subject are convinced that not a few of the suicides, which are now so
alarmingly on the increase in this country, are due to the frequent
reading in newspapers of the accounts of suicides. As we have said
elsewhere, brooding over the details of these is very likely to lessen
the natural abhorrence of self-murder in persons that are predisposed,
by melancholic dispositions, to such an act. The publication of cases
of suicide can do no possible good, while it undoubtedly does, in this
way, work incalculable harm. This is especially true with regard to
suicides among young people, that is, individuals under twenty-five
years of age. The saddest feature of recent {134} statistics with
regard to suicide is that this crime has become proportionately much
more frequent among young men and young girls, and even children, than
it was two or three decades ago. It has been noted, too, in many cases
that a previous suicide in the family seems to have familiarised the
young mind with the idea of self-destruction and thus suggested its
commission.
On the other hand, among young people especially, it has been noted
that there is frequently an imitative element in suicides. Three or
four suicides, practically with the same details, will occur, within a
few days of each other. Suicides at all ages are especially likely to
occur in groups, and are often cited to exemplify the truth of the old
axiom that evils never come singly. It is especially among young
people, however, that this relationship to previous suicides can be
traced, and there is no doubt that it is the unfortunate publicity
given to suicide, with the consequent suggestive influence, which
constitutes the most important factor in these cases. All the
influence that clergymen can exert, then, must be wielded to suppress
this, as well as the many other evils which flow from sensational
journalism.
JAMES J. WALSH.
{135}
XI
UNEXPECTED DEATH
Unexpected death and its problems constitute the principal reason why
there should be a pastoral medicine, and why the clergyman must keep
himself in close touch with advances in medicine. To have an ailing
member of a congregation die unexpectedly, that is, without the rites
of the Church, when perhaps there has been some warning as to the
possibility of such an accident, can not but be a source of the
gravest concern in pastoral work. Sudden death can be anticipated in
many diseases that are acute, while in chronic forms of disease the
sufferer can be prepared for its possibility by the administration of
the sacraments at regular intervals. There is, however, an old proverb
which says that death always comes unexpectedly; and even with all the
modern advance in medicine, this still contains a modicum of truth. As
an unprepared death is an occasion of the most poignant regret to the
friends of the deceased and to the attending clergyman, it is with the
idea of furnishing some data by which the occurrence of death without
due anticipation may be rendered more infrequent, that the following
medical points on the possibilities of a fatal termination in certain
diseases have been brought together. Unfortunately, even with all our
progress in modern medicine, they must be far from adequate for all
cases.
Needless to say, the only rational standpoint in this matter must be
that it is better to be sure than to be sorry. The impression is very
prevalent now that at least the sacraments of Penance and the Holy
Eucharist should be administered to the sick whenever there is even
the possibility of a fatal termination of the illness. Extreme Unction
is more usually delayed until there is some positive sign of {136}
approaching dissolution. Delay in its administration, however, not
infrequently leads to this sacrament being given when the patient is
unable to appreciate its significance. This would seem to be very far
from the intention of the Church. The idea has been constantly kept in
mind, then, so to advise the clergyman with regard to the liability of
a fatal termination as to secure, if possible, the administration of
Extreme Unction while the patient is still in the full possession of
his senses.
Assured prognosis, that is, positive foresight as to the course of any
disease, is the most difficult problem in medicine. Nearly 2400 years
ago, when Hippocrates wrote his chapter on the progress of diseases,
he stated that the hardest question to answer in the practice of
medicine is, will the patient live? That special chapter of his book
remains, according to our best authorities, down even to our own day,
a valuable document in medical literature. It can be read by young or
old in medical practice with profit. While our knowledge of the course
of disease has advanced very much, the wise old Greek physician
anticipated most of the principles on which our present knowledge of
prognosis is founded. This fact in itself will serve to show how
unsatisfactory must be any absolute conclusion as to the termination
of any given disease. Our forecasts are founded on empirical
data,--that is, they are the result of a series of observations,--and
the underlying basis of all the phenomena is the individual human
being, whose constitution it is impossible to know adequately, and
whose reaction to disease it is impossible, therefore, to state with
absolute certainty.
With this warning as to the element of doubt that exists in all
prognosis, we may proceed to the consideration of certain organic
affections which make sudden death frequent.
At the beginning of the present century, Bichat, a distinguished
French physician who revolutionised medical practice, said that health
and the favourable or unfavourable termination of disease depends on
the condition of three sets of organs--the brain, the heart, and the
lungs. This was what he called the vital tripod. It was not until
nearly thirty years after Bichat's death that Bright, an English {137}
physician, taught the medical profession to recognise kidney disease.
Since his time we have learned that even more important than Bichat's
vital tripod, as regards health and the termination of disease, is the
condition of the kidneys. We shall consider affections of these four
organs, and their influence on the human system and intercurrent
disease, in the order of their importance.
When kidney disease exists the individual's resistive vitality is much
lowered. The kidneys are the organs which serve to excrete poisons
that find their way into the circulation. When the kidneys fail to
act, these poisons are retained. As a result other important organs,
notably the nervous system and the heart, suffer severely because of
the irritating effect of the retained poison. A patient with kidney
disease runs a very serious risk in any infectious fever, no matter
how mild, and such patients should always be completely prepared for a
fatal termination when they acquire any of these diseases.
Nephritic patients bear operations very badly. The shock to the
nervous system incident upon operation always throws a certain amount
more than usual of excrementitious material into the circulation.
Diseased kidneys do not fulfil their function of removing this at
once, and the result is an irritated and fatigued nervous system.
Anaesthetics, that is, chloroform and ether, are not well tolerated
when nephritis exists, and this adds to the danger of operation in
such patients. No matter how simple or short the operation that is to
be performed on a person suffering from kidney disease, if an
anaesthetic is to be administered it would be well to prepare the
patient for an untoward event that may occur.
Kidney disease is often extremely insidious. It may develop absolutely
without the patient's knowledge, even though he might be deemed to be
in a position to have at least some suspicion of its existence. The
story is told of more than one professor of medicine who has presented
his own urine to his class for examination in order that they might
have the opportunity of studying normal urine, only to find to his
painful surprise that albumen was present and that he was the subject
of latent Bright's disease. In these cases it is {138} impossible to
foresee results. They constitute a large number of the cases in which
patients, seemingly in good health, succumb rather easily and
unexpectedly to some simple disease, like grippe or dysentery. It is
well to take the precaution, then, to ask the attending physician what
the condition of the kidneys is in such cases. If there are anomalous
symptoms, this precaution becomes doubly necessary. Even such simple
infectious diseases as mumps or chicken-pox may cause a fatal issue
where the kidneys are not in a condition to do their normal work of
excretion.
An important class of cases for the clergyman are those which are
picked up on the street. As a rule, these patients are comatose
because of the presence of kidney disease. A certain proportion of
them are unconscious because of apoplexy. Very often the patients have
had some preliminary symptoms of their approaching collapse, though
these were not sufficient to make them think that any serious danger
threatened. As a consequence, they will not infrequently have had
recourse to some stimulant. It seems unfortunately to be almost a
rule, when such cases are picked up, if there is the odour of alcohol
on their breath, to consider that the condition is due to alcoholism.
Every year, in our large cities, some deaths are reported in the cells
of the station houses because a serious illness was mistaken for
alcoholism as a result of the odour of the breath. Needless to say,
then, the odour of alcohol on the breath of a person in coma should
not deter a clergyman from waiting for a time to be sure his
ministrations may not be needed for something much more serious than
alcoholism.
Patients suffering from kidney disease bear extremes of cold and heat
very badly. In cold weather the fact that the blood is driven from the
surface of the body lessens the excretory function of the skin, and
this throws the work of this important organ, so helpful an auxiliary
in excretion, back upon the kidneys. Besides, congestions of internal
organs are not infrequent during cold, damp seasons, and these bring
on exacerbations of previously existing ailments that may make fatal
complications. In summer intense heat leads to many more changes in
the tissues, and so provides more material to {139} be excreted than
in temperate weather. Patients picked up on the street, then, at such
time, will usually be found to be suffering from kidney disease.
Though in profound coma, such patients seldom die without recovering
consciousness. Not infrequently, after the primary stroke of the coma,
there is, in an hour or two, a period in which the patient becomes
almost completely rational. This period of consciousness does not last
long, in many cases, and should be taken immediate advantage of, yet
without unduly disturbing the patient.
There is a well-known tendency in kidney disease to the production of
oedema, that is, to the outflow of the watery constituents of the
blood into certain loose tissues of the body. This is easily
recognised, and constitutes a valuable sign of kidney disease in the
swelling of the eyelids and of the feet, that occurs so often in
patients suffering from kidney trouble. The usual rule is, if the
oedema begins in the face, it is due to the kidneys; if in the feet,
to the heart. The cause in the latter case is the sluggish circulation
due to the weakness of the heart muscle, which delays the blood so
long in the extremities that its watery elements find their way out
into the tissues. In kidney disease this tendency to oedema
constitutes a distinct danger that may involve sudden death in certain
affections. In patients suffering from kidney disease any acute sore
throat involving the larynx and causing hoarseness may be followed by
what is called oedema of the glottis. This is often fatal in a very
short time. The glottis is the opening between the vocal cords through
which respiration is carried on. This opening is but small, and
swelling of the surrounding tissues readily encroaches upon it, and
soon causes difficulty of breathing. If the swelling is not relieved
without delay, death takes place from asphyxiation. This was probably
the cause of death in George Washington. In almost the same way any
acute affection of the lungs that occurs in a patient suffering from
kidney disease may be followed by oedema of the lungs. The outflow of
serum from the blood vessels into the loose tissues of the lungs so
encroaches upon the space available for breathing, and at the same
time so reduces the elasticity of lung tissue, that {140} respiration
becomes impossible, and death takes place in a few hours. This is
often the cause of unexpected death after operations. The kidney
affection in the patient is so slight as to have been unsuspected, or
to have been considered of not sufficient importance to render the
operation especially dangerous.
After kidney disease the most important factor in the production of
unexpected death is heart disease. In about 60 per centum of the
patients who die suddenly, in the midst of seemingly good-health,
death is due to heart disease. All forms of heart disease may be
considered under two heads--the congenital and the acquired. The
congenital form of heart disease usually causes death in early years.
If such patients survive the fourth or fifth year, they are usually
carried off by some slight intercurrent disease shortly after puberty.
A few cases of congenital heart disease, however, live on to a good
old age and seem not to be seriously inconvenienced by their heart
trouble. Most of the acquired heart disease, that is, at least 65 per
centum of it, is due to rheumatism. All of the infectious fevers,
however, may cause heart disease, and scarlet fever especially is
prone to do so; heart complications occurring in about one out of
every ten cases. The probabilities of sudden death in a case of heart
disease depend on what valve is affected and what the condition of the
heart muscle is. Most of the cases of sudden death occur in disease of
the aortic valves, that is, of the valves that prevent the blood from
flowing back from the heart after it has been pumped out. Diseases of
the other side of the heart, the mitral valve, cause lingering illness
until the heart muscle becomes diseased, when sudden death usually
closes the scene.
Diseases of the aortic valves of the heart cause visible pulsations of
the arteries, especially of those in the neck. This readily attracts
attention if one is on the lookout for it. Deaths in heart disease,
whether sudden or in the midst of apparent health, or as the terminal
stage after confinement to bed because of weak heart, are apt to occur
particularly during continued cold or hot spells. Each of the
blizzards that we have had in recent years has been the occasion for a
{141} markedly increased mortality in all forms of heart disease. The
cold itself is exhaustive, and the heavy fall of snow, by delaying
cars and modes of conveyance generally, is very apt to give occasion
for considerably more exertion than usual. Besides, cold closes up the
peripheral capillaries and makes the pumping work of the heart much
harder than before. At times of continued cold, in our large cities
particularly, the ordinary arrangements for heating the house fail to
keep it at a constant temperature, and this proves a source of
exhaustion to cardiac patients.
Heated spells, if prolonged, always cause an increased mortality in
such patients, because heat is relaxant and this leads to exhaustion.
Patients who have been nursed faithfully through a severe winter will
sometimes succumb to the first few successive days of hot weather that
are likely to come at the end of May or the beginning of June. The
deaths that occur during the hot spells of July and August are more
looked for and accordingly prove not so unexpected.
The warning symptom in heart disease that the patient is giving out is
the development of irregularity and rapidity of the pulse. On the
other hand, when a pulse has been running rapidly for weeks and then
drops to below the regular rate, to 50 or 60, a fatal termination may
be looked for at almost any time, though, of course, the patient may
rally. The prognosis of heart cases is extremely difficult. Confined
to bed and evidently seriously ill, they may continue in reasonably
good condition for months, and then some indiscretion in diet, which
causes a dilation of the stomach with gas, pushes the diaphragm up
against the heart, adds a mechanical impediment to the physical
difficulties the organ is already labouring under, and a sudden
termination may ensue. As a rule, lingering heart cases terminate
suddenly and often with little warning of the approach of death.
An interesting set of heart symptoms, for the physician as well as the
clergyman, are those which occur in what is called angina pectoris,
heart pang, or heart anguish. Serious angina pectoris occurs in
elderly people whose arteries are degenerate. Its main symptom is a
feeling of discomfort which develops in the praecordia,--the region
over the heart. {142} This discomfort may often increase to positive
cutting pain. The pain is often referred to the shoulder, and runs
down the left arm. This set of symptoms is accompanied by an intense
sense of impending death. When the patient's arteries are degenerated,
this train of symptoms must always be considered of ominous
significance. A readily visible sign of arterial degeneration can
sometimes be noted in the tortuous prominent temporal artery just
above the temple.
Heberden, an English physician, a little over a century ago, pointed
out that there existed in cases of true angina pectoris a degeneration
of the coronary arteries. These are the arteries which supply the
heart itself with blood. As might naturally be expected, their
degeneration seriously impairs the function of the heart muscle. The
first patient in whom the condition was diagnosed during life was the
distinguished anatomist, John Hunter. Hunter was of a rather irascible
temperament, and after he had had several of these attacks, and a
consultation with Heberden convinced him of their significance, he is
said to have remarked, "I am at the mercy of any villain who rouses my
temper." Sure enough. Hunter died in a sudden fit of anger within the
year after making the remark. Charcot, the distinguished neurologist,
suffered from attacks of angina pectoris, and was asked by his family
to consult a distinguished heart specialist for them. He said: "Either
I have degenerated heart arteries, or I have not. I believe that I
have not, and that my attacks are due to a nervous condition of my
heart. If I should consult the physician you mention, and he were to
tell me that my attacks are due to degeneration of the heart, he would
advise my giving up work. That I am not ready to do, and so I prefer
to take my own assurance in the matter." A few years later he was
found one morning dead in bed. In many of the cases of death in bed,
especially where some complaint of pain has been heard during the
night, death is due to that condition of the heart arteries which
causes angina pectoris, though it may be the first attack which proves
fatal.
There is a condition similar to angina pectoris, sometimes called
pseudo-angina, or false heart pang, which occurs in individuals from
fifteen to thirty years of age. It is often a {143} source of great
worry. It occurs in young persons of a nervous temperament who have
been overworked or overworried and have run down in weight. There are
always accompanying signs of gastric disturbance. The casual factor of
the symptoms seems to be a more or less sudden dilation of the stomach
with gas. As the stomach lies just below the heart, only separated
from it by the comparatively thin layer of diaphragm, the heart is
pushed up and its action interfered with. In healthy individuals this
causes no more than a passing sense of discomfort and some heart
palpitation. That it is which sends so many young patients to
physicians with the persuasion that they have heart disease, when they
have nothing more than indigestion. In nervous individuals, however,
this interference with the heart action disturbs the nervous mechanism
of the heart, which is very intricate and delicate, and gives rise to
the symptoms of false "heart pang." One of these symptoms is always,
as in true angina pectoris, an impending sense of death. This can not
be shaken off, and is not merely an imagination of the patient.
Pseudo-angina is, however, not a dangerous affection. Patients can
usually be assured that there is no danger of death. This assurance is
not absolute, however. For some of these cases have congenital defects
in their coronary arteries, and the nervous system of the heart
itself, which make them liable to sudden death. It is sometimes
impossible to differentiate such cases of organic heart defects from
the ordinary functional heart disturbance due to indigestion, which
causes simple curable pseudo-angina. Young patients may usually be
disabused of their nervousness in the matter, but absolute assurance
can not be given until the case has been under observation for some
time.
After the heart, the head is the most important factor in sudden
death. The most frequent form of death from intra-cranial causes is
apoplexy. Apoplexy, as the name indicates--a breaking out--is due to
a rupture of one of the arteries of the brain, and a consequent
flowing out of blood into the brain tissue. The presence of the exuded
blood causes pressure upon important nerve tracts, and so gives rise
to unconsciousness, to paralysis, and to the other symptoms which are
{144} noted in apoplexy. There are a number of symptoms that act as
warnings of the approach of apoplexy. First, it occurs only in those
beyond middle life, that is, in individuals over forty-five, and in
these only where there is marked degeneration of arteries. The
degeneration of the arteries can be easily noted, as a rule, in other
parts of the body. The condition known as arterio-sclerosis, that is,
arterial hardening, can be detected by the finger at the wrist, or by
the eye in the branch of the temporal artery, which can so frequently
be seen to take its sinuous course on the forehead behind and above
the eye. At the wrist the thickened artery is felt as a cord that can
be rolled under the finger. It is not straight as in health, but is
tortuous, because the overgrowth in the walls, which makes it thick,
has also made it longer than normal, thus producing tortuosity.
Besides these objective signs, as they are called, there are certain
subjective signs, that is, signs easily recognised by the patient
himself, which should put him on his guard, and at the same time serve
as a warning to the clergyman, should he hear of their presence. These
signs are recurring dizziness, or vertigo, not clearly associated with
gastric disturbance; tendency of the limbs, and especially the fingers
and toes, to go to sleep easily, and when there is no external cause
for this condition; tendency to faintness and to dizziness when the
patient rises in the morning, especially if he assumes the erect
position suddenly; tendency to vertigo when the patient stoops, as to
tie a shoe, or pick up something from the floor, and the like;
finally, certain changes in the patient's disposition, with a loss of
memory for things that are recent, though the memory may be retained
for the happenings of years before. When several of these symptoms
occur, patients who are well on in years should take warning of the
fact that they are liable at any time to have a stroke. Needless to
say, this has no reference to the cases of young nervous persons who
may readily imagine that they have some or all of these symptoms.
Apoplexy is typically the disease of those over fifty years of age.