MODES OF DYING

Syncope—death beginning at the heart.
Asphyxia—death beginning at the lungs.
Coma—death beginning at the brain.

Syncope.—From δνγκοπτω, I strike down. Sudden arrest of the action of the heart.

This condition may be brought about by

Causes—Heart Disease.—Aortic regurgitation, fatty degeneration, &c.

Hæmorrhages from wounds of blood-vessels or the heart, profuse hæmoptysis or hæmatemesis, uterine hæmorrhage, bursting of varicose veins, bursting of aneurysms.

Shock.—Emotion; blows on the head or epigastrium; sudden evacuation of fluids from the body, as in emptying an over-distended bladder, tapping a hydrocele, ascites, or a pleural effusion. Extensive injuries to the body (railway and machinery accidents). Drinking large quantities of cold water when heated.

Exhaustive diseases, chronic or infective.

Symptoms.—Pallor of the face and mucous membranes, dimness of vision, cold perspirations, sense of impending death, restlessness, air hunger and gasping for breath, nausea, and, maybe, vomiting, noises in the ears, passing delirium, quick, feeble, and fluttering pulse, or the latter may be imperceptible at the wrist, insensibility, convulsions.

In ordinary fainting attacks many of the above symptoms are absent; such as are present are temporary. In collapse, consciousness is retained.

Post-mortem Signs.—The cavities of the heart contain a normal quantity of blood in death by asthenia, but may be almost empty when death is due to anæmia. The blood in asthenic death is simply arrested in its course; blood is, therefore, found in the large veins and in the arteries. The brain and the lungs are not engorged with blood.

Asphyxia.—From ἀ priv. et δφνξιϛ, pulse. Apnœa is the better term—ἀ priv. et πνεω, I respire; but this word is now used by physiologists to denote a cessation of the respiratory movements due to artificially oxygenated blood. Blood in this condition fails to excite the respiratory centre in the medulla, and respiration ceases. To avoid confusion the term asphyxia had better be retained, especially as it is most commonly used and generally understood. Asphyxia, or death from defect in the quality of the blood, is brought about when any impediment is placed on the healthy action of the lungs. Experiment has shown that for a short time after respiration has ceased, the heart still continues to act, and that if the impediment to the proper aeration of the air by the lungs be removed, life may be prolonged. Taking therefore the primary meaning of the terms asphyxia and apnœa into consideration, it may be remarked that the latter precedes the former in point of time—asphyxia marking the period at which the action of the heart ceases, apnœa the cessation of the respiratory functions.

Causes of Asphyxia.—1. Mechanical obstruction to the air passages: foreign bodies, exudations, tumours, suffocation, strangulation, drowning, hanging, spasm of glottis from mechanical irritation, or irritant gases.

2. Interference with the action of the respiratory muscles: exhaustion of the muscles from cold; paralysis of muscles from injury to or disease of respiratory centre; poisons acting on the centre; continued pressure on walls of the chest; fixation of muscles from tetanus or strychnine poisoning.

3. Diseases of and injuries to the lungs: pleurisy with effusion, acute pneumonia, empyema, pneumothorax, pyopneumothorax, pulmonary apoplexy, embolism of pulmonary artery.

4. Inhalation of air deficient in oxygen.

Symptoms of Asphyxia.—Divided into three stages. First stage: deep, frequent, and laboured respiration; the extraordinary muscles of respiration are called into play. Second stage: the inspiratory muscles are less active than expiratory, convulsions of nearly all the muscles of the body occur. Third stage: paralysis of respiratory centres, dilated pupils, loss of consciousness, absence of reflexes. Gasping inspirations with prolonged intervals precede dissolution.

Post-mortem Signs.—Engorgement of the pulmonary artery, the right cavities of the heart, and vent cavæ; but on the left side of the heart the cavities, together with the aorta and pulmonary veins, are either empty or contain but little blood. It must be remembered, however, that cases of asphyxia do sometimes occur where the cavities on each side of the heart are empty, or nearly so. This is the case in the syncopal asphyxia of some writers. If also the obstruction to respiration be imperfect, the circulation may be continued for some time, congestion of one or more of the internal organs being the result. The blood is dark-coloured, contains much CO₂, and the hæmoglobin is almost completely reduced. The blood coagulates slowly.

Coma.—Insensibility ending in death. Causes.—Concussion of the brain, cerebral hæmorrhage, embolism, thrombosis, tumour, depressed fracture of skull, meningitis, and serous effusions; effects of poisons such as opium, alcohol, ptomaines, arsenic, barium, oxalic and carbolic acids; in certain diseases of kidneys and liver, uræmia, cholæmia, acetonæmia, profound anæmia, e.g. pernicious, and as a terminal stage to acute or chronic diseases.

Symptoms of Coma.—Coma is generally preceded by stupor, from which the patient may be roused to a certain extent, but only temporarily. The reflexes in this stage may be exaggerated, and the power of swallowing fluids may be retained. When coma is present there is complete abolition of consciousness, sweating, the patient is powerless, the breathing stertorous. The temperature may vary according to the cause; normal or subnormal generally, it may rise in lesions of the pons Varolii. The pulse is generally full and bounding, the pupils dilated or contracted and insensitive to light, the conjunctival reflex absent. Mucus collects in the air-passages and causes “the death rattle,” and the breathing becomes more and more embarrassed and irregular. The reflexes are lost, and the sphincters relaxed.

Post-mortem Appearances.—Causal lesions are found in the brain or other organs; there is usually hyperæmia of the brain and spinal cord and their membranes, unless there be profound anæmia preceding death. The condition of the heart and lungs is not constant; the general appearances resemble those in death from asphyxia.

Table giving the Diagnosis of Several
Forms of Insensibility

Injury to the Head—Concussion of the Brain.—The symptoms are very similar to those of shock, with unconsciousness, but it may be possible to rouse the person. The pupils are equal and dilated or contracted, and react sluggishly to light. The breathing is shallow and slow with sighing, the pulse feeble. The muscles are relaxed but not paralysed. Vomiting and involuntary micturition and defæcation may occur. The temperature is usually subnormal.

Cerebral Compression.—This, when due to injury, is usually associated with fracture of the skull and hæmorrhage. Insensibility is complete, the person cannot be roused. The pupils may be unequal, contracted or dilated, and may not react to light. The breathing is slow, stertorous, and may be irregular, or Cheyne-Stokes in type. The pulse is full and bounding, the cheeks are blown out during expiration. Paralysis, rigidity, or convulsions may be present on one side of the body. There may be retention of urine, with overflow incontinence.

In cases associated with severe fracture or hæmorrhage within the skull, the conjunctivæ may be chemosed, or there may be hæmorrhage from the nose or ear; and a flow of cerebro-spinal fluid may take place from the nose.

Alcohol.—In coma due to alcohol, there will be an alcoholic odour of the breath, alcohol in the stomach contents, and it can be detected in the urine. The odour of alcohol in the breath may be due to the administration of alcohol by an outsider at the onset of the symptoms which have ended in the coma. The pupils are equal, contracted, the conjunctival reflex present, and the pupil dilates on pinching the skin of the neck. The pulse is rapid, at first strong it becomes feeble, the respirations snoring. If the coma be not complete, muscular inco-ordination may be noticed. The person can usually be aroused by stimulation.

In pure alcoholic coma the presence of the special features of coma from other causes will be absent. It must be remembered, however, that alcoholic coma may be combined with other kinds, and the more serious form should be kept in mind. Where there is the slightest doubt in the diagnosis, one‘s procedure should be ruled by the possibility of the graver cause.

Opium or Narcotic Poisoning.—The skin is usually perspiring freely, moist and cold; the countenance placid, pale and ghastly, the lips livid. The eyes are heavy, and the pupils contracted to a pin-head and equal, the conjunctival reflex usually present. There is the odour of opium in the breath. The pulse is slow, and the respiration stertorous and slow. There is no paralysis, and the person can be momentarily roused by a sharp question or blow.

Apoplexy.—The person is with difficulty, if ever, temporarily aroused. The face is red and bloated. Respiration suspirious and stertorous, and there is often Cheyne-Stokes breathing. The pupils are dilated or irregular; in pontine hæmorrhage, contracted. The temperature may at first be subnormal but gradually rises.

There may be rigidity of the limbs, or hemiplegia. The pulse is full and bounding, often of high tension with hardened arteries.

Albuminuria may be present.

Uræmia.—This is less profound than in cerebral hæmorrhage; the patient may be temporarily aroused; the onset is usually gradual. There is albuminuria with casts; albuminuric retinitis may be present. The pupils may be contracted or dilated. The breath has a peculiar so-called “uræmic odour.” The pulse is generally slow, the tension high, and the heart enlarged. The respirations are slow and sighing, and may be Cheyne-Stokes in type. There is no paralysis. There may have been preceding convulsions, and the coma may alternate with these attacks.

Anasarca may be present.

Diabetic Coma.—This may come on suddenly, and may occur unexpectedly in a person in whom diabetes has not been discovered up to the time of coma. There is sighing respiration, “air hunger.” The odour of acetone in the breath is present, and sugar in the urine.

Epilepsy.—Unconsciousness is profound, and comes on immediately with rigidity, followed by convulsions, unilateral, limited to the side of the face, jaws, head and neck or arm, or generalised. Bloody froth exudes from the mouth, the tongue being bitten. The eyes are wide open, the pupils dilated and insensible to light. Micturition may occur. After the convulsive attack has passed off, post-epileptic coma may remain, though usually for a short time only.

Syncope.—This has been described under modes of dying ([p. 38]).

In all cases of coma when first seen examine the head for signs of injury, note the odour of the breath, observe the state of the pupils and their reactions, examine the limbs for paralysis, count the pulse and note its character, and the state of the arteries, note the size of the heart and auscultate it at each area. Count and note the character of the respirations, take the temperature, examine the urine, take note of the person‘s age, and inquire into the previous history.