described by Addison, an English physician, some fifty years ago,
which develops in individuals whose suprarenal capsules are
degenerated. The suprarenal capsules are little bodies of half-moon
shape which lie above the kidneys. {156} Their degeneration produces a
great lowering of blood pressure. The patient becomes intensely weak,
muscular movement becomes impossible, intellectual processes cause
great fatigue, and finally blood pressure becomes so low that fatal
collapse ensues from lack of blood in the brain. The external symptoms
of these cases is a pigmentation, that is, a very dark discolouration
of the skin, which develops rather early in the disease. The tongue
especially becomes a very dark brown. Areas of pigmentation also occur
where the skin is irritated,--at the wrists from the irritation of the
coat sleeves, at the edge of the hair from the irritation of the hat.
Dr. S. Weir Mitchell, in his _Autobiography of a Quack_, has described
one of these cases very strikingly. The hero of the tale is found dead
one morning by the nurse in the hospital, after he has been feeling
quite as well as usual for some time.
It must not be forgotten that patients who are burned extensively very
frequently die shortly after the accident. A burn that involves more
than one-half of the body, no matter how superficial the burning may
be, will always have a fatal termination. Deep burns in one part,
unless it is some very vital part, are not so serious as extensive
superficial burns. Patients with extensive burns frequently remain in
encouragingly good condition for several days, and then have a sudden
change for the worse. Sometimes death takes place in coma. Sometimes
it takes place as the result of a perforation of the duodenum. These
perforations of duodenal ulcers may take place as late as a week to
ten days after the burn. They are always followed by symptoms of
peritonitis and the condition of intense prostration which this brings
on. Such cases need to be prepared for the worst after the first acute
symptoms of the burn have subsided, when a certain amount of peace of
mind is restored.
Cirrhosis of the liver not infrequently causes sudden death. Cirrhosis
is an affection in which a large part of the liver substance proper
degenerates, and its place is taken by connective tissue. It is
typically a disease of people of alcoholic habit. It occurs in those
who are engaged in the sale of spirits, though the alcoholic
absorption does not take place {157} through the skin, but in a much
more direct way. It is most frequent in people who take strong spirits
on an empty stomach. Those who are much exposed to changes of
temperature are especially liable to form such habits. It is found
most frequently in the drivers of wagons and cars, in policemen, and
in sea-captains, sailors, and the like. When cirrhosis causes sudden
death, it is nearly always by hemorrhage. The hemorrhage takes place
from the oesophagus, some of the large veins of which have become
dilated until the thin walls are unable to retain the blood. The
dilatation is due to interference with the venous circulation in the
liver.
Of late years pathologists and medical men, especially those who are
interested in children's diseases, have devoted considerable time to
the study of certain cases of sudden death, which have long been very
mysterious. Infants often die while in apparent good health without
any adequate reason that can be found, even on the most careful
autopsy. Children of an older growth sometimes die suddenly as the
result of some slight shock or fright, or they die after the
administration of a few whiffs of chloroform, given to help in the
performance of some simple surgical operation, or they die at the
beginning of some infectious fever which they ought to be able to
withstand without any difficulty. A distinguished pathologist at
Vienna, Professor Paltauf, who was the coroner's physician of the city
and had a large number of these sudden deaths to investigate, found
that in most of the cases one abnormal condition was constantly
present. This consisted in an enlargement of the lymph glands all over
the body. The lymph glands in the neck were involved, also the tonsils
and lymphoid tissue at the back of the throat, the series of lymph
glands in the groin, and, finally, there was a hypertrophy of the
lymphoid tissue that occurs all along the intestinal tract. This
condition of hypertrophy of lymphoid tissue has come to be known as
the lymphatic diathesis or constitution. It is nearly always
accompanied by a distinct hypertrophy of the thymus gland. The thymus
gland is an organ which occurs in the upper part of the thorax of the
child, but which atrophies and practically disappears after the age of
two years. In these cases it is from twice to three {158} times its
normal size in the infant, and in older children it is
persistent--that is, retains its primary size, though in the ordinary
course of nature it should atrophy. This lymphatic diathesis
undoubtedly has considerable to do with the sudden deaths which occur
in these patients. What the exact connection is we do not as yet
definitely know. Unfortunately, moreover, this lymphatic constitution
gives no sure sign of its existence before the occurrence of the fatal
termination. Enlargement of the glands of the neck and of the groin,
with some enlargement of the tonsils, occurs in delicate children
without necessarily being symptoms of the lymphatic diathesis. The
enlargement or persistence of the thymus can be better recognised, and
doctors now seldom fail to notice it. Where any suspicion of such a
condition exists in children of from eight to sixteen or seventeen
years of age, proper precautions must be taken to prevent sudden fatal
termination of any even mild disease without due preparation.
Undoubtedly many of the cases of sudden death under chloroform and
ether in children and young persons are due to the existence of this
lymphatic diathesis.
Diseases, like tuberculosis and cancer, that run a long but assuredly
fatal course, usually terminate unexpectedly. The tuberculous patient
particularly will almost surely be planning for next year the day
before he dies. This condition of euphoria, that is, of sense of well
being, was recognised as associated with tuberculosis as far back as
we have any history of the disease. Hippocrates pointed out as one of
the symptoms of consumption the _spes phthisical_ or consumptive hope.
If the patient has been very much run down, death may take place from
thrombosis of some of the arteries. If the thrombosis takes place in
the brain, consciousness will be lost, and the patient will often die
without recovering it. Patients often develop tubercles in their brain
as the result of a spread of the disease beyond the lungs, and then,
as a rule, death will take place in the midst of a paralysis, which
may be accompanied by loss of consciousness that lasts for several
days or a week or more.
Cancer patients also die suddenly, or at least unexpectedly, at the
end. Very often in them, as in tuberculosis, {159} thrombosis plays an
important role in the fatal termination. In cancer of the stomach,
peritonitis from perforation of the stomach may close the scene. The
fatal termination in cancer of the uterus is often brought about by
the development of uraemic symptoms. The new growth in the pelvis
involves the ureters, prevents the free egress of urine, and so causes
the retention in the system of poisonous substances that should be
excreted. Cancer in other parts of the body often causes death by
metastatic cancers, that is, offshoots of the original cancer which
occur in other organs. Usually these are in the liver, but sometimes
they are in the brain, and sometimes in the bones that surround the
spinal cord. In the course of their growth they cause pressure
symptoms upon the nervous system, and this leads to death. If patients
become very much weakened, as is not infrequently the case, thrombosis
occurs, and portions of the clots may be shot into the pulmonary
veins, and cause death in this way.
Two affections which are quite common, one of them usually involving
no danger at all, sometimes cause sudden death. They are varicose
veins and a discharging ear. Varicose veins are the enlarged veins
which occur on the limbs of a great many elderly people. If these
people become run down in health and then exhaust themselves by
overwork, the circulation through these enlarged veins is sometimes so
impeded that clotting--thrombosis, as it is called--occurs. If a
portion of the clot becomes detached, and is carried off into the
circulation, a so-called embolus, this may cause sudden death, either
by its effect upon the heart, or more usually upon the lungs.
Middle-ear disease causes death, either by producing an abscess of the
brain, or by causing thrombosis of some of the large veins within the
skull. The dangers involved in a discharge from the ear are now well
recognised. Insurance companies refuse to take risks on the lives of
persons affected by chronic otitis media, as it is called
scientifically. Such persons may run along in perfect good health for
years without accident, but a sudden stoppage of the flow may be the
signal for the formation of the brain abscess, with almost inevitable
death.
{160}
Certain severe forms of the infectious fevers are very often fatal.
These forms are popularly known as black fevers, that is, black
measles, black scarlet fever, etc. These fulminant forms occur
especially in camps, barracks, orphan asylums, jails, and the like,
where the hygienic conditions of the patients have been very poor, and
where the resistive vitality has, as a consequence, become greatly
lowered. The black spots that occur on such patients are really due to
small hemorrhages into the skin. The hemorrhages are caused by a lack
of resistance in the blood-vessels and by a change in the constitution
of the blood that allows it to escape easily from the vessels. Where
such cases occur, patients should be fully prepared for the worst As a
rule, the mortality is from 40 to 70 per centum.
Acute pancreatitis is a uniformly fatal disease, though fortunately it
is rare. It occurs much more frequently, however, than used to be
thought. It occurs in persons over thirty who have been for some years
addicted to the use of alcohol. The symptoms of the disease are severe
pain in the upper left zone of the abdomen, that is, above and to the
left of the umbilicus. This is accompanied by nausea and vomiting.
Collapse ensues and death takes place on the second to the fourth day
of the affection. This disease may have important medico-legal
bearings. Some slight injury in the abdomen, as from a blow or a kick,
may precipitate an attack in predisposed individuals. Accusation of
murder may result. The mental attitude of the physician and the
clergyman with regard to such cases must be very conservative. No
opinion as to possible culpability should be ventured.
Cholelithiasis, that is, stone in the bile duct, may not only cause
severe pain, but may lead to rupture of the duct and a rapidly fatal
termination. Owing to the practice of wearing corsets, gall-stones
occur much more commonly in women than in men. Twenty-five per centum
of all women over 60 years of age are found to have gall-stones. While
these cases suffer from intense pain they are very seldom fatal. But
it must not be forgotten that a fatal issue can take place either from
collapse and stoppage of the heart, because of the intensity of the
pain, or from perforative peritonitis.
{161}
The perforation of a gastric ulcer may cause symptoms which rapidly
place the patient in a condition in which the administration of the
Sacraments is very unsatisfactory. Gastric ulcers occur especially in
young women, usually in those who follow some indoor occupation. Its
favourite victims are cooks, though laundresses, seamstresses, and
even clerks in stores, suffer from it much more than those engaged in
other occupations. It occurs by preference in anaemic or chlorotic
women. Sometimes, however, as in the case of cooks, the patients may
seem to be in good health. Acute pain in the stomach region, followed
by symptoms of collapse, should in such persons be a signal for the
administration of all the Sacraments. Fatal peritonitis soon brings on
a state of painful uneasiness ill adapted to the proper dispositions
for the Sacraments.
Two diseases that are fortunately very rare, but which are almost
uniformly fatal, deserve to be mentioned here. In both of them the
symptoms of the disease are manifested through the nervous system.
They are tetanus and hydrophobia. Tetanus occurs as a consequence
especially of a wound which has been contaminated by the street dirt
of a large city, or the refuse of a farm. It follows deep wounds such
as are made by a hayrake or a pitchfork; or seared wounds, such as are
made by a toy pistol. A serum for the treatment of the disease has
been discovered, but unfortunately the first symptom of tetanus is not
the first symptom of the disease, but the preliminary symptom of the
terminal stage of the disease, the affection of the nervous system.
Practically all cases of acute tetanus terminate fatally. As soon as a
patient exhibits the characteristic symptoms, the lockjaw, the stiff
neck, and the rigid muscles, all the Sacraments should be
administered. In tetanus, as a rule, consciousness is preserved until
very late in the disease. In severe cases, however, a convulsive state
of intense irritability develops in which the slightest sound or
effort brings on a series of spasmodic seizures. Patients must be
prepared, then, early in the disease, if possible.
Rabies or hydrophobia is a disease which claims a certain number of
victims every year in our large cities. {162} Its symptoms are the
occurrence of fever and disquietude, with spasmodic convulsions of the
muscles of the throat whenever an attempt is made to swallow. These
symptoms come on from three to fifteen days after the bite of a mad
dog. Unless the Pasteur treatment has been taken shortly after the
bite of the animal was inflicted, no treatment that present-day
medicine possesses is able to affect the course of the disease, and
patients nearly always die. Their preparation, then, is a matter of
necessity as soon as the first assured symptoms of the disease show
themselves. [Footnote 4]
[Footnote 4: One cannot help but add a word here as to the cause of
the disease, because clergymen can by their advice do something to
remedy the evil which lies at the root of the infliction.
Hydrophobia is due to stray dogs. In practically every case the
fatal bite is inflicted by some animal that no one in the
neighbourhood claims. Bites by pet dogs are rarely fatal. If
clergymen would use their influence to suppress the dog nuisance we
would soon have an end of hydrophobia.]
Alcoholic subjects are very liable to unexpected death from a good
many causes. Patients suffering from delirium tremens, for instance,
may die suddenly in the midst of a paroxysm of excitement. Such a
termination is not frequent, but it has occurred often enough to make
it the custom, at asylums for inebriates, to warn friends who bring
patients of the liability of such an accident. It is not so apt to
happen during a first attack of delirium tremens as during subsequent
attacks. It is most frequent among those whose addiction to alcohol
for years has caused repeated paroxysms of delirium tremens. The cause
of the sudden death is usually heart failure. This term means nothing
in itself, but it expresses the fact that a degenerated heart finally
refuses to act. Alcoholic poison in the circulation has led to fibroid
degeneration of the muscular elements of the heart and made them
incapable of proper function, or at least has greatly hampered their
action, and the heart ceases to beat.
It must be borne in mind that chronic alcoholism makes a number of
serious organic diseases run a latent course. The patient is apt to
attribute his symptoms to the after effects of the abuse of alcohol.
Unless the doctor who is called in makes a very careful examination,
serious kidney disease or even advanced pneumonia may not be
discovered. Alcoholic subjects bear pneumonia very badly, and the
preliminary {163} symptoms of the disease are often completely
concealed by the symptoms due to the patient's alcoholism. Other
infectious diseases, as typhoid fever, tuberculosis, and even various
forms of meningitis, may run a very insidious course and give but very
slight warning of their presence. The result is that these diseases
are very frequently fatal in alcoholic subjects.
Old inebriates bear operations badly, and the mortality after any
operation in such subjects is distinctly higher than in normal
individuals. One reason for this is that considerably more ether or
chloroform is required to produce narcosis in alcoholic subjects than
in ordinary individuals. Ether and chloroform are very irritant to the
kidneys. The kidneys are prone to be affected more or less in old
alcoholic subjects. Death from oedema of the lungs or from some form
of pneumonia is not infrequent in these post-operative cases, and
gives as a rule but little warning of its approach.
It is clear, then, that alcoholic subjects must be prepared with
special care whenever disease is actually present or an operation is
to be performed. Too great care can scarcely be exercised in their
regard. What would seem overcaution will save many a heartburn to
friends and priest, for it is in alcoholic subjects especially that
some of the saddest cases of unexpected death without preparation
occur.
JAMES J. WALSH.
{164}
XIII
THE MOMENT OF DEATH
It not infrequently happens that a priest reaches a patient who has
just died. Conditional absolution, baptism, or other spiritual
ministration might have been offered if there were signs of life, but
the heart and lungs are still, "the patient is dead," and the priest
leaves the place without doing anything. Yet the patient may not
really be dead.
Our knowledge of the precise time the soul leaves the body is very
imperfect. There is, we are aware, a close connection between the
vital functions of the body, taken together or singly, and cellular
activity. If the cells are not destroyed, a vital function sometimes
may be restored after its cessation, but if the cells are destroyed up
to a certain extent, the vital function is not recoverable. For
example, if the various bodily cells of a patient dead from diphtheria
are examined microscopically, it will be found that the diphtheria
toxin has disintegrated the nuclei of these cells. What number of
cells proportionate to the whole in, say, the heart should be
destroyed before the vitality of that organ is lost, is not clearly
known. Where the cells are intact, or nearly so, mere absence of
respiration, or of even the heart movement, are not absolute proof of
death. Numerous cases are found in medical records of persons that had
been lying under water for many minutes, up to even an hour, but who
were restored to life by patient and skilful efforts; and of late
remarkable restorations after what was practically death, under
anaesthesia and otherwise, have been reported. The technique consists
chiefly in rhythmical compression of the heart, commonly after
surgical exposure of that organ, with artificial respiration, and, in
Crile's method, peripheral resistance is {165} employed to raise the
blood pressure. Ludwig in 1842, experimented in cardiac massage, and
Professor Schiff at Florence was the first to apply the method to
human subjects. Kemp and Gardner, in the _New York Medical Journal_,
May 7, 1904, described various methods used in attempting
resuscitation.
Professor W. W. Keen of Philadelphia has collected the records of the
chief cases of resuscitation after apparent death (see _The
Therapeutic Gazette_, April, 1904), and some of these are the
following: Dr. Christian Igelstrud of Tromsoe, Norway, in 1901, was
operating upon a woman, 43 years of age, for cancer. During the
operation, which was a coeliotomy, she collapsed and her heart ceased
beating. After the usual means for resuscitation had been
ineffectively tried, her heart was laid bare. Igelstrud took hold of
the heart with his hand and made rhythmic pressure upon it. In about
one minute the heart began to pulsate. The patient was discharged from
the hospital five weeks afterward.
Tuffier (_Bull, et mem. soc. de chir._, 1898, p. 937) in 1898 had a
patient whose heart stopped after an operation for appendicitis. The
surgeon had left the operating room, but he returned, laid bare the
heart, pressed it rhythmically, and after two minutes it began to move
again. The patient breathed regularly, his eyes opened, the dilated
pupils contracted, and he turned his head. After the opening over the
heart had been closed, however, he died.
Prus (_Wiener klin. Woch._, no. 21, 1900, p. 486) by the same method
started contractions of the heart after 15 minutes in a man that had
hanged himself. The effort at resuscitation was made two hours after
the suicide had been discovered, but the recovery did not go beyond
imperfect movements of the heart, which gradually ceased.
Maag (_Centralbl. f. Chir._, 1901, p. 20) reports the case of a man
who under chloroform anaesthesia ceased breathing and whose heart
stopped. After 10 minutes the patient was pulseless, without
respiration, cyanotic, and cold. The heart was exposed and compressed
rhythmically; it was restored to action, and he began to breathe. He
remained alive for 12 hours, seemingly asleep; then he died.
{166}
Starling and Lane (_Lancet_, Nov. 22, 1902, p. 1397) were operating
upon a man 65 years of age. The heart and respiration ceased. Lane put
his hand into the abdominal incision and squeezed the heart through
the diaphragm. After twelve minutes of artificial respiration the
lungs and heart began to act. The patient afterward was discharged
from the hospital cured.
Sick (_Centralblatt f. Chirurgie_, Sept. 5, 1903, p. 981) reports a
very remarkable case. A boy of 15 years of age died upon the operating
table. _Three quarters of an hour_ after the heart had ceased to beat
it was laid bare. The flaps did not bleed, the pericardium was
bloodless, the heart was motionless, relaxed, and cold. After a
quarter of an hour, during which the heart was compressed, and
artificial respiration was kept up, that is, one hour after what any
physician would call death, the heart was beating and respiration was
restored. Two hours later the boy became conscious and complained of
great thirst and dyspnoea. He remained in this condition for
twenty-seven hours, and during that time his speech was indistinct but
intelligible. He then died.
Dr. George W. Crile, of Cleveland, Ohio, reports the case of a woman
whose heart movement and respiration had ceased for six minutes. She
was restored completely, even without exposing the heart. Dr. Crile
uses an inflated rubber suit on the patient to raise the blood
pressure by peripheral resistance--he does not expose the heart. He
had another case, a man 38 years of age, who "died during operation,
was resuscitated, and died again two hours later."
Two Hungarian labourers, whose skulls had been crushed in the same
accident, were brought into Dr. Crile's clinic in a dying condition.
The heart of one of these men ceased beating as he was brought into
the operating room. After nine minutes the surgeons began to work upon
him to resuscitate him. They succeeded, but he lived for only 28
minutes.
They then examined the other man and found him dead. Just 45 minutes
after this second patient had been brought into the operating room the
effort to resuscitate him began. As he had not been observed while the
physicians had been engaged with the first man, they do not know when
his heart {167} had ceased to beat, but he certainly was dead in the
opinion of skilled observers. They resuscitated him so well that he
moved his head away from the operator who was relieving the depression
of the skull, but he died again in 34 minutes.
These cases are not what is commonly called conditions of suspended
animation. All the patients would have been pronounced dead by any
physician, and if they had been left untouched, they surely never
would have been revived.