A

LTHOUGH the extraordinary

lesion of the medulla oblongata, which forms the nucleus of this report, is unique in medical literature, a recital of its case history and a presentation of its medical and medicolegal aspects must prove of interest, not only to the coroner's physician, but also to the practitioner whose relationship to forensic medicine is but an incidental outgrowth of his daily routine. The value in practical medicine of the analysis here presented rests upon its emphasis of the clinical syndrome of a bulbar lesion, its data upon medullar localization, its presentation of the method of attack in the solution of such medicolegal problems as this and, finally, its obvious. argument for the complete autopsy. Although in charge of a physician and trained nurse for a period of several hours, a bulbar lesion was not diagnosed, as is frequently true in the early hours of an encephalitis of this region, and without the complete autopsy the death. would undoubtedly have been registered as of toxic origin, with an unjust imputation of suicide. We are glad to record the appreciation of the mem

1 From the Department of Pathology, University of Michigan. Ann Arbor. Michigan.

bers of the family of the deceased that a complete autopsy revealed the true cause of death.

On January 19, 1924, the writer was asked by the coroner to perform an autopsy upon the body of a woman, a capable and successful social service worker, who had been found in a dying condition in her room in a private house. private house. With the request for

the autopsy came the meager information that this woman had been somewhat indisposed for several days and that she was found unconscious with her body resting partly upon a cot or couch and partly upon the floor. It was not clear whether she died immediately or shortly after she was found. It was noted that she had probably been darning a stocking at the time she became unconscious. The coroner suspected poisoning and was further concerned because of the fact that another woman, also a social service worker and a previous occupant of the same room, had died a few weeks before, a diagnosis of meningitis having been made in this case. With knowledge of this earlier death, the prosector anticipated the possible discovery of an epidemic cerebrospinal meningitis of unusually foudroyant character.

ANNALS OF CLINICAL MEDICINE, VOL. III, NO. 2

At the request of the coroner, who presumably had promised that the head would not be opened unless it should prove necessary in order to establish the cause of death, the examination of thoracic, cervical, abdominal and pelvic organs was undertaken and completed before that of the head, thus reversing the preferable order for a medicolegal autopsy. A condensed protocol of the autopsy follows.

Miss B. Age given as thirty-five. Social Service Worker. Autopsy about nineteen hours post mortem.

The body is that of a well-proportioned adult female, 163 cm. long, appearing younger than the reported age. General nutrition good. Head symmetrical. Facies symmetrical. Pupillary orifices intermediate in respect to size, equal and circular. Slight cyanosis of mucous membranes. Neck negative. Thorax symmetrical; intercostal angle nearly a right angle. Abdomen flush with the rib margin. Back negative.

No signs of trauma, surgical wounds or scars. Rigor mortis well marked in muscles of the jaw, present to a less degree in the extremities. Body heat absent. Hypostasis dorsal. All orifices of the body were negative, as were also the external genitalia.

The main incision showed a panniculus averaging 1.5 cm. in thickness and a well developed musculature. Liver border was found to be 10 cm. below the tip of the ensiform and 5 cm. below the rib margin in the right nipple line. Otherwise, general inspection of the abdomen showed nothing of importance. Mammae on section showed moderate cystic dilatation of some of the ducts. No evidence of functional hypertrophy.

Examination of the thoracic organs showed a definite mass of thymic tissue with marked fatty infiltration, a fatty atrophy of a persistent hyperplastic thymus. The cardiac apex was behind the fourth rib, just outside the nipple line. Pericardial fluid clear and in normal

amount. Pericardial surfaces negative. The heart was of normal size. It showed no pathological change of significance. Likewise the lungs were negative, except for a very marked congestion and edema, and a small focus of encapsulated caseating tuberculosis.

The neck organs showed no pathological changes.

The abdominal peritoneum was moist and shining throughout and without adhesions. The abdominal organs showed no pathological changes of significance except a general acute passive congestion. The stomach showed very marked post mortem autolysis of the greater part of the fundus so that it was only with great difficulty that the contents, consisting of about 150 cc. of a dark chocolate brown fluid, having a sour odor, were saved without contamination. Both adrenals showed a well marked hypoplasia affecting both cortex and medulla. In the kidneys there was a marked congestion.

The pelvic peritoneum showed a few tubo-ovarian adhesions, apparently associated with small parovarian cysts. The uterus was virginal in size and the pelvic organs, in general, showed no changes having significance in explanation of the cause of death.

The head was then opened, the scalp, periosteum and skull-cap being found normal. The dura was not adherent either to the bone or to the brain. The superior longitudinal sinus contained fluid blood and the inner meninges showed a moderate congestion which had not been drained out by the earlier removal of the thoracic organs. The meninges showed no exudate. There was no meningitis. After severing the upper cranial nerves and freeing the tentorium cerebelli from the bone, as the brain was being lifted preparatory to cutting the cervical cord, a sharp-pointed, slender, metallic object was found projecting for a distance of 3 mm. through the leptomeninges of the ventral surface of the medulla oblongata. This appeared to be the point of a needle. Without removing the brain, search was made for the eye-end of the needle and it could be felt beneath the scalp in the sub-occipital region. The cervical cord, lower cranial

of the latter (fig. 1). It could then be seen that the needle had entered the substance of the medulla point first, about 1 mm. to the left of the mid-dorsal line near

of the olivary eminences. With the cadaver considered as being in the erect position the course would have been slightly upward from the horizontal plane and

emergence of the needle point, small and rather firm red blood clots, each about the size of a kernel of wheat, were found. Otherwise, there was no evidence of hemorrhage into the meninges or into the subdural space.

Before removing the needle it was demonstrated with ease that rotation of the head upon the vertebral column caused the portion of the needle which had been within the substance of the medulla to move in a transverse arc. This was due to the firm fixation of the eye-end of the needle in the ligamentum nuchae, the

tions other than the medulla. Basal sinuses and base of skull were negative.

No other cause of death being found, a provisional report was returned to the coroner to the effect that death was caused by transfixion, presumably accidental, of the medulla oblongata by a darning needle.

Microscopical examination

Microscopical examination of all the organs was carried out in a routine manner. The data of significance thus afforded are summarized as follows: