of the heart. Affecting, too, this respiratory apparatus, are the ruptures of the diaphragm, which occasionally occur from natural causes. 387. Lesions of the digestive system. When the cause of death is in the digestive apparatus we may find cases where congestive pharyngitis has been the cause of death; but as the color characteristic of the disturbance is faded before the post-mortem examination, there may be nothing whatever to show for the disease. Such cases are analogous to the instances of inhibition which have followed touching the pharynx, of which Brouardel cites several. In the oesophagus there may be a dilatation, with minute ulcerations, such as would be found in a case of irritant poisoning. In the stomach cases, those without lesions (as those due to indigestion or to dyspeptic coma) are very doubtful. Martel, however, describes one case in which indigestion seems to be the only assignable cause of death; but here the patient was a convalescent from typhoid, who had overloaded his stomach. The presence of ulcers of the stomach would suggest, in cases of sudden death, the possibility of poisoning; but the round ulcers of disease, which have run a latent course, are usually distinct in form, and in the raised edge of beginning cicatrization, or the presence of vital reaction, give evidence of their long duration, which, of course, would not be found in instances of poisoning. Brouardel cites one instance of great interest,-the case of Mme. Lerondeau, who was accused of poisoning her husband. The examination showed a trace of oxalic acid in the stomach, and the presence of several ulcers; but the further examination showed the ulcers to be round, and it was also shown that oxalic acid is produced to a greater extent than the trace found here, during the digestion of bread. Therefore, on the second trial, the case was abandoned. The round ulcers of the stomach must, of course, in each case be distinguished from the post-mortem ulcerations due to hypersecretion, and from post-mortem erosions.

In the intestine we may find ulcers of the duodenum which not rarely have run a latent course. Ulcers of the jejunum are rare, but ulcers of the ileum, due to dysentery, typhoid, tuberculosis, or cancer, are more common. Associated with these there may be intestinal hemorrhages that have led to death. Among the other intestinal causes which, at times, lead to unexpected death with obscure symptoms, are embolism of the mesenteric arteries, appendicitis, intestinal strangulation or obstruction, and even constipation.

With the liver affected we find cases of severe acute jaundice (which may be indistinguishable from acute phosphorus poisoning),

VOL. III. MED. JUR.-24.

of cirrhosis of the liver, of biliary colic, of rupture of the gall bladder, or of an hydatid cyst. Rupture of the spleen may be the cause of sudden death after a malarial infection and marked enlargement of the organ. Pellereau' collected seventeen cases of rupture of this organ as a cause of death, the rupture being due to some slight traumatism. In one of the cases a man, running across a field, was lightly struck by a cactus branch, which he brushed against in passing. The spleen was ruptured and death followed as a consequence. Hemorrhage into the pancreas may be the cause of death; usually, however, such is interpreted as but an associate lesion to some other disturbance. In tuberculosis of the suprarenal capsules (Addison's disease), death may come on unexpectedly. In peritonitis, whether acute or chronic or due to a new growth, we may have a sudden death.

388. Constitutional diseases.- Certain infectious diseases, such as malaria in its pernicious forms, and the eruptive diseases, in their hemorrhagic forms, may develop suddenly and terminate fatally, in a most unexpected manner. So, too, certain constitutional diseases, with no characteristic lesions, such as hemophilia or diabetes, may lead to sudden deaths,-hemophilia by producing hemorrhages that are uncontrollable. Brouardel cites two cases where a tooth extraction by a dentist led to fatal results. Diabetes most frequently runs a latent course, to show itself a short while before death in the development of pneumonia, anuria, or coma.

389. Lesions of the female generative system. The female genital organs may show lesions explanatory of sudden death in a fair number of cases. Brouardel cites several cases where mere vaginal examination with the fingers has led not merely to abortion, but also to the sudden death of the woman examined. In one of his cases the mere giving of a vaginal douche (the fourth one given) to a girl of sixteen who had a gonorrhea but had not had her hymen ruptured, produced death. The more usual cases of death, where the lesion is found in the female genital organs, are, however, the extrauterine pregnancies that rupture, or the rupture of the uterus during preg nancy, or rupture of vulvo-vaginal varices, or the syncope or throm bosis associated with labor.

390. Lesions of the urinary system. Lesions of the kidneys are an extremely frequent cause of sudden death. Not merely does death follow in the course of the development of a latent nephritis, but the renal insufficiency may show up most unexpectedly, causing death in

'Pellereau, Ann. d'Hyg. Pub., 38.,

the acute fevers or in toxic conditions which persons with normal kidneys would be able to overcome. Many of the drug idiosyncrasies seem to be due, or at least to be associated with, renal insufficiency. In the course of the kidney disease itself, death may come on with bronchial symptoms, developing into an acute dyspnea, with edema of the lungs; or it may follow the gastrointestinal type, with vomiting and purging, so simulating acute poisoning with some irritant drug; it may take the comatose form and simulate opium poisoning; or the convulsive form, and simulate strychnin poisoning; or it may be extremely sudden, as in the fulminating form, where death occurs in a few minutes or an hour.

422. Kidneys.

423. Urinary bladder.

424. Esophagus.

425. Pancreas.

426. Diaphragm.

427. Arteries and aorta.

428. Uterus.

429. Saponification.

430. Mummification.

IV. TIME SINCE DEATH.

431. General evidence.

432. Entomological evidence.

433. Evidence from freezing point of body fluids.

I. APPARENT DEATH VERSUS REAL DEATH.

391. Premature burial.- To the casual observer the distinction between life and death is so marked that it would seem an easy matter to tell the difference, and so it is in the majority of instances. But there are certain conditions where the distinction is not so easy. On the other hand, there is a prevalent idea that burials alive occur with alarming frequency. But, while this is true if it occurs in but a single instance, the stories of premature burial are mostly without foundation. Yet a few such authentic instances must be admitted. However, since the establishment in Europe of the mortuaries for the timely detection of this awful calamity, not a single instance has been found in those places.

392. Conditions simulating death. The conditions that have led to the greatest doubt as to whether the person was alive or dead are: Syncope, where, during a short period, the heart action is so weak that the pulse may not be felt, the color disappears from the skin, and the breathing becomes very shallow. The condition of death may be still more closely simulated in the instances of acute alcoholism, associated with exposure to cold, where not merely is there a loss of consciousness, and absence of response to stimulation, but the body temperature has fallen from the normal to a degree generally considered incompatible with life; as in the case described by Peter,' where the temperature of the man reached 26° C. (79° F.) and the man recovered. So, too, in the cases of opium poisoning, where the breathing drops down to one or two a minute, the question of the existence of life becomes one of difficult determination. Simulating the condi

'Peter, Gaz. Hébdom. de Méd. et de hibernation in animals, as described in Chir., 1872. Compare the condition of Brouardel's Mort et Mort Subite, p. 9.