion
was present. I do not venture to make the unqualified
assertion that sudden death in gout always has a renal
origin ; I am strongly inclined to believe it, but I have not
myself seen enough cases of the kind — a dozen at most —
and my experience has not been long enough to make me
sure of it.
In what manner may it be necessary for the medical jurist
to intervene ? All physicians. Trousseau especially, who
have seen much of gout, have said : * You should never try
to arrest an attack of gout ; on the contrary, you should try
to prevent a retrocession.' Gouty patients, naturally, are not
of that opinion. A gouty attack — and it has not varied
since Sydenham described it in such a masterly way — is very
painful and very hard to bear. So what do the gouty
patients do ? Their physician does rot relieve them, there-
fore they fly to quacks ; they have recourse to secret
remedies, or what profess to be such. Now, in this country
302 SUDDEN DEATH
the secret remedy for gout is nothing else than colchicum,
and it must be admitted that it is effectual. Fatal cases of
gout have nearly always been treated by some medicine, the
basis of which is colchicum — the * liqueur de Laville,' or
something of the sort. Colchicum may act in two different
ways : it either increases the quantity of urine excreted, or
else it lessens it by causing congestion of the kidneys. If
the quantity of urine is increased, the treatment is favour-
able ; if it is diminished, it is dangerous.
You know. Gentlemen, that a congested organ does not
perform its functions properly ; when an individual works at
his desk with attention and application, and especially if his
shirt-collar is tight, his brain becomes congested, his face
becomes purple, and the activity of his brain is not increased,
but diminished.
When in any organ the exit of blood is more difficult
than its entry, the organ becomes turgid and congested, and
its functions are impeded. It is altogether different when
an organ is in full activity, when the blood flows to it freely
and no obstacle hinders its return. It is the same with the
brain as with the salivary glands (CI. Bernard). When the
kidney is working actively, physiology has taught us. that
the blood of the renal veins is red. But repeat the experi-
ment in animals in which you have produced congestion of
the kidneys by obstructing the renal veins — by a loose liga-
ture, for example ; then the blood of the renal veins is black.
The same thing happens in the kidneys of gouty persons ;
when renal congestion is produced by the ingestion of a
substance which irritates the kidneys, the secretion of
urine is diminished, and there is retention of products which
ought to be excreted. J
Moreover, a gouty man is a frail creature. He often has^
sclerosis of the arteries and of the heart ; he has lesions of
the liver; if some disturbance of the circulation should
supervene, his condition immediately becomes grave. As
long as the kidneys are working properly, his health is good ;
but as soon as the functions of the kidney are checked,
whether by atrophy or by congestion, he is in danger.
DUE TO THE KIDNEYS 303
C. DROPSY— OEDEMA OF THE GLOTTIS.
[The following is an example of a mode of sudden death in
Bright's disease which should be borne in mind. A woman,
aged 34, had been a frequent heavy drinker, with a fondness
for beer and spirits in any quantity, and had often been
drunk. She would obtain drink in any possible way.
She began to be ill in June, 1892, while drinking heavily,
suffering from dyspepsia, vomiting, dulness of mind, and
insomnia; then dropsy of the legs and genitals appeared.
She took to bed, and continued to pass only a few ounces of
urine daily. On July 25 she was in much the same condition
as on previous days : anasarca was general but not extreme ;
and there were some signs of oedema of the lungs, but there
was not any cough or much dyspnoea. At night she was
rather delirious and had hallucinations of a man being in the
room, and her breathing became laboured, with a hoarse
cough. She talked sensibly to her husband, who went out to
work at 5 a.m. She became drowsy and slept rather heavily.
About 9 a.m. she was found very much worse, and she died in
half an hour.
Post-mortem. — The body was oedematous, and there was
considerable oedema of the lungs. The mucous membrane
of the larynx and adjacent portion of the pharynx was very
much congested: the arytaeno-epiglottidean folds were much
swollen and oedematous, looking like a pair of bladders, and
leaving a very small chink for the admission of air. There
was a * nutmeg ' liver, and the kidneys weighed about six
ounces apiece, the cortex being thick, soft, pale and smooth.
This case presents one or two points of interest. Though
anasarca in an extreme degree is common enough in both
acute and chronic Bright's disease, yet it is very unusual for
oedema of the larynx to supervene. This is prevented by the
attendant dyspnoea (due to hydrothorax and pulmonary
engorgement and oedema) instinctively compelling the patient
to maintain the trunk erect. In this case, the patient's
sensibility had at the last become dulled, partly from uraemia
and the state pf the lungs, and possibly from a surreptitious
supply of alcohol, so that she subsided into a horizontal
304
SUDDEN DEATH
position, when the larynx soon became oedematous from
gravitation.
It would be an interesting question, and one which has not,
as far as I know, been decided, whether passive cedema can
be produced or removed after death by altering the position
of the corpse.]
LECTURE XII.
SUDDEN DEATH IN ALCOHOLISM.
Gentlemen, — Alcoholism has already engaged our atten-
tion on various occasions in the course of these lectures ;
nevertheless, it is necessary to describe certain phases of it
with greater precision.
Alcoholism presents itself in several forms. In the first
degree there is the individual who has only been guilty of a
single excess, which is fatal only in exceptional cases ; such
is the individual who is picked up dead drunk. Then comes
delirium tremens, and lastly chronic alcoholism.
A. DRUNKENNESS.
How does death take place in a fit of drunkenness, the
consequence of a single excess ? It is by the body becoming
cold. You know that in slight degrees of intoxication the
face becomes flushed and turgid ; when drunkenness is more
profound, the capillaries of the surface dilate, and a peripheral
vaso-motor paralysis takes place. Consequently the indi-
vidual radiates a large amount of heat. When a man who
has been found dead drunk is taken to the hospital, the
thermometer in the rectum shows that the central tempera-
ture has fallen to 75*2° F. Two cases of this class have been
recorded — one by M. Laborde, the other by M. Bourneville.
Is this the only mode of cooling to which people in the
state of drunkenness are exposed ? I do not think so.
Magnus Huss, a Danish physician, demonstrated the pre-
sence of little globules of fat in the blood of individuals
20
3o6 SUDDEN DEATH
who died while drunk. I myself observed in 1871, when
making experiments on the blood of persons suffering from
small-pox, scarlet fever, and delirium tremens, that the blood
corpuscles lost an appreciable amount of their oxidizability ;
as they no longer retain oxygen, they cannot distribute to
the various parts of the body the gas which maintains com-
bustion, regularity of respiration, and calorification.
[Bing states* to the same effect that morphia and other
narcotics cause reduction of temperature by means of im-
perfect oxidation, venous blood, and the relaxed state of the
cutaneous vessels and the striated muscles.]
In former times a method of treatment was adopted
towards drunkards which recent researches have justified.
They placed the drunkard on a dung-hill and covered him
up ; as the dung-heap is warm, it counteracted the tendency
of the drunken man to become cold.
This method still prevails in Brittany and Norm.andy ;
sometimes persons who are dead drunk are placed in a
baker's oven ; but the effect of this is a matter of chance,
for the oven may be too hot or may have already become
cold. When you read descriptions of the anatomical lesions
which the organs present in the bodies of those who have
died in a state of intoxication, you will be told that the
stomach is contracted with prominent ridges, and that spots
or ecchymoses are scattered over the mucous membrane.
Only a short time ago I had to make an autopsy on a girl
who had committed suicide by swallowing absinthe ; a paper
that was found by the side of the girl left no doubt that the
case was one of suicide.
That girl had taken about 25 oz. of absinthe. We
thought at the time that we should be sure to find in her
viscera the characteristic signs of acute alcoholic intoxica-
tion ; we could not, however, detect the smell of alcohol or
of absinthe : the stomach was empty and not shrunken ;
the mucous membrane was normal, and the rest of the
viscera were perfectly sound. If this girl had not given
evidence, by her writing, of her determination to commit
suicide, and if a bottle holding i| pints of absinthe had not
■^ *■ Phar77iacology^^ vol. i. (Syd. Soc. Translation).
IN ALCOHOLISM
307
been found by her side, do you think that an autopsy would
have afforded an explanation that would satisfy the law?
Not at all. Remember, then, that death from ingestion of
alcohol may leave no mark on the body that will guide you
in your search, and that will reveal to you the mode of death
in the case you are examining.
[Examples of the enormous quantity of spirits that is
sometimes imbibed are furnished from time to time by fatal
cases on which inquests are held. The following are some
that have been thus recorded :
1. Gunners J. B. and W. S., of the Royal Marine
Artillery, serving on board the battleship Sanspareil, were
employed in stacking rum in the spirit-room ; and during
the absence of the officer in charge they must have got
access to the rum, as they were subsequently found lying
helpless outside the spirit-room. Seven pints of rum were
missing.*
2. A navvy had been at work all day in a new tunnel at
Staverton ; he left off work at 6 p.m. and went with his mate
to a public-house, and calling for half a pint of whisky,
drank it off neat. He said he had pains in his side, and six
half-pints of whisky would cure him. The second half-pint
he drank immediately ; the third was partly consumed by
another navvy; the fourth he drank himself; the fifth a
companion drank a little of. All these five half-pints were
drunk neat within an hour. The landlord's son refused to
serve him with a sixth. The deceased rose, as if to strike
him, but fell unconscious on the floor. He died in a few
hours. t
3. Just before Christmas deceased visited a neighbour's
house at Canterbury in the company of another girl, a soldier
and a sailor. Deceased was very drunk at the time and held
up a bottle containing a pint and a half of whisky, saying
that she meant to get all she could down her throat before
Christmas. She then drank half the contents before anyone
could stop her. The four persons occupied the same room
during the night. Next morning the woman was found
■dead. J
* The Times. t /did. t ^bid.
20 — 2
3o8 SUDDEN DEATH
In this case exposure to cold does not seem to have been
a factor in causing death.
4. A Polish skin-dresser, aged 20, drank a quart of neat
whisky at a draught for a wager of £1. He died in con-
sequence.*
5. Chevers cites f the case of a hawker at Hackney, who
drank twenty-four quarterns of rum at various public-houses,
and did not seem drunk ; afterwards he took fourteen half-
quarterns, besides a quantity of beer at different times
during the day. He died the following morning. The same
author says that cases of alcoholic coma are very common
in Calcutta, and the danger is doubled by the tendency to
insolation during the hot months. Some cases have only
been restored by artificial respiration.
6. Christison narrates! the case of a man who stole a bottle
of whisky, and, being in danger of detection, drank it all up,
as the surest way of concealing it. He died in four hours
with pure symptoms of coma.
He also quotes from Orfila the case of a soldier who
drank eight pints of brandy for a wager and died instantly.
He also goes on to say that death from alcoholic poisoning
* happens still more frequently from the occurrence of some
trifling accident, which in his torpid state the individual
cannot avoid or remedy, such as exposure to cold, falling
with the face in mud or water, suffocation from matters of
vomiting getting into the wind-pipe, and the like.'
A rather peculiar case of the sort was the subject of an
inquest a few years ago. A man and woman, the latter a
confirmed drunkard, had spent nearly an entire day in
dissipation of one sort and another, and finished up the
evening at a public-house, where they found their way into
a large, empty, dimly-lighted billiard-room at the back.
The woman was by this time pretty well overcome by the
liquor she had taken, and sat down on a bench that was fixed
against the wall, with a table in front, and fell asleep with
her head resting on the table. In this condition and
attitude she was left by her companion (so he said) the last
* The Tz'meSf April 4, 1897. t Op. cit.^ p. 249.
X ' Treatise on Poisons,' p. 678.
I
IN ALCOHOLISM 309
thing at night ; the potman entered the room soon after-
wards to turn out the gas, but did not notice anybody there.
Next morning the woman's body was found beneath the
table. I was called in and found that she had been dead
some hours. She was lying face downwards on the sawdust-
sprinkled floor. A little bloody fluid had escaped from the
nostrils and mouth, and had caked with the sawdust and
dried, and had evidently closed up these orifices.
Post-mortem. — The liver was very large, and the thoracic
viscera gave clear evidence of asphyxia. There were no
marks of a struggle or of any violence, and there was no doubt
that the woman met her death in this accidental manner,
being too much stupefied to help herself.
Another mode of death in acute alcoholism has been
observed — viz., by spasm of the glottis — and an illustrative
case has been recorded by Mr. G. Simpson.* A man,
aged 31, was insensible from drinking a large quantity of
beer and more than a pint of brandy, and all voluntary
movement had ceased for four hours.
Three or four pints of fluid were removed by the stomach-
pump. Emetics were given without effect, coma was in-
creasing, and the pulse was almost imperceptible. The
' shrill tone and extreme difliculty of inspiration ' led
Mr. Simpson to suspect ' collapse of the glottis,' and
tracheotomy was performed with immediate benefit and
ultimate recovery.
In this case I think the view is tenable that the undoubted
obstruction of the glottis may have been due to dropping
back of the tongue, as is apt to occur in deep anaesthesia,
rather than to approximation of the vocal cords ; at any
rate, lifting the lower jaw and traction of the tongue might
be resorted to before tracheotomy, if a similar case were to
happen again.
Ogston also reportsf a fatal case, where it is probable that
the immediate cause of death was asphyxia, due to spasm of
the glottis.
* 'Trans. Med. Chir. Soc, Lond.,' 1837.
t Edinburgh Medical Jour 7ial.
3IO SUDDEN DEATH
Chevers cites* several cases of supposed alcoholic poison-
ing, which were really due to choking by vomited matter
entering the bronchial tubes while inebriated, as in Professor
Corvisart's case, already referred to (p. 2og). They are as
follows :
1. A seaman returned from leave in a state of helpless
intoxication ; he was seen by the assistant-surgeon, but as
he only appeared to require rest he was sent below to his
mess, where he commenced singing. Half an hour after-
wards he was found on deck quite dead.
Post-mortem. — A piece of half-masticated beef was found in
the rima glottidis.
2. The body of a Hindoo was examined on account of
suspected poisoning. In the lower lobes of the lung were
observed, on section, numerous round, cheesy masses of
variable size, from that of a mustard-seed to that of a split
pea. This deposit was contained in the bronchial tubes.
The upper portions of the lungs were healthy. The larynx
and trachea contained similar but thinner fluid and in less
quantity. The same stuff was found in the stomach. It
was found to be the remains of food (suttoo). The man
had had a hearty meal at noon, vomited in the course of a
few hours, and was then seized with dyspnoea and noisy
respiration ; he gradually became speechless and insensible,
and died within an hour. Probably the sole cause was
repletion ; there was no evidence of any narcotic poisoning,
though he had most likely fallen into a drunken sleep.
3. A private soldier, aged 28, who had been drinking rum
and beer one evening, was discovered with noisy dyspnoea
by his neighbours during the night. He died in fifteen
minutes.
Post-mortem. — Small pieces of potato were found in the
bronchial tubes.
Other cases are also referred to.
This irregular consequence of vomiting is met with almost
solely in persons who are thoroughly intoxicated, but it has
occurred, though very rarely, in others who have been per-
fectly healthy and sober.]
* Op. cit.
4
IN ALCOHOLISM 311
B. DELIRIUM TREMENS.
The second form of alcoholism is characterized by
dehrium tremens. It is familiar to you, and I will not
describe it at length. A long while ago a distinguished
physiologist demonstrated how frail a being Hercules may
be when drunk. You know that this delirium is often
accompanied by acts of violence ; you know that a large
number of alcohoHc subjects of this class have to be con-
fined in a madhouse. The superintendent of the asylum
does not fail to warn those who bring the patient that the
latter is in a condition which exposes him to great danger,
even from the delirium itself, and that he may die suddenly.
In fact, it sometimes happens that one of these patients
dies in a paroxysm of excitement the very day after his
admission into the asylum. The superintendent and at-
tendants of the asylum may be held responsible, and you
should know that in the immense majority of cases they are
quite free from blame.
C CHRONIC ALCOHOLISM.
I have already told you that chronic alcoholism, i.e., the
third stage of alcoholism, has the power of making acute
diseases run their course in a latent manner ; this applies
to cases of pneumonia, meningitis, etc., of which I have
cited examples to you, so that I need not return to them.
Alcoholism, moreover, creates lesions in every organ, and
the subject of it is -thus exposed to the danger of sudden
death in every form which may, in fact, result from lesions
of these organs.
[The following case ended in a convulsive seizure, the
cause of which is obscure, as no post-mortem examination
was obtained. A cabman's wife, aged 30, a habitual tippler,
had suffered from alcoholic peripheral neuritis, and was
partially affected with a second attack of this form of
paralysis at the time of her last illness and death. Her
husband came home at 6.0 p.m., gave her some tea, and
went to bed by her side. Both went to sleep. At nine
312 SUDDEN DEATH
o'clock the husband was woke by his wife calling out
* Oh !' He found her in a fit, the first she had ever had ;
her face and arm twitched and some blood escaped from
her mouth. The fit may have lasted five minutes, and she
died in it. The fatal result seems to have beeh too rapid
to have been caused by cerebral haemorrhage. Is it possible
that the attack may have been due to neuritis of the vagus,
thus interfering with the action of the heart ? Neuritis of
the vagus is very likely to account for some cases of sudden
death in chronic alcoholism.]
This is not all : sudden death often overtakes alcoholic
persons who have recovered from their primary disease, and
have become convalescent ; is this because the myocardium
is affected ? The lesions from which alcoholic subjects
suffer are so numerous and of such variety that it is difficult
to enumerate them. Sudden death occurring in them is
attributable, above all, to fibroid degeneration of the heart,
kidneys or liver.
The same phenomena are wont to appear as a sequence
of injuries or of surgical operations. Dupuytren was accus-
tomed to say that he did not lose any of his operation-
cases, except those who were attacked by delirium tremens.
Dupuytren practised at a period. Gentlemen, when the
classification of diseases was less precise than it is now,
and when purulent infection was not uncommon. I am
inclined to believe that among these cases of * delirium
tremens ' were included many cases of septicaemia.
[Chevers* is of opinion that intemperance, with organic
disease, especially in India, may cause an artificial haemor-
rhagic diathesis so that a person may bleed to death from
very slight wounds.]
D. MEDICO-LEGAL INTERVENTION.
Two important points still await our attention : the inter-
vention of the medical expert in alcoholism constitutes one
of the longest chapters in medical jurisprudence. The
individual whose condition is to be investigated may be
either the author or the victim of a criminal act ; he may
* Op. cit.. p. 522.
IN ALCOHOLISM 313
be a culprit in such a way as this : You have all seen tipsy
people ; you know that a person who has taken rather too
much is sometimes amusing for a time ; he says whatever
comes into his head, he becomes confidential, and, however
stupid he may be, his sallies are often very comical. But
he does not always content himself with exuberance of
language ; in an individual under the influence of alcohol
there is no barrier between the idea and the act : there is
no room for reflection. He sees a ditch and leaps over it,
without thinking whether he will clear it or fall in. The
idea of hanging himself enters his head, and he does hang
himself, without knowing why, and this idea is so firmly
rooted in his mind that nothing can erase it.
Lasegue has reported the following suggestive case, bear-
ing on this subject :
A sentinel heard a noise one night by the side of his box.
He wished to ascertain where the noise came from, and
saw a drunken woman who had fastened a twisted cord to
the window of the sentry-box and was going to hang her-
self. The soldier ran after her, but saw that she stopped a
little way off in order to make a fresh attempt. He called
the attention of the guard to her, and the woman's attempt
was thwarted again, and her life was saved ; but she
managed to carry out her project by turning round a corner
of the street, where the sentinel could not see her.
Nearly thirty years ago a wine-merchant's porter, who
was an alcohoHc subject, threw himself from the top of the
Bastille column ; at that time the railings which surround
the monument were undergoing repairs, the weather-cocks
at the top were being gilded, and a large well-stretched
awning had been put up all round the base of the column.
The man fell on to this awning, rebounded, alighted on the
ground, and walked away without having sustained any
injury. But the poHce ran after him and arrested him ; and
when taken before the superintendent he stated, now that
he was sober, that he had no motive for committing suicide,
and that the idea of throwing himself down had come into
his head suddenly while he was on the top of the column.
This man afterwards became a hospital porter, and has
314 SUDDEN DEATH
J
acted as porter in the post-mortem theatre for fifteen years,
yet the idea of suicide has never returned, and he has never
been able to explain why he ever wanted to commit the act.
The alcoholic subject does not make attempts on his own
life merely. He is a dangerous man both to his relatives
and to his neighbours. He sleeps badly ; he imagines that
he sees glittering objects, and fancies that he is surrounded
by animals, which make offensive remarks and insult him ;
he has hallucinations of touch, and believes that he is
exposed to violence of greater or less severity ; in short, he
has hallucinations of sight, touch, and hearing.
Allow me to remind you of a certain butcher-boy, who
imagined one night that his wife struck him on the head
with a boot ; he got up, took his knife and cut her throat ;
then he chopped her in half, as if she were a carcass of
veal or pork, and set to work to cut her body into joints as
if he were preparing meat for sale. He was arrested, and
confined in Mazas Gaol, and at the end of three weeks his
alcoholic delirium had entirely disappeared.
This man was instigated by an impulse whose direction
was determined by his professional habits ; the murderer
literally butchered his victim, and seemed to act in a blind
attack of epileptic fury. Individuals who commit crimes of
this sort are those who display the greatest propensity to
commit suicide.
Statistics prove that the number of crimes and suicides
is in proportion to the consumption of alcohol. The curve
which indicates the consumption of alcohol in each depart-
ment is identical with that of suicides and crimes against
the person. The consumption of alcohol is ten times as
large as it was twenty years ago ; the number of suicides
has increased to the same extent.
[The late W. Mathew-Williams made some interesting
remarks, tending to show that the worst symptoms of intoxi-
cation depend on the impurity or adulteration of wine, or on
concocted liquors, rather than on the pure fermented juice
of the grape. In 1842 he undertook a walking tour through-
out the whole length of Italy, mingling freely with all classes
of people, chiefly with the poorest, and often lodging and
I
IN ALCOHOLISM 315
feeding with them at the poorest inns. He says :* ' Every man
had his flask of wine, commonly holding about a pint, and
drank it freely, but at the roughest of these places I saw no
drunkenness from one end of Italy to another. In 1842 and
1843 when I was thus in Italy — and the year or two before
were years of celebrated vintages — rich wine was most abun-
dant, and as cheap as our common London porter. In the
summer of 1855 I re-visited Italy. On landing from one of
the Alpine lakes and walking along its banks, I saw a newly-
erected cross on an eminence. Knowing that it marked some
tragedy, I made inquiry, and learnt that a man, madly
drunk, had rushed from an osterie opposite, flung himself
into the lake, and was drowned. On expressing my surprise
at such drunkenness in Italy, my informant — a peasant I
had met on the road — told me that since the grape disease
(not the phylloxera, but a fungus that grew on the outside of
the fruit), which had prevailed during the previous three or
four years, drunkenness had become quite common. At first
I thought this was an exaggeration due to local prejudice ;
but as I walked on, and dropped into sundry osterie, I found
that it was too true. The wine they then sold was very
bright, strong of spirit, and dear, not grown by the inn-
keeper and his neighbours as of old, but purchased from
merchants who brought it from a distance. I had been
accustomed, on my first journey, to mix J pint of wine,
or thereabouts, with an equal quantity of water, and drink
this when I was hot and thirsty. It was a cooling, refresh-
ing, and thirst-quenching beverage, but was more clear and
transparent than our ordinary English ale (genuine wine
cannot be reliably brilliant). The dearer wine of 1855 was
bright enough to satisfy an ordinary Englishman, and hot
enough. About an hour after drinking it I found myself
more thirsty than before, with a dry mouth, a parched
tongue, and a decided crave for stimulants. Had I satisfied
this by repeating the dose I should have suffered propor-
tionately. It appeared, as I went on, that this abomination,
being too dear for the poorer people, other and worse con-
* ' Chemistry in the Kitchen,' chapter xxiii. (the Caterer, December 15,
1888.)
,i6 SUDDEN DEATH
coctions were used, a coarse saline beer and a vile spirit
distilled from potatoes.']
Gentlemen, if, disregarding the interests of society, we
answer the question which is put to us, whether or not the
man who commits such a crime is or is not conscious of
what he is doing, and responsible for his actions, we might be
tempted to say, when brought face to face with a crime com-
mitted by an alcoholic subject : * This man is not responsible,
because he delivered the blow during an attack of alcoholic
insanity.'
Well, Gentlemen, these words have never crossed my lips
in the court of assizes. I cannot admit the irresponsibility
of persons under the influence of alcoholic excess ; it is not
the same thing as insanity. He has become enraged because
of his vicious habits, and he is at least responsible for those
preliminary acts which led to the perpetration of the crime.
A madman, a poor lunatic, is not responsible ; but a man
under the influence of alcohol, a man who knows that his
drunken habits will by degrees bring him into such a condi-
tion that he may kill his fellows, is responsible for his
actions.
Moreover, the question which the Code lays before us is
badly worded. We know how dangerous persons suffering
from alcoholic delirium are. If we state that they are not
responsible, they will be set at liberty. Now, the more a
man is addicted to alcohol, the more dangerous he is ; but
he would be deemed irresponsible all the more, and, therefore,
the more dangerous an alcoholic subject is, the more surely
would he be set at liberty.
Here is a typical example :
An individual, after a good luncheon at a restaurant in the
Cannebiere at Marseilles, was sitting on the terrace of a cafe
amusing himself with shooting at the passers-by with a
revolver. He was arrested, but was declared irresponsible,
and was confined in a lunatic asylum. In a few months his
alcoholic insanity had passed off; he was discharged, and
went to Toulon, and again after luncheon fired at the passers-
by, wounding one or two of them. He was again arrested
and sent to an asylum. This time he remained eleven
IN ALCOHOLISM 317
months in an asylum in the department of Vaucluse ; at the
end of this time, as he appeared to be in perfect bodily and
mental health, he was restored to liberty. He took the train
to Dijon, and there, after luncheon, tried to strangle the
station-master on the platform of the station. He was taken
back to the asylum, and at the end of three years the same
scruples took possession of the superintendent, and he
thought that he had no right to keep a man shut up who no
longer had anything the matter with him, and discharged him.
This time he went to Paris, and after a good luncheon
there he again openly fired at the passers-by near the Odeon
omnibus station in the Boulevard des Italiens, and wounded
several persons more or less dangerously. The unfortunate
man was sent to an asylum for a fourth time, and has now
been in confinement about three years. What will happen
when he is again discharged ?
You see that the medical jurist has a somewhat delicate
duty to discharge in deciding as to the responsibility of
alcoholic subjects and lunatics.
Medico-legal intervention is called for equally on behalf of
the victim of the drunkard. Works on forensic medicine
are full of such cases as the following :
Some men were drinking at a tavern, when a discussion
arose, which became heated and led to a quarrel, and at last
one of the drinkers gave another a box on the ear. The
latter did not return the blow, but withdrew to another table,
put his head on his arm as if he were going to sleep, and
remained motionless. The proprietor of the tavern heard
him snoring, but took little notice of him at first, thinking
that the man was sleeping himself sober. But after a while
he went up to him and shook him, in order to wake him ;
the man was dead. At the autopsy, meningeal haemorrhage
was found, covering the surface of the brain ; the skull was
not fractured, and the brain itself was normal. All the other
organs of the body were healthy.
Tardieu has reported the following case : A father and son
were quarrelling ; at the end of the dispute the father gave
his son a slight box on the ear; the latter fell down, and died
a few hours after from meningeal haemorrhage.
3iS SUDDEN DEATH
The gravity of the lesions in these cases depends on the'
victim, not on the culprit ; the blows exchanged are actually
insignificant. The medical jurist should lay stress in his
evidence on the slight nature of the injury, and explain that
the same blow would not have been followed by any
disastrous results in a person who was not addicted to
drink.
I could multiply such cases and examples ; I will only
remind you that alcoholic subjects recover very badly from
surgical operations, as M. Verneuil has shown,* and that
erysipelas is a frequent and dangerous complication of wounds,
in them.
In the kitchen of a restaurant in one of the boulevards,
the plate-w^asher and a scullion were quarrelling. They
became more angry, and the scullion threw a plate at the
plate-washer's head ; the plate did not break, but the plate-
washer received a small superficial wound on his forehead.
He was taken to a druggist, who gave him a * vulnerary '
draught, and he then took several nips of spirits to steady
his nerves. Two days afterwards erysipelas set in, and he
died. The little scullion was in great measure responsible,
you see. A medico-legal autopsy on the plate-washer's body'
was ordered ; we learnt thereby that the kidneys were con-
tracted, and that the liver was in the condition of classical]
cirrhosis. It is evident that the blow caused by the plate ^
would not have caused a fatal result in a person not addicted
to alcoholic excess. The culpability of the little scullion was
therefore much diminished.
* Verneuil, ' De la Gravite des Lesions traumatiques et des Operations
chirurgicales chez les Alcooliques.' Paris, 1871.
LECTURE XIII.
SUDDEN DEATH IN CHILDREN.
Gentlemen, — Sudden death in children is different, as
regards pathogeny, from that which we have studied in its
various forms in adults. The predominant feature is the readi-
ness with which, in children, extremely violent attacks of
congestion are brought on, which may be accompanied b}'
certain reflex actions, owing to the excitability of the nervous
centres.
However, I think it would serve no useful purpose to
recapitulate, from the point of view of sudden death in
children, all the diseases and disorders which we have
studied together one after the other when we were engaged
with sudden and suspicious death in the adult.
I shall content myself with laying before you the principal
factors, and with pointing out their dominant features.
Sudden death is of frequent occurrence in children. West
states that, out of 627 cases of sudden death dealt with by
the London police in 1854, 272 were those of children under
the age of five years, and 126 of these were under one year.
Sudden death in children is usually due to one of five
principal causes, viz., syncope, convulsions, asphyxia, pul-
monary congestion, and intestinal troubles.
A. SYNCOPE.
Before going further into the study of these cases, allow
me, Gentlemen, briefly to elucidate a certain point which
has sometimes led to unfavourable conclusions being drawn,
320 SUDDEN DEATH
and has given rise to the suspicion that death was due to foul
play. I refer to syncope. Syncope is common in children ;
should it be attributed to a violent pain, to reflex action, or
to inhibition ?
Devergie, Rilliet, and Barthez were of opinion that
syncope was a frequent cause of sudden death in children.
Barthez cites several such cases happening at the age of
six or seven months — Devergie at the age of one year.
This kind of death may be due to some cardiac affection,
which may be present in a young child even at birth, and
may be due to patency of the foramen ovale or of the ductus
arteriosus, or to a communication between the two ventricles,
etc. These cases are more frequent than those due to
inflammatory mischief. But fatal syncope may take place
in children quite apart from all lesion or malformation of
the heart, and it is far from being rare.
B. CONVULSIONS.
It is not uncommon for children to die in convulsions.
In former times, Gentlemen, physicians as well as the
public unanimously believed that convulsions were of
cerebral origin, and therefore regarded them as extremely
serious. Trousseau headed a reaction against this belief,
and did not admit that convulsions were so very dangerous.
Gentlemen, a child in convulsions is always in danger.
Convulsions may be due to various causes ; sometimes thej
are caused by some lesion of the brain, such as haimorrhage,j
softening, tumours, or large masses of tubercle, as in a case
recorded by Parrot. These cases appear all the more]
suspicious because children at that early age are not ex-|
pected to suffer from diseases of the kind.
One of the most frequent causes of death at this age isl
congenital syphilis, which may produce vascular lesions
simulating haemorrhage or meningitis, and which may lead
to sudden death. Sometimes caries of the bones and peri-
or end-arteritis are found post-mortem in such cases.
Another cause is meningeal haemorrhage. This is more^
often met with in children at the period of dentition. Al
IN CHILDREN 321
this time congestive attacks may take place, including
lesions of the parietal arachnoid, which becomes vascular.
The little vessels newly formed therein may burst, and sudden
death follows, due to meningeal haemorrhage.
When you are called to attend a child in a fit of con-
vulsions, ascertain first of all if it is feverish.
If pyrexia is present, the case is probably one of the
exanthemata in its initial stage. In children, convulsions are
the equivalent of a rigor in the adult. Sydenham observed
that convulsions at the commencement of an eruptive fever
are of little importance. It is quite the reverse when they
occur at the end of the eruption.
If the child is not feverish, you may confidently say that
the cause is situated between the lips and the anus. Nine
times out of ten, convulsions are due to the process of den-
tition, indigestion, constipation, diarrhoea, or a collection of
worms in the intestines. In ninety-nine persons out of a
hundred affected by tapeworm, there will be no nervous
symptoms, but in the hundredth such symptoms will be
present. Children are always in this exceptional condition.
They are strongly predisposed to suffer from convulsions
when their alimentary canal is out of order. These con-
vulsions are never quite free from danger, so give your
opinion guardedly. Through omitting to do so, I once
put myself into rather an awkward position, as I will tell
you :
When I was a young doctor, I was called in to a child in
convulsions. As my mind was deeply imbued with the
teachings of my masters, Trousseau especially, I reassured
the parents, telling them that it was an everyday occurrence,
and that. there was no danger. Before I had finished speak-
ing the child died.
The truth. Gentlemen, is neither on the side of Trousseau,
who underrated the gravity of convulsions, nor on the side of
the physicians of the last century, who overrated it. Re-
member that an accident of this kind is not necessarily
fatal, but at any rate do not regard it as trivial, and mind
that you never neglect to attend to the state of dentition and
of the alimentary canal.
21
322 SUDDEN DEATH
C. ASPHYXIA.
I come now to the study of sudden death due to
asphyxia. Let us first consider the phenomena which
nurses call * inward convulsions.' Nurses are not altogether
wrong, although these convulsions have a different origin
from those which we lately discussed. ' Inward convulsion *
most commonly implies spasm of the glottis, due to laryngeal
irritation, or stridulous laryngitis, such as may take place in
the course of measles, bronchitis, or a common cold.
Stridulous laryngitis presents this characteristic feature,
viz., that the stridulous attacks always take place between
the hours of lo p.m. and 4 a.m. These spasms (for no other
name can be applied to the symptom) are due to slight
inflammation of the mucous membrane of the larynx. Every
form of laryngeal inflammation may give rise to spasm of
the glottis. Croup is one form. When we make an autopsy
on a child who has died of croup, we often find only thin
membranes no thicker than paper, which are quite insuffi-
cient to block the lumen of the trachea and larynx ; but the
inflammation of the mucous membrane has induced spasms
which contributed largely to diminish the entry of air into
the bronchi, and led to suffocation.
These spasmodic attacks are usually easily cured, except
in very young children and in those suffering from diph-
theria.
[An equally dangerous and far more frequent cause of
spasm of the glottis, at least in England, where rickets is
such an extremely prevalent disease, is laryngismus stridulus.
This disease consists, as is well known, of a brief stoppage of
respiration by a convulsion, or tonic or clonic spasm of
some or all of the respiratory muscles, but always including
a spasm of the glottis. As the spasm yields, air enters the
chest with a peculiar crying or whistling sound, which has
led to the name of * crowing breathing ' being given to the
disease. In English text-books of medicine it is nowadays
too often omitted that laryngismus stridulus may be the
cause of sudden death in infants, yet it is a very common and
sufficient cause. When an attack occurs, and the spasm
I
IN CHILDREN 323
does not speedily relax, the child dies quietly and immedi-
ately, and there will be no definite post-mortem signs of the
seizure. By far the greatest number of cases occur in
rickets, but typical cases are to be met with in weak,
ill-nourished infants also, who are not rickety. It is common
to meet with more than one case in the same family. Quite
lately Dr. Hunter"^ has recorded the occurrence of two cases
in the same family. Dr. C. West describes the following
typical case :t A boy, aged 8 months, had cut two teeth at
6J months, and always seemed well, except that now and then
the hands were a little clenched. The bowels were rather
constipated, and a small dose of castor oil was given. He
had hardly swallowed it when he stretched out his tongue y
the face became livid though scarcely at all distorted, and
he died without any struggle or cry. Dr. West thinks that
laryngismus stridulus will account for three out of every four
cases of sudden death in children under one year. It is not
generally fatal ; and in proportion to the frequency of its
ocurrence, the mortality arising from it is small, but the fatal
event is apt to be very sudden.
The following case came before me a few years ago : The
patient was the youngest child of a large family of poor
people, more than one of which had died in infancy, the last
one of pneumonia, and the previous one suddenly of laryn-
gismus stridulus. The mother was unable to nurse it, and
consequently the child was ill-fed and becoming rickety. It
was treated for bronchitis when 9 months old and again when
II months old, when it was very ill, but recovered. Four
months later, when being placed in a perambulator one day
to go out, the child began to cry, its breathing stopped, it
turned black and stiff, and died forthwith. The mother said
that the child had been liable to such catches in the breath.]
A special form of asthma used to be described, viz.,
* thymic asthma,' to which the name of Millar has been
attached. Then the existence of the disease was forgotten,
and it has been brought to light again within the last few
months. A few isolated instances had, however, attracted
* British Medical Journal, April 2, 1898, p. 880.
t Medical Times and Gazette, November 26, 1859, p. 521.
21 — 2
324 SUDDEN DEATH
attention in the interval. Some years ago, as I was making
an autopsy on a child 3 or 3^- months old, which was
supposed to have been suffocated by its mother, I found the
thymus very much hypertrophied. Normally, according to
Sappey's observations, the thymus weighs go to 120 grains,
and measures 2 inches in length, -J inch in breadth, and
f inch in thickness. The thymus in the case of which I
am speaking weighed 360 grains, and measured 3J- inches
in length, i] inches in breadth, and 4 inch in thickness.
Before my case happened, Herard in 1847 and Bontemps in
1882* had reported similar ones, without drawing any medico- ;
legal conclusions from them.
Dr. Grawitz, a German physician, made some researches
on this subject in 1888. He noticed that all the children in
whom an abnormally enlarged thymus was found post-mortem
died in the same manner ; they were in good health, when,
while sucking or drinking out of a cup or a spoon, they
threw back their heads and died without a cry or convulsion,
or even any movement at all.
Some weeks ago M. Marfan found a thymus weighing over
an ounce, and measuring 3^ inches in length, i| inches in
breadth, and | inch in thickness, in an infant. The dimen-
sions in this case are almost the same as in that which
I met with myself, and which I have just mentioned to you.
Dr. Grawitz does not think that death is due to pressure
on the trachea and bronchi ; he bases his belief on the fact
that the calibre of the air-passages was not reduced in any
of his autopsies. This agrees with my own observations ; I
have never found the trachea distorted. But the trachea
and bronchi are very elastic in children, and resume their
natural form directly the sternum is removed. No con-
clusion can therefore be drawn from this fact. For my part,
I believe, as does M. Marfan also, that the thymus does
compress the trachea ; this compression gives rise to a
slight degree of spasm, which rapidly causes the child's
death.
Subpleural ecchymoses and ecchymoses on the thymus are
* Bontemps, ' De la Mort subite chez les jeunes Enfants.' These,
Paris, 1882.
^
IN CHILDREN 325
found in these cases. You see at once how necessary it is,
in presence of these phenomena, always to examine the
thymus in a child who has died suddenly, in order that no
suspicion of crime may fall upon an innocent person.
[Mr. William Rutty* published some cases of enlarged
thymus gland :
1. A fine and healthy child, aged g months, suddenly
stiffened in its mother's lap and died. The child had been
fed partially at the breast, but chiefly by spoon ; it had cut
six or seven teeth. The fit consisted of spasmodic con-
traction of the limbs.
Post-mortem. — The stomach was distended with food ; the
thymus weighed loj drachms.
2. In a child aged 10 months the thymus weighed 10
drachms.
3. In a third case the thymus weighed g drachms.
Though two of these cases died suddenly, the writer of
the article, while recognizing the size of the thymus, and
knowing it to be alleged as a cause of sudden death, does not
believe in this explanation, but ascribes death to spasm of
the glottis. Trousseau t also, as is well known, held the
same opinion.
That sudden death may ensue from an enlarged thymus
may now be regarded as certain. The following case,
recently published by Mr. J. E. S. Barnett, F.R.C.S., affords
a good illustration : J A very big, fat male child began to
suffer soon after its birth from attacks of dyspnoea, described
by its mother as * grunting, and blue all over.' It was first
seen by the writer at the age of 3 J months ; the fits were
then becoming more frequent and enduring. Respiration
was habitually laboured, with suprasternal and subcostal
recession, action of the nares and locomotion of the larynx :
during the attacks these symptoms were exaggerated and
there was cyanosis. There was free but noisy entrance of
the air into the lungs during the intervals. Temperature
gy'S° F. in the groin. Heart normal. The child took the
* Medical Times and Gazette^ August 15, 1857, p. 160.
t ' Clinical Medicine,' (Syd. Soc. Transaction), vol. i., p. 354.
% The Lancet, April 30, 1898, p. 1185.
J26 SUDDEN DEATH
breast well. The fits seemed to threaten life, and hot
fomentations and steam were useless. Tracheotomy was
performed at the age of 4 months ; there was no difficulty
in introducing the tube, and there was not much immediate
relief, but respiration was easier next day ; and though the
attacks continued, the cyanosis disappeared, and the child's
condition improved. Three weeks later there was a pro-
longed attack of dyspnoea, cyanosis increased, and the child
died. .
Post-mortem. — The thymus was enlarged, outlying lobules
of the gland extending into the root of the neck. * There
must have been considerable pressure on the trachea ' ; this
was evident when the deep fascia was cut. There was no
ulceration of the trachea or papilloma of the larynx.]
Polypi of the trachea also give rise to analogous spasms.
Whooping-cough has not a very bad reputation, generally
speaking, among the public ; however, it may end fatally by
broncho-pneumonia, or by laryngeal spasm. M. Ducastel*
collected, in 1872, 10 cases of sudden death in whooping-
cough in children under the age of 4 years.
Lastly, fragments of food may enter the trachea and
bronchi ; it is always necessary to see whether these tubes
are clear in making medico-legal autopsies. Parrot has
reported several cases of the kind. It happens nearly
always in a child lying on its back and suffering from indi-
gestion, so that food regurgitates into the respiratory
passages.
M. Miquel,t of Amboise, relates a curious instance of this
accident :
It happened in a child 20 months old, whose father had
just returned from work, and gone to bed. The child, which
was on its nurse's lap, began to cry. The father was out of
temper, and went towards the child and said : * Will you
not be quiet, then, you ugly little monkey!' The child
became silent, drew a deep breath, and died immediately.
The child was strong, and had been healthy hitherto. It
^ Ducastel, * De la Mort par Acces de Suffocation dans la Coqueluche.'
Paris, 1872.
I
t Dr. Miquel, d'Amboise, Gaz. des Hop., 1848.
IN CHILDREN 327
had eaten nothing that morning, though it had just been
drinking some sugar-and-water. Its death was put down to
emotion, to the fear which the father's exclamation had
aroused. This was evidently the starting-point of the un-
toward event.
Post-mortem, — The trachea was found full of food, sticky
yellowish Hquid similar to the contents of the stomach.
The child had had a regurgitation as a result of emotion,
and died because the trachea was obstructed by fragments
of food.
D. PULMONARY CONGESTION.
Another common cause of sudden death, in children 5 or
6 months old, is bronchitis. The following example shows
how suspicion may arise in such cases :
A child is found dead in its cradle one morning, and its
nurse and mother, especially if the mother is an unmarried
girl, are accused of having smothered the child by pressure
with the arm. An autopsy is ordered, and this is what is usually
found : — You know that, in what is called * capillary bronchitis *
or * suffocating catarrh of children ' (Laennec), intense pul-
monary congestion now and then occurs, which places the
child's life in jeopardy for several hours. When the child
is strong, and is more than 7 or 8 months old, it seldom
dies of the first attack of congestion. But when the age is
less than 6 months, death may occur in the first attack, and
at the autopsy Tardieu's* subpleural spots and froth in the
bronchi are found. On examining the lungs, some portions
of the tissue are felt by the finger to be rather hard, though
they float in water. When you have to deal with such a
case, squeeze these portions of the lung between your
fingers, and you will make little rods of muco-pus emerge
from the divided ends of the bronchial ramifications.
This experiment is the only one which will enable you to
recognize positively the existence of bronchitis in the new-
born or very young infant : it ought always to be practised
when any one is accused of murdering a child ; it may help
you to exonerate an innocent person.
* Tardieu, ' Etude mddico-l^gale sur I'lnfanticide.' 2*" edition, 1880.
328
SUDDEN DEATH
Bronchitis is one of the most dangerous diseases to which
children are Hable : the child cannot cough ; it does not
know how to expectorate, or how to free itself from the
obstruction to its breathing; part of the respiratory area
thus becomes useless, and the lesions just described, of
atelectasic portions of the lungs, are found post-mortem:
it is Laennec's * suffocating catarrh.'
[Bronchitis, as above described, is probably the explana-
tion of many cases of so-called * overlying '; laryngismus
stridulus will account for many more ; but still in some, as
in the following one, death is simply the result of accidental
smothering, the child being placed to sleep in a large bed,
and slipping down beneath the bed-clothes, or turning face
downwards on a large soft pillow. E. H., a healthy female
child, aged 3 months, that I had known from its birth, and
had vaccinated a fortnight before, was found dead in bed at
noon one day. The child had been suckled and was in no
way neglected, but for the last few days it had been restless,
crying and not sleeping well. It had never had convulsions.
The father, who worked during the night, went to sleep on
his return home in the morning, and was lying on one side of
a large bed with a spring-mattress, the child being at the
other side of the same bed, not yet dressed. The child was
found lying on its face just below the pillow, froth coming
from its mouth and soaking into the sheet. The child had
last been seen alive by the mother at 9 a.m. When I
arrived, at 2.30 ^.iw., the body had been moved and the head
placed on the pillow ; the face was flushed and turgid, the lips
swollen, the arms and hands semi-flexed.
Post-mortem. — The larynx and trachea were normal ; the
lungs contained little air, and there was most congestion
about the upper lobes. Bloody fluid exuded from the
nostrils. The other organs were healthy.]
Pulmonary congestion is an accident which may complicate
any sort of fever : it is a serious condition, but it is rare for
pulmonary congestion to give rise to rapid and suspicious
death under these circumstances.
Pulmonary tuberculosis has been the cause of many medico-
legal autopsies that have been made at the Morgue : the
TN CHILDREN 329
presence of tubercle had been absolutely unsuspected, and
yet the little patients had sometimes been in our hospitals
under the care of our most eminent physicians. These
cases, it is true, mostly happened some time ago, when
nothing was known of micro-biology, and no one dreamt
of looking for Koch's bacillus, the existence of which was
unknown ; it is plain that such things cannot happen so
frequently nowadays.
M. Vibert has three times made an autopsy on children
under one year of age who have died of typhoid fever ; these
cases have been published. In none of them was the child
suspected to be suffering from typhoid fever; none of them
had been seen by a medical man. When interrogated, the
mothers or nurses all repHed that the children had not taken
the breast well for some days ; but they all declared that
there had been no fever, and nursing-women know very well
whether the child has fever or not by the heat of its mouth.
Post-mortem. — M. Vibert found hypertrophy of Peyer's
patches, which is an indication of typhoid fever, but the
immediate cause of death in each case was pulmonary con-
gestion.
E. INTESTINAL DISORDERS.
The disorders of the alimentary canal which may give rise
to sudden and suspicious death are cholera infantum, which
is sometimes attributed to poisoning, and is generally due
to bad feeding ; and intestinal licemorrhage. Intestinal
haemorrhage has been supposed to happen in tuberculous
children, but Bouchut long ago called attention to the
frequency of these haemorrhages in children where it is
impossible to assign any definite cause for them.
I repeat, in conclusion, that the three affections which
dominate the pathogeny of sudden death in children are
convulsions, spasms of the larynx, and pulmonary conges-
tion.
THE END.
BaillUre, Tindall ^ Cox, 8, Henrietta Street, Covent Garden, W.C.
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