Agony

AGONY (from Greek agon-struggle), a state preceding the onset of death and externally representing a kind of struggle between life and death. The higher centers of consciousness at this time are already completely or almost completely paralyzed, while the work of the heart and breathing still continue to some extent. Agony is by no means expressed in all cases of gradual dying, but only when there are symptoms of excitation of the neuromuscular system, which actually creates the impression of a struggle. In reality, there is no struggle as such at this time, it has already ended, and before us is a slow, apparently painful dying with the simultaneous extinction of individual organs and systems. The appearance of the dying person changes sharply at this time: the lower jaw hangs down, the cheeks collapse, the nose appears to sharpen depending on the redistribution of blood, and along with it lymph, which normally creates the elastic appearance of tissues, the cornea of the eye loses its transparency, the face becomes earthy-colored, which in combination gives the face a special expression (so-called facies Hippocratica - after Hippocrates, who described it in detail); cold clammy sweat appears on the skin; movements become trembling; sphincters are paralyzed often earlier than the muscle groups controlling peristaltic movements, as a result of which conditions are created for the involuntary discharge of urine and feces; in other, rarer cases, there is instead a delay in urination and bladder distension (in cerebral agony - see below); the paralysis of the muscles controlling peristalsis, in turn, leads to the so-called atonal invagination of the intestine, especially in children suffering from intestinal colic; breathing becomes difficult and wheezy; in the lungs, edema often occurs, mostly of mechanical origin, due to the earlier weakening of the left ventricle of the heart compared to the right and the resulting stagnation of blood in the pulmonary circulation, but sometimes toxic factors are also involved here (increased vascular permeability in infections, uremia); mucus accumulates in the bronchi, which cannot be expelled due to the weakening of the corresponding muscular mechanisms, which together with the accumulation of edematous fluid in the lungs, when expectoration is impossible, makes breathing rattling and causes what is known as the death rattle (stertorous breathing). The pulse is not always uniform, in most cases it becomes frequent but weak and thread-like: the first depends on the decrease in tone of the vagus nerve, both direct and secondary - on the basis of decreased blood pressure, and the second - from the weakening of the left ventricle of the heart. Body temperature in some cases decreases by 1-2° during agony (especially rapid cooling of the body with the so-called gooseflesh appearing on it is observed in acute and significant blood loss - external and internal), apparently due to decreased oxidative processes, in others it is, on the contrary, increased, and even quite significantly - up to 40° and more, and moreover not only during agony but also after death. The latter is usually observed in cases when agony is preceded by diseases accompanied by significant heat production (diseases with high temperature, especially tetanus, etc.), and must be explained by the delay in heat release by the body, depending mainly on the sharp slowing of peripheral circulation. Of the senses, smell and taste disappear first, then sight, and only later hearing. As can be seen, the clinical picture of agony in different cases is different, depending on the underlying condition and other reasons. In this respect, the following three types of agony can be distinguished (Popov): 1) cardiovascular, characterized mainly by the decline of cardiac activity and the fall of vascular tone with increased pulse and respiratory movements, decreased blood pressure and gradual decrease in body temperature (peritonitis, sepsis, cancer, etc.); 2) rarely occurring cerebral type, representing a progressive decline, mainly of the functions of the central nervous system and accompanied, in addition to loss of consciousness, by pathological modifications of respiration (Cheyne-Stokes, Kussmaul), with relatively good pulse for a long time [the latter is often slowed, depending on the underlying disease (meningitis)] and blood pressure and with increased temperature, and 3) mixed type, often occurring and characterized by progressive weakening of all three main vital functions - cardiovascular, respiratory, and cerebral. As for the blood, during agony the appearance of the so-called atonal leukocytosis is noted, which at first was considered very constant, almost physiological, and not depending on the disease that led to death. But then a connection was established between its appearance, duration, and nature of the disease. In earlier stages of agony it is neutrophilic in nature with a 'shift to the left', later there is an even greater 'rejuvenation' of the leukocyte formula, and finally, just before death, the blood picture becomes extremely polymorphic due to the appearance of the most diverse forms of both leukocyte and erythrocyte series, among which there are many young, partly degenerative forms: myeloblasts, Rieder's erythrocytes, polychromatophils, normoblasts, etc. The cause of this is considered to be the mechanical washing out of leukocytes from the bone marrow, which has lost the ability to retain them due to impaired innervation. At the moment of agony, some (Ribbert) also attribute the formation of blood clots found after death in corpses, although this is categorically disputed by Aschoff and Marchand and partially, as an initial stage, recognized by other researchers. But marantic thrombi and infarcts of various organs can be attributed to the pathological anatomy of the atonal period, as well as the miliary hemorrhages found in the mucous membranes of some organs at autopsy, especially in the most acute forms of agony, on the basis of rapidly developing venous stagnation in them. Among the factors acting during agony, along with moments caused by the underlying disease, a certain role should apparently be attributed to acid self-poisoning, due to severe disturbances in the area of metabolism. The duration of agony varies in different cases: from several hours to several days, but most often - no more than two days. The moment of the end of agony and the onset of death is usually considered the last heartbeat, but since ultimately the fatal outcome results not only from the stopping of the heart but also from the paralysis of the respiratory center, with equal right the end of agony could be considered the last breath. And indeed, in a number of cases, for example, in animals in a state of anaphylactic shock, the heart continues to beat for a few more moments after breathing has stopped and the organism has died. In general, after the death of the individual as a whole, individual tissues and organs (except for the centers of higher nervous activity) continue to live for a certain time. This is proved both by experiments on growing tissues taken from a fresh corpse (in so-called tissue cultures outside the organism) and the functioning of whole organs isolated from the rest of the body (provided they are placed in a medium of appropriate temperature and washed with a saturated oxygen Ringer-Locke solution), and by observations on the revival of a just-stopped heart with the help of the same solution with the addition of adrenaline (experiments by Geibel, Locke, Bocharov, Kulyabko, Andreev). The possibility of reviving the heart under such conditions indicates that in the agonal period the gradual decrease in the work of this organ in many cases should be attributed not to its exhaustion in the strict sense of the word, but to its poisoning by metabolic products. A more in-depth study of a number of issues related to agony, besides purely scientific interest, would not be without practical significance to some extent, in terms of the possibility of sometimes preserving consciousness in the dying person for a longer time where this is dictated by special indications, and especially in terms of more skillfully alleviating his suffering, creating a painless death, so-called euthanasia, although we have at our disposal an arsenal of pain-relieving means at the present time.