The Coroner Series

by Thomas T. Noguchi

  Eventually it would be found that the repeated glucose pushes lowered the blood sugar instead of elevating it as it should have done, an indication that there was an excess of insulin, which “eats” sugar, in Sunny’s blood. It was this finding that would later form the core of the case against Von Bülow, who was charged with attempting to murder his wife by the surreptitious injection of insulin. At the time, however, all the facts seemed to point to Von Bülow’s innocence of any role in her illness.

  First, he had had no opportunity to inject her. The family had been together all evening, until Claus went into his study. While he was there, Sunny, in the library with her children, became ill. It was a surprising feature of the case against Von Bülow that the prosecution admitted he had had no opportunity to inject his wife. Instead, it was hypothesized that he injected her with insulin later that night after she had become ill for other reasons.

  Secondly, Von Bülow claimed he had promptly called for medical assistance upon finding his wife ill—and thereby saved her life. And thirdly, he had saved his wife’s life once before, just a few weeks prior to this terrible event, by rushing her to a hospital when he found her unconscious from an aspirin overdose.

  Why, Von Bülow would ask, would he save his wife’s life and less than three weeks later attempt to kill her? He could have allowed her to expire from the aspirin overdose if he was, indeed, a murderer.

  Nevertheless, the state pressed charges, and at his trial a web of circumstantial—and medical—evidence gradually wove around him.

  To begin with, Dr. Gerhard Meier testified to the presence of insulin in Sunny’s blood as revealed by the reaction to glucose pushes administered when she arrived at the hospital. But had it been naturally produced or was it artificial insulin that had been injected into her body? Because he was so busy saving the life of his patient and did not suspect murder, the doctor had not immediately ordered the C-peptide test which would have indicated whether the insulin was artificial or natural. That test could have settled the case right there: if the insulin was artificial, it had to have been injected; if natural, Von Bülow was innocent.

  But the most stunning early revelation in the trial was that, almost exactly one year before, Sunny had been admitted to the hospital in a similar coma. That time she had recovered, but the incident fueled suspicions in the mind of her maid, Maria Schrallhammer, and eventually in the minds of the two Auersperg children, Ala and Alexander, for the maid said that Von Bülow had delayed calling the doctor the year before, even though she had pleaded with him that his wife was ill. And on several occasions thereafter, Maria would later testify, she saw a “little black bag” among Von Bülow’s possessions, filled with drugs, hypodermic needles and, on two occasions, a bottle marked “insulin.”

  It was also revealed that after her first coma Sunny’s health seemed to deteriorate, and that in April 1980 she checked into a hospital for tests. There, when it was discovered that her blood sugar was remarkably low, she was diagnosed as suffering from “reactive hypoglycemia,” which is a temporary reaction to an abundance of blood sugar in which excess insulin is produced. But the insulin output is not enough to cause a coma, as Dr. Richard Stock, Sunny’s family doctor in New York at the time of her checkup, testified at the trial. Instead, he told the court, he believed the cause of her coma was “the surreptitious administration of insulin.”

  Oddly, another prosecution witness, Dr. Kermit Pines, one of the specialists brought in by Dr. Stock to examine Sunny at the time of that checkup, disagreed with Stock’s testimony. He said that when he had asked Stock if there was any possibility that Sunny was receiving insulin injections, Stock had looked aghast at the idea and denied it.

  All during that year, 1980, Sunny suffered spells of wooziness, with slurred speech. Then, on December 1, she took an overdose of aspirin, and Von Bülow saved her life. Three weeks later in Newport she was found prostrate in the coma which she still endures.

  After that coma occurred, the children, inspired by the suspicious maid, hired a private investigator, Richard Kuh, whose fee drew gasps from the court: almost $100,000. But Kuh earned his money. He journeyed to the Newport home with Alexander and a locksmith to search for “the little black bag.” The locksmith wasn’t needed, because the key to the closet in which the bag was found was in a drawer in Von Bülow’s desk. There was no insulin bottle in the bag, but Kuh did discover a hypodermic needle that appeared to have been used, as well as various drugs. When tested, the drugs turned out to be Amobarbitol (a sleeping pill) and Valium (a tranquilizer). And when laboratory tests revealed the presence of insulin on the used needle, the evidence was turned over to Rhode Island police. It was later introduced at his trial, and the web of evidence tightened more strongly around Claus von Bülow.

  The testimony of two distinguished medical experts, Dr. Harris Funkenstein and Dr. George Cahill, further strengthened the prosecution’s case. There was no other explanation for Sunny’s low blood sugar and the presence of insulin at the time of her coma, they testified, than that the insulin was exogenous (injected). According to these experts, there were only two causes of excessïve natural insulin created in the body, one from insulin-producing tumors in the pancreas, and the other from a disorder of the liver caused by alcoholism. Neither of these two conditions, they said, had been found in Sunny von Bülow.

  The medical experts were cross-examined on the fact that Sunny had been diagnosed as having reactive hypoglycemia that very year. In fact, at the time of her routine hospital checkup in mid-1980, she had an even lower blood sugar count than at the time of her second coma. Could the coma have been caused in some way by her natural hypoglycemia? Cahill replied, “I know of no case in my experience in which reactive hypoglycemia caused a coma.”

  In sum, the insulin had to have been injected; there was no other explanation for it. Together with the fact that the bag found in Von Bülow’s closet contained a used hypodermic needle encrusted with the drug, the evidence was damning. But, the defense countered, what was the motive? Von Bülow had plenty of money. Just that year Sunny had given him a trust fund of two million dollars as an outright gift. This plus his other wealth gave him an income of $120,000 a year, which, Von Bülow said, might not seem much to the prosecutors, but was “plenty” to him.

  To supply the missing motive, the prosecution summoned a reluctant witness, Von Bülow’s lover, Alexandra Isles. Lovely, chic, youthful, she was a former soap opera actress. But no soap opera ever televised contained more drama than her testimony, climaxing with the fact that she had given Von Bülow an “ultimatum” to leave his wife the very month Sunny was stricken with her final coma.

  So the jury had medical evidence pointing to Von Bülow’s guilt—and now a motive. In vain the defense produced witnesses who testified that Sunny often injected herself with drugs; and argued, finally, that if Von Bülow had attempted to kill her twice, as alleged, why hadn’t Sunny said so when she recovered from the first coma in 1979? Would a woman continue living with a man who had tried to murder her?

  The jury was faced with a dilemma. The evidence against Von Bülow was purely circumstantial—as it always is in cases where there are no eyewitnesses to the crime. Yet the weight of the medical evidence was so great that on March 16, 1982, Claus von Bülow was found guilty of twice attempting to murder his wife and was sentenced to twenty years in prison.

  4

  Like many thousands of others, I was intrigued by the Von Bülow case, but perhaps not for the same reasons. In my own experience as a medical examiner, I have encountered cases where murders were committed by the surreptitious injection of insulin. In fact, such a murder had once been considered a “perfect crime,” for while it was possible to detect the presence of excessive insulin in the body, there was no way to determine whether it was naturally produced or artificial—like the insulin used in the treatment of diabetes—and therefore injected. That is no longer the case. Forensic science is now able to detect the presence of artificial ins
ulin. Thus it troubled me that if Claus von Bülow had attempted such a crime—not once but twice—he would not have been aware of that fact. And if he had used insulin and hypodermic needles in attempts to murder his wife, why would he not have destroyed such incriminating evidence?

  I could not subscribe to the theory—put forth by some of Von Bülow’s friends—that the insulin and the hypodermic needles were planted by his stepchildren, or perhaps even by the maid. I could not imagine for a moment that they would do such a monstrous thing for any reason. But I did have a theory that could explain the used needle and the insulin. Sunny loved sweets; she adored such delicacies as sugar-rich eggnogs and ice-cream sundaes with caramel sauce; and she therefore worried constantly about her weight. I believed she might have tried insulin as a means of weight control, but when she was diagnosed as hypoglycemic she realized the danger of the practice, and the insulin and the needles were left in the little black bag, along with the other drugs that she apparently used.

  That, however, was pure conjecture. As a medical man, I had an even stronger reason to believe that the insulin found in the little black bag was not the cause of Sunny’s comas, whether she had been injected by her husband or had injected herself—a reason that was not mentioned by any of the medical experts at the trial, perhaps because it didn’t occur to them: insulin had to be refrigerated. New insulin developed within the last two years does not need to be refrigerated, but the insulin in use at the time of Sunny’s comas would have had to be kept in a refrigerator or it would very soon spoil.

  William Wright, author of the book The Von Bülow Affair, described the maid’s reaction to the “discovery” of a bottle of insulin in the little black bag, which fueled her suspicions. She said, “What for insulin?” As a physician, I reversed the question to ask, “Why insulin in a bag and not in a refrigerator?”

  Thus, my theories about the Von Bülow case led me in a circle. Experts at the trial testified that exogenous insulin had caused Sunny’s final coma. If they were correct, that meant it had to have been injected. But if Von Bülow used insulin to inject his wife, he would have had to keep it refrigerated. But where? The maid saw the bottle of insulin in the bag, but neither she nor anyone else saw insulin in any of the refrigerators of the Von Bülow households. There appeared to be no solution to the mystery.

  5

  Free on bail set at one million dollars (which he was able to raise easily) but with his passport revoked, Claus von Bülow appealed the verdict of his trial. Upon review of certain irregularities in the collection and the presentation of evidence used against him, he was granted a new trial, and in the early months of 1985, approximately three years after his conviction, the stage was set in Providence, Rhode Island, for what promised to be little more than a rerun of the nation’s most popular, real-life television soap opera. In theory, the facts of the case had not changed. The change was in the team Von Bülow had assembled for his defense, headed by Thomas Puccio, the brilliant attorney who had made his name as federal prosecutor in the Abscam trials.

  In those same intervening years, my own career had taken a dramatic turn when I was fired from my post as Chief Medical Examiner of Los Angeles County. My appeal was unsuccessful and I joined Los Angeles County—University of Southern California Medical Center as a pathologist and teacher. There, in one of the great hospitals of the nation, I was privileged to work with a superb staff of specialists in almost every field of medicine. And there, quite by chance, I met a man whose medical experience shed an entirely new light upon the Von Bülow case.

  As part of the medical center’s continuing search for excellence, a “grand round conference” is held each week in the auditorium of the hospital. Leading specialists present medical cases of unusual interest for discussion among the physicians present. And at one such conference, Dr. Francis Buck, chief physician in charge of anatomic pathology, presented the case of Willie Statum, a woman diagnosed as hypoglycemic who had died of excessive insulin. Later, he came to my office to discuss it in greater detail. Dr. Buck did not know of my interest in the Von Bülow case, but what he told me offered a possible answer to the unresolved mystery of who or what had caused Sunny von Bülow’s comas.

  Intrigued, I did further research of my own and wrote a chapter on the Von Bülow case in preparation for this book, although I knew it would be impossible to complete while Von Bülow’s retrial was still pending and his guilt or innocence had yet to be determined. But a few weeks before the second trial began, my collaborator, Joseph DiMona, who lives in New York, received a call from Herbert Fischer, a law partner of Thomas Puccio. It seemed that Puccio had heard of my research and wanted to know what I had uncovered.

  Puccio and DiMona met in New York, where DiMona found the trial attorney to be extremely businesslike—and extremely unlike most defense counsels he had ever covered at trial. Puccio possessed no deep hypnotic voice, no flowing locks of hair, no flamboyant charm to mesmerize a jury. Instead he evinced an incisive intelligence, and an apparent willingness to go to the ends of the earth to find evidence to assist his client’s cause. In this case, he persuaded us to let him see the unfinished chapter and, after reading it, flew immediately to California to interview me on the facts I had found. There I introduced him to Dr. Francis Buck, and we discussed a medical phenomenon that, I believed, might change the outcome of the new trial.

  That phenomenon can best be described in the conversation I had with Dr. Buck about the Willie Statum case as I had recorded it earlier. “Mrs. Statum had had a number of proven episodes of hypoglycemia in the past,” Buck told me. “When she was admitted to the hospital in 1980, she showed an astonishingly low blood sugar count. And when we administered glucose, her blood sugar count went down, instead of up. So we knew excessive insulin was in her blood.

  “In this case,” Buck continued, “there was no question of exogenous [injected] insulin. A poor black woman in her sixties, she told us on another occasion that she had never even heard of insulin. So we assumed that the hyperinsulin [excessive insulin] in her blood was caused by one or the other of the two classic causes: an insulin-secreting tumor in the pancreas or a liver diseased by alcoholism.”

  Dr. Buck performed the autopsy on Willie Statum. “Her liver was not diseased or damaged, so I examined the pancreas very closely—and no tumors were present.

  “In other words,” he continued, “here was a woman who died of excessive insulin, and there was neither of the two classic sources for that insulin—and no injection. Now, that was unusual but not unique at this hospital. In fact, I had studied a case which occurred a few years ago where a baby had died of hyperinsulin, again with neither of the classic natural causes and certainly no injection.”

  “In other words,” I asked Dr. Buck, “you think there’s another natural cause for excessive insulin that could result in death.”

  “I’m convinced of it, from my study of personal cases and a review of the literature,” Dr. Buck replied. “And I also believe I know what that other natural source is: islet cell hyperplasia.”

  As pathologists know, the pancreas serves two functions in the body’s mechanism. The bulk of the organ is made up of exocrene glands, which produce enzymes to aid digestion. Scattered among these glands are nests of cells called islets of Langerhans, which produce insulin to control the level of blood sugar. Islet cell hyperplasia, to which Dr. Buck referred, is a condition in which these islet cells increase in number. (“Hyperplasia” means more growth.)

  “I believe that in rare instances these islets start multiplying naturally,” Dr. Buck said, “and thus produce excessive insulin which pours into the blood, and the patient goes into a coma.”

  I then told him of my interest in the Von Bülow case and described what I knew of the circumstances surrounding Sunny von Bülow’s condition.

  “To all appearances,” Dr. Buck said, “Mrs. von Bülow’s case is almost identical to Mrs. Statum’s. Like Statum, she had previous hypoglycemic episodes, and like Statum s
he went into a coma and there was no source for the excessive insulin. No cancerous tumor, no diseased liver—and no exogenous source, if her husband did not inject her.”

  Could islet cell hyperplasia be the key to the mystery of the Von Bülow case—a hitherto unknown natural cause for Sunny von Bülow’s comas? That was the question I asked in my unfinished chapter. And I concluded that it was perfectly possible that she lapsed into her final coma from the same natural causes that struck down patients in Los Angeles. If that was indeed the case, Claus von Bülow was innocent.

  6

  When the second trial of Claus von Bülow began, it was clear that the prosecution intended to follow the same strategy pursued in the first trial: relying on the circumstantial evidence of the maid, Maria Schrallhammer, and of Von Bülow’s former lover, Alexandra Isles, but even more heavily on the medical evidence which, I believed, had been largely responsible for the original conviction. As for Puccio, his strategy was yet to be revealed. It was clear that he would have to shake the credibility of the circumstantial evidence where possible. But even more important, in my opinion, would be the necessity to cast doubt upon the prosecution’s medical evidence by summoning medical experts of his own. Dr. Francis Buck was among those witnesses whom he might call to the stand.

  As it happened, Puccio was able to score several important points in the cross-examination of prosecution witnesses, even before he began his case for the defense. When he was able to establish that Maria Schrallhammer had started saying that she discovered a bottle of insulin in the little black bag only after she heard about a laboratory report which said that insulin had been found in Sunny’s blood, a shadow was cast over the credibility of her entire testimony.