In such cases of sudden death, from the operation of violent mental emotions, we apprehend that dissection will frequently demonstrate the existence of previous disease in some of the organs immediately essential to life; and we shall hereafter have occasion to refer to the influence of the passions in hastening the fatal termination of a chronic disease; on the present occasion we introduce the following extremely interesting case, in confirmation of the position we are endeavouring to maintain; the case was originally published in the Transactions of the Physico-Medical Society of New York, by Dr. Valentine Mott; it afterwards appeared in the Journal Universel des Sciences Medicales, Avril, 1819; and lately it has found its way into the Medical Repository of this country. A robust and plethoric female, aged 22, long addicted to dissolute and intemperate habits, had complained for some time of slight and apparently rheumatic pains; but within a day or two of the fatal event, she had been deserted by a man to whom she was engaged in marriage; in consequence of which her mind became very deeply affected; after having supped on the preceding night, she retired to rest as usual, and in the morning was found dead in bed; she lay in a bent position on the left side; and was hence supposed at first to be in a profound sleep; neither the countenance nor the limbs were in the least distorted. On dissection the pericardium was found to contain ten ounces of coagulated blood, and two of serum; the heart on all sides being covered by it, was of ordinary volume, but much loaded with fat; at the summit of the aortic ventricle was discovered the breach from which the effused blood had issued; the parietes of the ventricle around the rupture were much thicker than in the natural state, and on close examination a very sensible fluctuation was distinguished, to the extent of an inch on one side of it, from which flocculi of a cheese-like substance were discharged on pressure; the pericardium also presented traces of inflammation.
We have here then a case in which a morbid change in the structure of the heart had existed for a considerable period, and which was suddenly brought to a fatal termination by an affection of the mind.
Before we quit the consideration of Syncope, we have to notice a fatal variety of that disease, which well deserves the attentive consideration of the forensic Physician, whose highest duty, let it be remembered, is the investigation of sudden death. It is described by Mr. Chevalier[[24]] under the term Asphyxia Idiopathica, in which the patient suddenly faints and dies; the essential circumstances of the disease evidently denote, says Mr. Chevalier, a sudden loss of power in the extreme vessels to propel the blood; in consequence of which the heart after having contracted, so as to empty itself, and then dilated again, continues relaxed for want of the return of its accustomed stimulus, and dies in that dilated state. On dissection all the cavities of the heart are found completely empty, and the viscus itself in a state of extreme flaccidity.
SUFFOCATION.
Suffocation may be defined, the destruction of life by the suspension of the function of respiration, occasioned by external violence. Unless we add “by external violence” we shall perceive that the definition would be far too comprehensive; and the term Suffocation would be made to embrace a much wider range of subjects than its popular acceptation would allow. If the physiological views be correct which we have adopted and explained in the foregoing section, “On the causes and phenomena of sudden death,” we should be compelled, without such a protecting adjunct, to include under the history of Suffocation, not only the phenomena of Drowning, Strangling, Hanging, Smothering, and noxious inhalation, but even those of Apoplexy, fatal Intoxication, and various diseases of the brain and spinal marrow, together with the effects of a great proportion of Poisons; for by such agents death is undoubtedly occasioned through the failure of the respiratory functions.
In Death from Suffocation the heart continues to pulsate for several minutes after the breathing has entirely ceased, in consequence of which the blood which passes through the pulmonary vessels no longer receives the influence of oxygen, and therefore black blood circulates; the brain, it would appear, soon feels the want of the florid arterial stream, by which alone its energies can be maintained. Bichat has shewn that when dark coloured blood is injected into the vessels of the brain, by means of a syringe connected with the carotid artery, the functions of the brain become immediately disturbed, and, in a short time, entirely cease; the effect is precisely similar, whether the dark coloured blood be transmitted to the brain by the syringe of the experimentalist, or by the heart itself. It is not until after the full effects of the suspended respiration are thus produced on the brain, that the motions of the heart become enfeebled, and that the ventricles contract less powerfully, and at longer intervals; at length, the action of the heart is altogether arrested, and if the thorax be examined at the instant that the circulation has ceased, nothing is observed, except a slight tremulous motion of the auricles; the cavities of the left side are much contracted, and contain only a small quantity of blood, while the right auricle and ventricle, and the large vessels communicating with them, are distended to an unusual size. This state of the heart, it will be observed, is very different from that which we have described as constantly occurring after Syncope. In the contemplation of these phœnomena, a question very naturally suggests itself in regard to the probable interval which elapses between the cessation of respiration, and the consequent failure of the heart’s action; in other words, it may be asked, how long can the heart support its contractions without the aid of respiration? It would appear that this interval not only varies in duration in different animals, but even in the same animal under different circumstances, such as that of age,[[25]] capacity of the thorax, quantity of air in the lungs, state of the stomach, and general vigour of the animal; but in man, under the most favourable circumstances, it is extremely doubtful whether the heart ever continues to pulsate for so long a period as five minutes[[26]] after the lungs have ceased to perform their office; and it is very questionable whether, in most instances, the interval is not considerably shorter than this.
BY DROWNING.
It was formerly believed that Asphyxia[[27]] from drowning, always depended upon the lungs and intestinal canal being filled with water;[[28]] whereas it is hardly necessary to observe that it alone depends upon the blood, in consequence of the suspension of breathing, ceasing to possess the qualities which are essential to the preservation of life. M. Gauteron immersed a dog for more than a quarter of an hour, without inflicting the least injury, having previously inserted a long tube in the trachea, which was kept elevated during the experiment above the surface of the water.
If a small animal be immersed in water, contained in a transparent glass vessel, the phenomena of drowning are readily discernible; there is first a deep expiration, by which bubbles of air are expelled from the lungs; there is then an effort to inspire, but the effort is ineffectual; there being no air which can be received into the lungs, and a spasm of the muscles of the glottis seems to forbid the admission of any considerable quantity of water into the trachea. The attempts to breathe are repeated several times, and at each attempt at expiration a small proportion of air is expelled from the mouth and nostrils, until the air-cells of the lungs are almost emptied;[[29]] then the animal becomes insensible; and convulsive action of the voluntary muscles mark the instant when the brain begins to suffer from the influx of the dark coloured venous blood. After the cessation of these convulsive actions, the animal becomes motionless, and gives no sign of life; but if the hand be applied to the thorax, the actions of the heart, gradually becoming fainter and fainter, indicate that some remains of vitality still linger in the system. Before the circulation of the blood altogether ceases, the muscles of respiration once more resume their actions, and ineffectual efforts are made to breathe. It is a remarkable circumstance that the diaphragm continues to exert itself nearly as long as the heart itself, and that the interval between the cessation of the motions of the diaphragm and that of the motions of the heart, which is so short in animals that die by strangulation, is still shorter in those who perish by drowning.[[30]] These phenomena follow each other in rapid succession, and the whole scene is closed, and the living animal is converted into a lifeless corpse, incapable of recovery, in the brief space of a few moments, (Brodie’s Manuscript Notes). If however the animal be taken out of the water before the total extinction of life, and the diaphragm contract afterwards, so as to draw air into the lungs before the action of the heart has ceased, the circulation is maintained, and the animal continues to respire; he will thus have escaped immediate death from suffocation; but his life still remains in jeopardy, for there is a second period of danger, and one at which death may take place, when we are the least prepared to expect it; for the dark coloured blood which has been transmitted through the circulatory system, during the suspension of respiration, would seem to act like a narcotic poison upon the brain; no sooner therefore does it enter that organ, but deleterious effects are produced, the animal at first falls into a state of stupor, the pupils of the eyes become dilated, the respiration laborious, the muscles of the body convulsed, and the animal dies, poisoned by its own blood.
The body of a person who has died from drowning exhibits a physiognomy which it is important to notice. The whole surface is distinguished by a remarkable coldness and pallor; the eyes are half open, and their pupils considerably dilated; the tongue is pushed forward to the internal edges of the lips, and sometimes wounded; and the mouth and nostrils are covered with foam. At other times, instead of a pallid visage, we have one that is swelled, and bloated with livid blood.