Sudden Death

SUDDEN DEATH, or instantaneous death, represents a type of death that occurs within several minutes or even seconds; thus, the agonal period in S.D. either completely absent or reduced to a very brief period of uncoordinated reflex movements. However, depending on causal factors, the consciousness of such dying individuals may be preserved for some time, they do not lose the ability to make elementary movements, the ability to speak, etc. S.D. most often affects people appearing in complete health, but can occur as a completely unexpected, mysterious outcome of various diseases, especially during the convalescent period; it is observed at very different ages. The basis of S.D. lies either in so-called paralysis of the heart (see) or paralysis of respiration (respiratory center). Proper paralysis of the heart may be preceded by a state of collapse, shock (see). Being a frequent object of investigation by forensic experts (such cases are often autopsied in the regular course by the pathologist), S.D. requires a special approach in this investigation to resolve two questions: 1. What objective data from external and internal examination of the corpse actually indicate S.D.? 2. What pathological changes underlie this case of S.D.? The first question is sometimes raised in cases where data from preliminary investigation concerning the pre-death period are absent or not worthy of trust. Finding the deceased in their usual environment, engaged in their usual occupation or in a position that excludes the possibility of a serious condition before death, speaks in favor of S.D. A doubtful sign of S.D. is the freshly shaven face of the deceased; one must observe seriously ill patients with a very prolonged preagonal period and at the same time finding in themselves the strength to make such a toilet; this is especially often encountered in consumptive patients. In general, there are no absolutely precise morphological data on which a diagnosis of S.D. could be made at autopsy. Nevertheless, based on autopsy data, it is often possible to make a logical conclusion about undoubtedly former sudden death, when, for example, such changes in organs are found in which continuation of life even for the shortest time is absolutely impossible. In conclusions of this kind, however, great caution must be observed, as cases of non-sudden death are observed with very severe damage to even such organs as the heart, brain. The greatest practical importance lies in clarifying the causes of S.D. The most important causes of S.D. are: 1. Traumas accompanied by severe damage to organs necessary for life (brain, large vessels, heart); this also includes contusions, action of electric current, concussion of the brain. Rarely is fatal psychic trauma observed, for example, during excitement, fright; usually, however, this concerns people already ill, especially with heart diseases. 2. Poisoning substances, distinguished by their ability to be quickly absorbed and act on the most important centers of the brain and medulla oblongata, for example, potassium cyanide. 3. Mechanical suffocation (aspiration of vomit, acute edema of the larynx, etc.); to this also belong cases of asphyxia of the fetus from compression of the umbilical cord in the birth canal, etc. Traumas, poisonings, various types of suffocation are recognized by the usual methods adopted in autopsy of corpses and with the usual precautions; one must always keep in mind that this or that external influence may only serve as a pretext for exacerbation or manifestation of some old suffering, which actually causes S.D.; such are, for example, cases of S.D. during chloroforming of a subject with marked obesity of the heart, as well as with a secretly occurring Addison's disease or cases of sunstroke in subjects with underdevelopment of the adrenal glands. As traumatic S.D. one should consider shocks during severe operations in the area of the central nervous system, adrenal glands, pancreas. 4. The question of possible causes of S.D. of endogenous order has the greatest practical significance; here are found the most diverse diseases of acute and chronic character. Among them, the following have the greatest significance: a group of cardiovascular diseases and, above all, arteriosclerosis with predominantly cerebral and cardiac localization; in these cases S.D. can be observed from apoplexy of the brain, from thrombosis of the coronary arteries. In the first case, the location, volume and speed of bleeding are of great importance. With regard to S.D. from closure of the coronary arteries, observed not only in persons already previously suffering from attacks of angina pectoris (see), but sometimes affecting a person without any signs of this disease, it is important to take into account, besides the caliber of the closed artery and the speed of closure, also the general condition of the rest of the heart muscle, the degree of development of anastomoses, etc.; one should also not forget that in cases of S.D. from closure of the coronary artery, a complete closure of the vessel lumen is sometimes not found on autopsy of the corpse; this is explained by the fact that in the mechanism of closure of the artery lumen, spastic contraction of its wall can also play a part. Apoplexy of the brain, closure of the coronary arteries of the heart can also be observed in heart defects, in the order of embolism of the corresponding arteries. Typical S.D. is often given by defects (insufficiency) of the aortic valves. In patients with heart defects, S.D. relatively often occurs after food intake, especially abundant. One of the most important findings from the vascular system in S.D. are embolism and thrombosis of the pulmonary artery; as the starting point in such cases, thrombotic phenomena are most often found in the femoral, iliac, pelvic veins, especially in women. S.D. is observed with air, fat embolism (see). Obesity of the heart (adipositas cordis) by itself does not lead to death, all the more to sudden death, but various, even mild diseases in such patients, relatively harmless and non-serious manipulations with them (especially general and local anesthesia) can lead to S.D. The frequently mentioned in lay circles 'rupture of the heart' is actually observed very rarely; it usually turns out to be myomalacia of the heart or apoplexy of the brain. The occurrence of S.D. is noted with strong displacements of the heart, for example, with pleural exudates. Relatively often S.D. is observed with ruptures of aneurysms and spontaneous ruptures of the aorta, with various other hemorrhages, for example, with tubal pregnancy, from abdominal typhoid ulcers, from veins of the esophagus in liver cirrhosis, etc. S.D. is sometimes caused by severe degenerative and inflammatory changes in the myocardium, for example, in infectious diseases, such as: diphtheria, anthrax, rheumatism, sepsis, etc. Relatively often S.D. is observed with absolute arrhythmia (see Heart Arrhythmias), with various processes along the course of the atrioventricular bundle of the heart (hemorrhages, gummas, tumors, etc.), with latently occurring meningitis. Typical S.D. can be caused by anaphylactic shock. The question of mors thymica, associated with the so-called status thymicus or thymico-lymphaticus, causes many disputes. In recent years, in this question, a significant shift has been observed in the sense of almost complete denial of the importance of the thymus gland (its hyperplasia, or so-called thymus persistens) and the constitutional status denoted by its name (also sufficiently controversial). It is more probable that in such cases the matter generally concerns acute infections or intoxications occurring hyperergically, i.e., anaphylactically; one of the theories of stat. thymico-lymphaticus (Jaffe and Wiesbader), indicating well-developed thymus and lymph glands as a sign of good health, also speaks in favor of such an analogy with the anaphylactic reaction, indeed observed relatively more often in subjects of 'good build and nutrition'. In small children, S.D. is often observed as a result of capillary bronchitis. Finally, cases of S.D. are noted when in autopsy and microscopic, forensic-chemical and bacteriological examination nothing pathological is found. Here the data from preliminary investigation receive especially important significance (acute overwork, psychic trauma, strong cutaneous reflexes, for example, during a cold shower, insolation, etc.); it is also important to remember that sometimes even fatal traumas leave no marks on the body, for example, when striking in the epigastric region, testicles, area of the larynx. A. I. Kryukov pointed to the significance of features of the structure of the skull, in the form of premature closure of sutures, which, in his opinion, with relatively small increases in intracranial pressure can lead to sudden death. Autopsy in S.D. is performed with certain precautions: thus, the contents of the pulmonary artery must be examined before the sternum is dissected, without removing the brain and heart, i.e., at the very beginning of the autopsy. (For precautions in air embolism see Embolism.) According to existing rules, all cases of S.D. outside the hospital, clinical setting, i.e., somewhere at home, in state, public institutions, are subject to autopsy in the order of forensic-medical examination; this measure aims to exclude the possibility of concealing violent death.

It should be noted, however, that since among those who died suddenly, violent death, for example, poisoning, injuries, occurs comparatively rarely (Ignatovsky), the aforementioned rule represents a measure that is not entirely rational. It would be more appropriate to direct all cases of Sudden Death where there is no obvious suspicion of violent death to the morgues of the nearest hospitals for routine pathological-anatomical autopsy, of course, while observing the necessary precautions taken in forensic autopsies (see Autopsy). Such referral of bodies of those who died suddenly would also be advisable because these cases are often the most difficult precisely from the pathological-anatomical and clinical side, and moreover often represent enormous epidemiological interest, for example, in terms of timely detection of latent forms of anthrax, epidemic cerebrospinal meningitis and other infections. Finally, it is essentially important in Sudden Death to perform the autopsy as soon as possible after death, which, given the significant formalities required for forensic autopsy, is rarely possible. Theories, pathogenesis of Sudden Death—see Death.