484

DEATH FROM STARVATION OR DISEASE.

as a condition of the intestines diagnostic of starvation, that they are not only contracted, but shrunken and diminished in size, shortened in length as well as in calibre, and like a mere cord, as if the canal were obliterated. (Med. Times and Gaz., 1861, i. p. 344.) He met with this state in three cases-once in starvation from want of food, and twice from total obstruction to its ingestion. Fletcher found the following appearances in the cases of two children who died from starvation-the elder aged one year and ten months, the younger four months. In the body of the elder there was extreme emaciation, without the slightest trace of disease in any of the viscera. Some dirty creamy fluid and four cherry-stones were found in the small intestines, but no distinctly fecal matter, a few grains of which, however, were found in the large intestines; scarcely a trace of fat was visible. In the infant the same appearances were presented, although the emaciation had not proceeded to the same extent. (Proc. of Liverpool Med. Soc., 1855-56.) In some alleged deaths by starvation, ulceration of the bowels is met with. This has been considered to arise from want of food; but Donovan did not meet with it in the bodies of those who died of lingering or chronic starvation. (Dub. Med. Press, 1848, p. 66; also Lancet, 1845, i. p. 681; 1849, i. p. 180; Dub. Jour. Med. Sci., vol. iii. p. 273.) Copland describes among the appearances in the cases which he quotes, shrinking of the viscera, with increased vascularity of the brain and its membranes, with sometimes a limpid serous effusion between them. According to Osborne (Dub. Jour., 1839, vol. xv. p. 423), in cases which prove fatal from long abstinence, chronic inflammation of the stomach is one of the appearances met with. He says that those who die of starvation usually die with the mucous membrane of the stomach and bowels in a state of inflammation, and generally of ulceration. Hence it may be presumed that long fasting is injurious by inducing a state of irritability, causing the membrane to pass very readily into an inflammatory condition. A congested state of the stomach is, therefore, consistent with death from starvation.

Death from Starvation or Disease. The post-mortem appearances, in order to throw a light upon the cause of death, should be accompanied with an otherwise healthy state of the body; since, as is well known, some of them may be produced by organic disease, and death may really be due to disease and not to the privation of food. It will not be always easy to say whether the emaciation depends on disease or want of food, unless we are put in possession of a complete history of the case. On this account, in all charges of homicidal starvation, the defence generally turns upon the coexistence of disease in the body, and the sufficiency of this to account for death. As in most cases of death from protracted abstinence or privation of food, disease is likely to be set up, or, if already existing, to be aggravated by the want of proper nourishment, so it follows that in the bodies of persons who have died of starvation traces of disease are generally found. The cause of death may here be contested, and the case often admits of a strong defence.

In no instance probably has this conflict of medical opinion been more strikingly shown than in what has been called the Penge case. (Reg. v. Staunton and others, C. C. C., Sept. 1877.) The deceased, Harriet Staunton, had been kept in close confinement by the accused, four in number, and, while in an almost moribund state, she had been suddenly removed by them to Penge, where she died, in a state of complete exhaustion, on the day following her removal. She was seen a few hours before her death by a medical man; she was then insensible and in a state of complete collapse.

MEDICAL EVIDENCE IN THE PENGE CASE.

485

As the only persons about the deceased were the four accused and a servant-girl, a relative of two of the prisoners, it was difficult to procure any trustworthy account of the symptoms preceding her removal and death. Such as they were, they substantially corroborated the conclusions drawn from a post-mortem examination of the body. The body was examined by Wilkinson, Bright, Harman, and three other surgeons. The appearances which they found were the body greatly emaciated; the skin parchment-like, dry, and shrivelled; the muscles shrunken and entirely destitute of fat; the breasts almost imperceptible; the body covered with vermin. The entire weight was only seventy-four pounds, while in a healthy adult of the same age it would be about a hundred and twenty pounds. The stomach was small and so much thinned that the undigested food in it was distinctly visible through its coats. The intestines were pale, shrunken, and empty; they contained neither food nor fecal matter. When held up to the light, the wasting of the coats was well marked. The omentum was scarcely visible and quite destitute of fat, of which there was, indeed, a total absence in every part of the body. The organs of the chest and abdomen were shrunken and smaller than usual. They were generally in a healthy condition. The only appearances of disease in the body were: 1. A slight tubercular deposit at the apex of the left lung. 2. A congested appearance of the cardiac extremity of the stomach as well as of the duodenum. 3. There were two small patches of miliary tubercular deposit (recent) upon the arachnoid membrane on the upper surface of the left hemisphere of the brain. There was no deposit on the pia mater or on the base of the brain, and the arachnoid and pia mater were not adherent. There was no trace of meningitis, i. e. inflammation of the membranes of the brain, either simple or tubercular. There was no efusion, softening, or disease of the brain. From the appearances the medical men who examined the body drew two conclusions: 1. That there was no disease in the body sufficient to cause death, or to account for the extreme emaciation and exhaustion. 2. Considering that the appearances included all those which the best authorities assigned to death by starvation, it was their unanimous opinion that the cause of death in the deceased, Harriet Staunton, was starvation and neglect, understanding by this an insufficient supply of proper food.

For the defence it was urged that the emaciation and other symptoms of starvation were due to disease-i.e. to tubercular meningitis, and not to the privation of food or the supply of insufficient food. If there was any truth in this theory, it followed that a grave mistake had been made in charging the accused with any crime. This defence was set up by three medical men who had not had an opportunity of seeing the body or even of consulting with those who had made the inspection. The general evidence given at the trial satisfied the jury that there had been on the part of the accused intentional and deliberate neglect, and they returned a verdict of wilful murder. In accordance with public opinion the capital sentence was commuted to penal servitude for life against three of the accused; while the fourth, Alice Rhodes, against whom the evidence of complicity and motive was weak, was discharged.

Looking at all the medical facts of this remarkable case the author saw no reason to doubt that the deceased died from starvation as the result of an insufficient supply of food. He thought there was no proof whatever that the diseased appearances met with in the body had reached a stage sufficient to account for death irrespective of starvation and neglect. No medical man had been called in to see the deceased during her long confinement. Her mother and all her relatives had been studiously prevented

486

MEDICAL EVIDENCE IN THE PENGE CASE.

from visiting her. She was, in fact, for many weeks completely isolated from the word by the accused persons; and within the last twenty-four hours of her life, while in an exhausted and prostrate condition, she was hurriedly removed in an open vehicle and by rail a distance of more than twenty miles. The only motive which could be suggested for this violent proceding was that the accused persons might thus be enabled, as death was imminent, to procure a certificate of death from a medical man not acquainted with the facts. They succeeded in procuring a certificate of death from apoplexy; but the medical man who signed it had so much doubt that on hearing something of the previous history of the case he gave information to the coroner.

It has been complained that on this occasion an undue importance was attached by the witnesses for the defence to the presence of a miliary tubercular deposit, about half an inch in diameter, on the arachnoid membrane of the brain. The witnesses for the prosecution, who saw it, agreed that it was recent and quite insufficient to account for the extreme emaciation or death of the woman. One witness for the defence so far agreed with them as to say that he had never known such an amount of emaciation as was here described to take place from such a cause within so short a time.

In all cases of death from alleged starvation, but especially in those where a charge of murder is raised, a medical man or expert is bound to give full effect to the presence of disease, its extent, and its adequacy to cause appearances such as are found on the body. All the medical witnesses for the prosecution agreed that there was no meningitis (inflammation of the membranes of the brain) nor any of the products of inflam mation. As this statement was made by them from actual observation any expert subsequently dealing with the case was bound to accept and act upon it, or to reject the evidence altogether. In place of this, however, and in the absence of any inspection of the brain, they affirmed that meningitis was present and that the woman died of it in a tubercular form. In a summary of the case in its pathological aspects by Virchow (Med. Exam., Nov. 1877, p. 882), he states that he should not consider himself justified in regarding a deposit of tubercle such as that described as of fatal significance, at least in a case (like this) where such deposit has its seat upon the convex surface of the left cerebral hemisphere. The jury at the trial, and the authorities to whom an appeal was subsequently made, rejected this theory of the cause of death. If this mode of dealing with medical evidence and medical facts were generally followed, it would be scarcely possible to obtain a conviction in any case of actual homicidal starvation.

The editor is of opinion that Harriet Staunton's death was accelerated by the cruel and neglectful treatment to which she-a tubercular womanwas subjected; but that there was not sufficient evidence that her death was due to sheer starvation.

Voluntary Starvation. Pretended Fasting.-There are a few cases recorded in which persons have voluntarily abstained from food, liquid or solid, for the purpose of self-destruction. Suicide as a result of perfect abstinence is, however, exceedingly rare; the person cannot resist the intolerable thirst, or the desire for food, when placed within his reach. It has been sometimes observed among the insane. As it requires a period of about ten days for the destruction of life under these circumstances, i.e. in the acute form of starvation, the resolution to abstain can be rarely maintained, and for the purpose of self-destruction starvation would never be resorted to except when all other means of destroying life were removed.

PRETENDED FASTING.

487

Pretended fasting has been a subject of imposture at various times. The case of Sarah Jacobs, the Welsh Fasting Girl, shows how it may be certainly detected by strict watching. This girl, æt. 13, was stated to have voluntarily abstained from any kind of food for a period of two years. She had kept her bed during that time-lying in it decorated as a bride, visited by hundreds of persons-in fact, she was thus publicly exhibited by her parents as a girl of miraculous powers. Her lips were moistened with water once a fortnight, but, according to the parents, no food was given to her. Four professional nurses from Guy's Hospital were set to watch her, and the result was that, after passing through the usual stages of actual starvation, she died on the ninth day. She refused to take food at any time during the strict watching, and voluntarily accepted a lingering death rather than reveal the imposture. Her parents and those around her allowed her to die. A post-mortem examination presented the following appearances: The body was plump and well-formed; the membranes of the brain were much injected, the brain itself was healthy and of proper consistency. There was a layer of fat from half an inch to an inch thick beneath the skin of the chest and abdomen. The contents of the chest were healthy. The stomach contained three teaspoonfuls of a semi-gelatinous substance of the consistency of syrup, having a slightly acid reaction. The small intestines were empty, and presented no attenuation or thinning of the coats. In the colon and rectum there was half a pound of solid excrement in a hardened state, which might have been there, according to the medical witness, a fortnight or longer. The liver was healthy, and the gall-bladder was greatly distended with bile; the kidneys and spleen were healthy, and the urinary bladder was empty.

The medical evidence was to the effect that the child had died from exhaustion as the result of starvation. The parents were tried on a charge of manslaughter. (Reg. v. Jacobs and wife, Carmarthen Sum. Ass, 1870.) An attempt was made in the defence to refer death to shock and not to the want of food. The medical facts relied upon in support of this theory were the presence of fat in the body and the absence of any thinning of the coats of the intestines; but as Fowler very properly pointed out (Lancet, 1870, ii. p. 150), the absence of fat and the thinning of the intestines are only likely to be met with after long or chronic fasting when the person has survived many weeks on insufficient or innutritious food. In the case of this girl, the only proved abstinence from food was during the last eight days of her life, when she was thoroughly watched, and this period of time would not suffice for the entire removal of the fat and the thinning of the coats of the intestines. The prisoners were convicted of causing the death of their child by criminal negligence. (Lancet, 1870, ii. p. 132.)

In 1880, Dr. Tanner, an American physician, entered upon, and is said to have successfully accomplished, a forty days' fast. It is doubtful whether this was a great imposture or a remarkable feat of foolhardy endurance. The conditions under which he was watched were by no means satisfactory. Water was taken, at times freely; and at one time it was said that he increased his weight upon a water dietary. (Brit. Med. Jour., 1980, ii. p. 215.) No complete medical history of this case has been published. Tanner is said to have had several imitators. [Succi, the Italian, made a successful experiment in New York, under the personal supervision of a committee of physicians and representatives of the press (N. Y. Herald), and fasted forty-five days. Water was taken freely, and occasionally a fluid called elixir not containing sustenance. The watch was perfectly kept in his case.]

488

SIGNS OF PREGNANCY.

PREGNANCY.

CHAPTER XLIV.

SIGNS OF PREGNANCY.-SUPPRESSION OF THE MENSES.-QUICKENING.—SOUNDS OF THE FETAL HEART.-FEIGNED PREGNANCY.-CONCEALED PREGNANCY.-PREGNANCY IN THE DEAD. IMPREGNATION IN A STATE OF UNCONSCIOUSNESS.-LEGAL RELATIONS.

SIGNS OF PREGNANCY.

Suppression of the Menses.-It is well known that, in the greater number of healthy women, so soon as conception has taken place, this secretion is arrested. But there are certain abnormal conditions which must not be overlooked. There are some cases recorded which show that women in whom the menses have never appeared may become pregnant. This, however, is allowed by all accoucheurs to be rare; and, when it occurs, which we may readily learn from the account of the woman, it will be necessary to search for other signs in order to determine the fact of pregnancy. Irregularity as to the period at which the function takes place is common among females. This irregularity may depend upon the age of the person, or upon disease, either of which causes it will not be difficult to recognize. The continuance of the menses after conception may make a pregnancy appear short. A case is reported in which a woman was married in the summer of 1856, and the menses continued after as before marriage. In Oct. 1857, they ceased for the first time, and in the following December the woman was delivered of a full-grown child: as the abdomen was not much enlarged, she thought that she was only two months pregnant. (New York Jour., 1859, p. 286.)

There are numerous disorders of the womb under which, irrespective of pregnancy, the menses may become suppressed. The continuance of the menstrual discharge, when once set up, is not a necessary condition for impregnation. Murphy has reported the case of a woman who for sixteen years went on bearing children, eight in number, without having had during that period any appearance of the menses. Reid, who quotes this case, mentions five instances that fell within his own knowledge in which females became pregnant notwithstanding a long previous cessation of the discharge. (Lancet, 1853, ii. p. 236.) The absence of the menses as a consequence of pregnancy is generally indicated by the good health which a female enjoys; and although disease may coincide with pregnancy, yet a careful practitioner will be able to estimate from the general symptoms the probable cause to which the suppression is due. On the other hand, a discharge analogous to the menstrual sometimes manifests itself, not merely for several periods in a pregnant woman, but during the whole course of pregnancy. (Murphy's Obst. Rep., 1844, p. 9; also Henke's Zeitschrift der S. A., 1844, p. 265. See Ann. d'Hyg., 1873, t. 2, p. 140.) Whitehead has collected seven well-marked instances of menstruation during pregnancy. (On Abortion, p. 218.) These facts show that we should