It must not be forgotten that patients who are burned extensively very frequently die shortly after the accident. A burn that involves more than one-half of the body, no matter how superficial the burning may be, will always have a fatal termination. Deep burns in one part, unless it is some very vital part, are not so serious as extensive superficial burns. Patients with extensive burns frequently remain in encouragingly good condition for several days, and then have a sudden change for the worse. Sometimes death takes place in coma. Sometimes it takes place as the result of a perforation of the duodenum. These perforations of duodenal ulcers may take place as late as a week to ten days after the burn. They are always followed by symptoms of peritonitis and the condition of intense prostration which this brings on. Such cases need to be prepared for the worst after the first acute symptoms of the burn have subsided, when a certain amount of peace of mind is restored.
Cirrhosis of the liver not infrequently causes sudden death. Cirrhosis is an affection in which a large part of the liver substance proper degenerates, and its place is taken by connective tissue. It is typically a disease of people of alcoholic habit. It occurs in those who are engaged in the sale of spirits, though the alcoholic absorption does not take place [{157}] through the skin, but in a much more direct way. It is most frequent in people who take strong spirits on an empty stomach. Those who are much exposed to changes of temperature are especially liable to form such habits. It is found most frequently in the drivers of wagons and cars, in policemen, and in sea-captains, sailors, and the like. When cirrhosis causes sudden death, it is nearly always by hemorrhage. The hemorrhage takes place from the oesophagus, some of the large veins of which have become dilated until the thin walls are unable to retain the blood. The dilatation is due to interference with the venous circulation in the liver.
Of late years pathologists and medical men, especially those who are interested in children's diseases, have devoted considerable time to the study of certain cases of sudden death, which have long been very mysterious. Infants often die while in apparent good health without any adequate reason that can be found, even on the most careful autopsy. Children of an older growth sometimes die suddenly as the result of some slight shock or fright, or they die after the administration of a few whiffs of chloroform, given to help in the performance of some simple surgical operation, or they die at the beginning of some infectious fever which they ought to be able to withstand without any difficulty. A distinguished pathologist at Vienna, Professor Paltauf, who was the coroner's physician of the city and had a large number of these sudden deaths to investigate, found that in most of the cases one abnormal condition was constantly present. This consisted in an enlargement of the lymph glands all over the body. The lymph glands in the neck were involved, also the tonsils and lymphoid tissue at the back of the throat, the series of lymph glands in the groin, and, finally, there was a hypertrophy of the lymphoid tissue that occurs all along the intestinal tract. This condition of hypertrophy of lymphoid tissue has come to be known as the lymphatic diathesis or constitution. It is nearly always accompanied by a distinct hypertrophy of the thymus gland. The thymus gland is an organ which occurs in the upper part of the thorax of the child, but which atrophies and practically disappears after the age of two years. In these cases it is from twice to three [{158}] times its normal size in the infant, and in older children it is persistent—that is, retains its primary size, though in the ordinary course of nature it should atrophy. This lymphatic diathesis undoubtedly has considerable to do with the sudden deaths which occur in these patients. What the exact connection is we do not as yet definitely know. Unfortunately, moreover, this lymphatic constitution gives no sure sign of its existence before the occurrence of the fatal termination. Enlargement of the glands of the neck and of the groin, with some enlargement of the tonsils, occurs in delicate children without necessarily being symptoms of the lymphatic diathesis. The enlargement or persistence of the thymus can be better recognised, and doctors now seldom fail to notice it. Where any suspicion of such a condition exists in children of from eight to sixteen or seventeen years of age, proper precautions must be taken to prevent sudden fatal termination of any even mild disease without due preparation. Undoubtedly many of the cases of sudden death under chloroform and ether in children and young persons are due to the existence of this lymphatic diathesis.
Diseases, like tuberculosis and cancer, that run a long but assuredly fatal course, usually terminate unexpectedly. The tuberculous patient particularly will almost surely be planning for next year the day before he dies. This condition of euphoria, that is, of sense of well being, was recognised as associated with tuberculosis as far back as we have any history of the disease. Hippocrates pointed out as one of the symptoms of consumption the spes phthisical or consumptive hope. If the patient has been very much run down, death may take place from thrombosis of some of the arteries. If the thrombosis takes place in the brain, consciousness will be lost, and the patient will often die without recovering it. Patients often develop tubercles in their brain as the result of a spread of the disease beyond the lungs, and then, as a rule, death will take place in the midst of a paralysis, which may be accompanied by loss of consciousness that lasts for several days or a week or more.
Cancer patients also die suddenly, or at least unexpectedly, at the end. Very often in them, as in tuberculosis, [{159}] thrombosis plays an important rôle in the fatal termination. In cancer of the stomach, peritonitis from perforation of the stomach may close the scene. The fatal termination in cancer of the uterus is often brought about by the development of uraemic symptoms. The new growth in the pelvis involves the ureters, prevents the free egress of urine, and so causes the retention in the system of poisonous substances that should be excreted. Cancer in other parts of the body often causes death by metastatic cancers, that is, offshoots of the original cancer which occur in other organs. Usually these are in the liver, but sometimes they are in the brain, and sometimes in the bones that surround the spinal cord. In the course of their growth they cause pressure symptoms upon the nervous system, and this leads to death. If patients become very much weakened, as is not infrequently the case, thrombosis occurs, and portions of the clots may be shot into the pulmonary veins, and cause death in this way.
Two affections which are quite common, one of them usually involving no danger at all, sometimes cause sudden death. They are varicose veins and a discharging ear. Varicose veins are the enlarged veins which occur on the limbs of a great many elderly people. If these people become run down in health and then exhaust themselves by overwork, the circulation through these enlarged veins is sometimes so impeded that clotting—thrombosis, as it is called—occurs. If a portion of the clot becomes detached, and is carried off into the circulation, a so-called embolus, this may cause sudden death, either by its effect upon the heart, or more usually upon the lungs.
Middle-ear disease causes death, either by producing an abscess of the brain, or by causing thrombosis of some of the large veins within the skull. The dangers involved in a discharge from the ear are now well recognised. Insurance companies refuse to take risks on the lives of persons affected by chronic otitis media, as it is called scientifically. Such persons may run along in perfect good health for years without accident, but a sudden stoppage of the flow may be the signal for the formation of the brain abscess, with almost inevitable death.
Certain severe forms of the infectious fevers are very often fatal. These forms are popularly known as black fevers, that is, black measles, black scarlet fever, etc. These fulminant forms occur especially in camps, barracks, orphan asylums, jails, and the like, where the hygienic conditions of the patients have been very poor, and where the resistive vitality has, as a consequence, become greatly lowered. The black spots that occur on such patients are really due to small hemorrhages into the skin. The hemorrhages are caused by a lack of resistance in the blood-vessels and by a change in the constitution of the blood that allows it to escape easily from the vessels. Where such cases occur, patients should be fully prepared for the worst As a rule, the mortality is from 40 to 70 per centum.
Acute pancreatitis is a uniformly fatal disease, though fortunately it is rare. It occurs much more frequently, however, than used to be thought. It occurs in persons over thirty who have been for some years addicted to the use of alcohol. The symptoms of the disease are severe pain in the upper left zone of the abdomen, that is, above and to the left of the umbilicus. This is accompanied by nausea and vomiting. Collapse ensues and death takes place on the second to the fourth day of the affection. This disease may have important medico-legal bearings. Some slight injury in the abdomen, as from a blow or a kick, may precipitate an attack in predisposed individuals. Accusation of murder may result. The mental attitude of the physician and the clergyman with regard to such cases must be very conservative. No opinion as to possible culpability should be ventured.