CHAPTER XI SUDDEN DEATHS FROM NATURAL CAUSES. 383. Definition. 384. Lesions of the circulatory system. 385. Lesions of the central nervous system. 386. Lesions of the respiratory system. 387. Lesions of the digestive system. 388. Constitutional diseases. 389. Lesions of the female generative system. 390. Lesions of the urinary system. 383. Definition. There are a certain number of deaths the sudden and unexpected occurrence of which allows of the interpretation that the death has come from some violent means, rather than from a natural cause. If the conditions under which these deaths take place are suspicious, they may lead to medico-legal investigation to determine the cause of death. In a great number of instances the history of the case, or the examination of the body post-mortem, will disclose an evident cause of death: as in apoplexy, pulmonary embolism, or subcutaneous wounds. In other cases the examination reveals conditions which allow of the interpretation that death has been due to either a natural or a violent cause, for the lesions found are not characteristic of anything more than a general type of death. Such, for instance, are the deaths from epilepsy, which so closely simulate those from suffocation in their post-mortem findings. Again, the examination may reveal nothing which will point to the cause of death as in the cases of death from fright, or shock, or poisoning, when no trace of the poison can be found.1 Brouardel has given2 a masterly description of the causes of sudden and unexpected death occurring from natural causes, and on his work, largely, the following two chapters are based. Sudden death from a natural cause is the rapid and unexpected 'Brouardel says that 10 per cent of Brouardel, La Mort et la Mort Su the cases where no adequate cause is bite, Paris, 1895. fatal termination of an acute or chronic malady which has developed in latent form. This latent form of disease is especially common in infants, in old age, and in people addicted to the use of alcohol. In these classes the diseases in which we ordinarily find distinct symptoms from near the time of onset may continue until a few hours before death with only very indistinct or no symptoms. Brouardel describes the causes according to the site of the lesion. 384. Lesions of the circulatory system. When the cause of death is in the circulatory system the lesion may be in the heart muscle itself, which is overloaded with fat, as in very obese persons, or the muscles may be degenerated by fatty or fibrous changes. These degenerations of the heart muscle may lead to death, not merely by the inability of the heart to respond when it is called upon to do extra work, as in cases of exertion or violent emotion, but even during rest. They tend, also, to lead to the ruptures of the heart, which occur more frequently in the left side of the heart than in the right, unlike the traumatic ruptures of the heart, which occur more frequently in the right side. Closely associated with these lesions of the heart muscle are the lesions of the coronary arteries of the heart, on which the nutrition of the heart muscle depends. Lesions of the pericardium, leading to adhesions of its visceral to its parietal layers, similarly may produce sudden death. Endocardial lesions, whether the valves of the heart be diseased in some chronic process or in some acute ulcerative or vegetative condition, and aneurysms of the valves, lead to similar fatalities. New growths of the heart, though rare, may have the same effect. In angina pectoris there is no constant or positive lesion to be found to account for the result. Lesions in the arteries are an important factor in the cause of sudden deaths. There may be either a congenital lesion of the aorta or the large arteries may have developed upon them weak spots, leading to aneurysms or to rupture of the vessel. The arteriosclerosis of the vessels is a common factor. In the vessels of the brain it leads to one form of apoplexy without extravasation of blood; in the kidneys it is associated with the chronic nephritis cases. This change in the vessel walls leads to rupture, too, of the blood vessels, which, in the arteries of the brain and of the heart, is especially dangerous to life. Lesions of the veins are significant in three general types of cases: by the rupture of the large, venous trunks that have become weakened by varices; by the formation of thrombi in the vessels, from which portions are broken off to lodge in the heart, lungs, or, more rarely, the brain, and cause sudden interruption of the function of the organ in which the embolus lodges. These thrombi are peculiarly liable to form in the veins that are the seat of varices, during preg nancy, associated with fibroids of the uterus, and ovarian cysts, in primary and secondary anemias in mastoid disease, in typhoid fever, in furuncles of the face and lips, in prostatic inflammation after gonorrhea, after fractures and dislocations. In this connection Brouardel cites an extremely interesting case of double accidental death of two old people who were alone together in their house. The woman, in going to the cellar for wine, had evidently fallen and fractured her neck; the husband, who was seated at the table at the time of the accident, had evidently heard her cry, and the sudden rising from his chair, possibly associated with the excitement, had broken a bit from a prostatic thrombus, and the embolus had lodged in the lungs, causing instant death. A third way in which the examination of the veins may lead to the discovery of the cause of death is in the cases of air emboli in the vein, such as may follow uterine manipulations during or just after pregnancy; in the return to normal pressure of men who have been working in compressed air, as in the case of divers (caisson disease); and in the case of infection by gas-producing bacilli. Lesions of the small vessels-capillaries and arterioles-lead to the capillary hemorrhages, which are especially significant in connection with apoplexy. Here, too, should be noted the instances of meningeal hemorrhage, the cases of pachymeningitis, which, when found, even in the absence of alcoholism, and insanity (the usual causes) do not prove violence. In the capillaries, also, we find the small septic emboli and the fat emboli, which account for some of the sudden deaths. There are also certain troubles connected with the distribution of the blood to the various parts of the body, which are dependent upon the contraction and dilatation of the vessels of the various regions, where local congestion causes distant anemia: as, after removal of fluid from the abdominal cavity, from the pleura, or after emptying a distended bladder, or after merely rising suddenly after a long illness, or after a distinct hemorrhage. In these cases the blood pressure has been so decreased in some special region that, before its appropriate redistribution can take place, there has been a fatal anemia of some of the other organs of the body. 385. Lesions of the central nervous system. When the cause of death is in the central nervous system, we may find lesions in the cov erings of the brain, in the brain itself, or in the spinal cord. example of the sudden development of meningitis, Vibert gives the instance of a public woman, some thirty years of age, who was picked up by a man and went to a hotel to spend the night with him. He left the next morning, and in the afternoon the woman was found in the room, unconscious. She was taken to the hospital, and died there thirty-six hours later, never having regained consciousness. The autopsy showed no evidence of violence as cause of the death, but a layer of pus several millimeters thick, covering the brain, a quantity which could not have developed since the time when the man and the woman met, even if there had been any evidence of a cause for a traumatic meningitis. The sudden development of a fatal termination in abscess of the brain or in tumor of the brain, after a long latent period, is characteristic of the symptoms of these troubles. Similar development may occur in acromegaly. So, too, a lesion of the spinal cord, whether inflammatory or a new growth, not infrequently develops fatal symptoms on very short notice, especially if the lesion is in the cervical region. Epilepsy is a disease of the central nervous system, apparently without any characteristic lesions. Deaths primarily due to epilepsy, while they are certainly not common, may possibly occur. In such cases the only signs of the cause of death would be in the effect of the epileptic seizure: the punctate hemorrhages in the skin of the face, neck, and shoulders, the injected conjunctivæ, the lacerations in the tongue, due to the biting, and the foam in the bronchi and trachea, practically the same lesions as are found in the deaths from strangulation. The differentiation is extremely difficult by a medical examination, and depends more often upon circumstantial evidence. The cases where hysteria leads to convulsions and death are less frequent than those of epilepsy, and here, again, there are no lesions characteristic of the disease. Classed under lesions of the central nervous system must also be considered the cases of death from shock and inhibition; though, in these cases, there are no lesions to show the cause of death or to distinguish between natural or violent means. Here, as cases of natural death from inhibition, are the instances where death follows a strong emotion. Templemann3 describes the death of a man ten minutes after a violent scene with his drunken son. No blows were struck on either side, and there was no lesion found to account for the death. And such cases are far from rare. Francis describes1 the case of a very sensitive man, who had a great fear of snakes. He Templemann, Edinburgh Med. Journ., 1893. 'Francis, Med. Press and Circular, 1883. was roused one night by feeling something crawling across his legs. The man went into collapse, and died inside of six hours; and yet it was only a harmless lizard which had crawled across him. Similar experiences have occurred in the hands of surgeons, where the simplest of operations have been followed by altogether unprovoked deaths. Nussbaum cites the case of a surgeon who was examining the bladder of a woman, with a sound, when she closed her eyes and forthwith died. Cazenave reports a similar case of a surgeon who passed a sound upon a man, and inside of a minute the man was dead. To be distinguished from these deaths, for which we cannot account except by calling them reflex inhibitions of the heart or lungs by the slight and usually harmless external stimulation, are the instances of similar inhibition following blows. Such blows most frequently are those given upon the epigastrium, especially after a full meal; on the hypogastrium, on the larynx, neck, nose, mouth, and in the region of the distribution of the fifth cranial nerve. Here we may have absolutely nothing to show that violence has been used. 386. Lesions of the respiratory system. When the cause of death is in the respiratory apparatus we may find as lesions edema of the larynx or polyp obstruction of the larynx; or, with laryngismus stridulus, causing death, we may find no lesion giving the immediate cause, and only possible rachitic lesions to point to the cause. In the trachea there may be found, in other cases, vomitus, or pus from an abscess that has ruptured into the trachea, or even a lumbricoid worm that has attempted to crawl from the intestines. The trachea may be compressed by the glands in the mediastinum, by a cancerous growth, by the thyroid or by the thymus glands. These latter two glands, even without giving symptoms of compression of the trachea, may be the cause of sudden death, as in the cases of exophthalmic goiter and of lymphatism. In the lungs proper we very rarely, if ever, find a primary congestion as the cause of sudden death. More often More we find a pneumonia, as in the aged or alcoholics, where it frequently develops without any symptoms; possibly, in other instances, a suffocating catarrh, due to hypersecretion of the bronchi; or a pulmonary phthisis, where death has come from thrombosis or from rupture of a blood vessel in a phthisical cavity. So, too, there may be a pleurisy, with effusion, which has interfered with the action of the lungs or Nussbaum, Ueber Unglücke in der Chirurgie. •Cazenave, Gaz. des Hôpitaux, 1866. |