foot that point to the occurrence of small hemorrhages in the brain,
that is, slight preliminary "strokes."
{145}
Patients that have had these symptoms should not, as a rule, be
allowed to leave home unattended. If the apoplexy occurs in the street
they are liable to be mishandled by those ignorant of their true
condition. The clergyman is usually summoned at once in these cases
and may reach the stricken individual before the physician. Some
words, then, with regard to the general management of such patients
will not be out of place. As a rule, when a patient is taken with some
sudden illness which causes him to fall down unconscious, the first
thing done is to dash water in his face, force a stimulant down his
throat, put his head low down, and loosen the clothing around his
neck. Most of these proceedings are the very worst things that could
be done for a patient suffering from apoplexy. The rough handling,
particularly, and the administration of a stimulant, will surely do
harm. The water on the face will certainly do no good.
Apoplectic patients can be recognised from those who are merely in a
fainting fit, first, by the fact that they are usually old, while the
fainters are young; and secondly, by the manner of the breathing. In a
faint the breathing is shallow and faint, not easily seen. In apoplexy
it is apt to be deep and long. It may be irregular, and it is always
accompanied by a blowing outward and inward of the cheeks, and
especially of the side of the face which is paralysed, as a
consequence of a hemorrhage into the brain.
The lips are forced outward and drawn inward during the respiration.
In such cases the patient should be moved as little as possible;
stimulants should be avoided, and the head should be placed higher
than the rest of the body, so as to make the hemorrhage into the brain
as small as possible, by calling in the assistance of gravity to keep
the heart from sending too much blood into the head. Besides this
placing the head high, there is only one other helpful measure that
even the physician can practise, except in rare cases, that is, to put
an ice-bag on the head. For this a cloth dipped in cool water may be
used in an emergency. Of course, as soon as the doctor arrives, the
patient should be left entirely to his care.
The artery that ruptures in the brain, in cases of apoplexy, {146} is
practically always the same. Its scientific name is the
lenticulo-striate artery, but it is oftener called by the name given
it by Charcot--the artery of cerebral hemorrhage. The reason why
arteries in the brain rupture rather than arteries in other organs is
that in the brain, in order to avoid the demoralising effect of too
sudden changes of blood pressure upon the nervous substance, the
cerebral arteries are terminal, are not connected directly with a
network of finer arteries as in the rest of the body, but gradually
become smaller and smaller, and end in the capillary network which is
the beginning of the venous vascular system. This special artery
ruptures, because it is almost on a direct line from the heart, and so
blood pressure is higher in it than in other brain arteries.
The tradition that people with short necks are a little more liable to
apoplexy than are those of longer cervical development has a certain
amount of truth in it, though not near so much as is often claimed for
it. Another predisposing element to apoplexy is undoubtedly heredity.
Families have been traced in which, for five successive generations,
there have been attacks of apoplexy between fifty-five and sixty years
of age. Short-necked people, with any history of apoplexy in the
family, should especially be careful, if they have any of the
symptoms--dizziness, sleepy fingers, etc.--that we have already
noted.
There is a tradition that the third stroke of apoplexy is always
fatal. This is without foundation in experience, though of course the
liability of death increases with each stroke, and few patients
survive the third attack. I remember seeing in Mendel's clinic, in
Berlin, a man who was suffering from his seventh stroke and promised
to recover to have another. Each successive stroke is much more
dangerous to life than the preceding one, however. In general, the
prognosis of an apoplexy, that is to say what the ultimate result will
be, is impossible. The patient may come to in an hour or two, and may
not come out of the coma at all. There is no way of deciding how large
the artery is that is ruptured, nor how much blood has been effused
into the brain, nor how much damage has been done to important nerve
centres. Nor is there any {147} effective way of stopping the
effusion, though certain things seem to be of some benefit in this
matter. We can only wait, assured that, in most of the cases, the
patient will have a return of consciousness, at least for a time.
Next to apoplexy, injuries of the head are most important. The
symptoms presented by the patient will often be nearly the same as
those of apoplexy. If the skull is fractured, and the depressed bone
is exerting pressure upon the brain substance, there is a similar
state of affairs to that which exists in apoplexy. Any return to
consciousness must be taken advantage of for the administration of the
Sacraments. As a rule, it is impossible to tell the extent of the
injury or to forecast the ultimate result.
A very characteristic set of symptoms develops sometimes after
injuries in the temporal region or just above it. For a short time up
to an hour or two after the injury, the patient is unconscious. Then
he comes to for a while, but relapses into unconsciousness, from which
he will usually not recover except after an operation. The explanation
of this succession of symptoms is that the primary unconsciousness is
due to shock--concussion or shaking up of the brain. The injury has,
however, also caused a rupture of an important artery which occurs in
one of the membranes of the brain in this region, the middle meningeal
artery. During the state of shock blood pressure is low and hemorrhage
is not severe. When consciousness is regained, blood pressure goes up
and the laceration of the middle meningeal artery, already spoken of,
provides an opening for the exit of considerable blood, which clots in
this region and presses upon the brain, causing the subsequent
unconsciousness. As a rule, the patient's only hope is in operation
with ligature of the torn artery. The condition is always very
serious, and complete precautions as to the possibility of fatal
termination should be taken, as soon as consciousness is regained
after the blow, in any case where the head injury has been severe
enough to cause more than a momentary loss of self-possession. No one
can tell whether there may be further change or not, and if this
happens it will be in the form of an unconsciousness gradually
deepening until relieved by operation or ended by death.
{148}
Tumours of the brain often produce death, but usually give abundant
warning of their presence. The symptoms by which the physician
diagnoses the presence of a brain tumour are vertigo, headache,
vomiting, usually some eye trouble, and frequently some interference
with the motion of some part of the body, because of pressure exerted
upon the nerve centres which preside over its motions. Brain tumours
are especially liable to develop in two classes of cases--in patients
who are suffering from tuberculosis in its terminal stages or from
syphilis. Where patients are known to have either of these diseases
and present any two of the symptoms of brain tumour that I have
mentioned, it is well to suggest at least the preliminary preparation
for a fatal termination. Sometimes states of intense persistent pain,
or of mental disturbance, develop in these cases and make the
administration of the Sacraments unsatisfactory.
Meningitis is a fatal affection which sometimes causes sudden death,
but more frequently produces unconsciousness without very much
warning, and the unconsciousness lasts until the death of the patient.
Meningitis is seen much more frequently in children than in the adult.
Ordinarily it is due to tuberculosis. Sometimes, however, there are
epidemics of cerebrospinal meningitis--spotted fever, as it used to be
called. In about one-half the cases this affection is fatal.
Unfortunately this disease gives very little warning of its approach
in many cases before unconsciousness sets in. We have had renewed
epidemics of the disease in the eastern part of the United States in
recent years, and the affection is likely to occur more frequently for
some time to come. The first hint of the onset of the disease during
an epidemic should be the signal for the administration of all the
rites of the Church.
Of late years we have learned that the pneumococcus, that is, the
bacterium which causes pneumonia, may produce a fatal form of
meningitis. The first symptom of meningitis is usually a stiffness of
the muscles at the back of the neck. If this stiffness becomes very
marked in a patient suffering from tuberculosis, or who has, or has
recently had, pneumonia, or at a time when there is any reason to
suspect that epidemic cerebrospinal meningitis exists in a
neighbourhood, the {149} prognosis of the case is always very serious.
Every precaution should be taken to prepare the patient for the worst.
Unconsciousness may ensue at any moment and no opportunity for
satisfactory administration of the consolations of religion be
afterwards afforded.
While Bichat put the lungs down as one of the vital tripod on which
the continuance of life depends, affections of these organs very
seldom lead to sudden or unexpected death. Pulmonary affections
usually run a very chronic course. Acute bronchitis, however,
occurring in a patient with kidney trouble, may lead to the
development of oedema of the lungs, and death will usually ensue in a
few hours. It may be well to note here that individuals who have what
are called clubbed fingers, or as the Germans picturesquely put it,
drumstick fingers, that is, fingers with bulbous ends, the finger
beyond the last joint being larger than the preceding part, nearly
always have some chronic affection within the thorax. This means that
there is some organic affection of the heart or lungs which has lasted
for many years. The existence of such condition makes them distinctly
more vulnerable to any serious intercurrent disease, and this sign
alone may be enough to put the attending physician on his guard as to
the possibility of fatal complications in the case.
JAMES J. WALSH.
{150}
XII
UNEXPECTED DEATH IN SPECIAL DISEASES
Besides the general systemic conditions in which sudden death may
occur without anticipation, there are certain specific diseases of
which unexpected death is sometimes a feature. For the clergyman to
know the condition in which the sudden fatal termination is liable to
occur is to be forearmed against the possibility of death without the
Sacraments, or their enforced administration in haste, when the
recipient is in a very unsatisfactory condition of mind and body. It
has been said that if a normally healthy individual reaches the age of
twenty-five he is reasonably sure to live to a good old age, provided
he does not meet with an accident or catch typhoid fever or pneumonia.
Pneumonia is an extremely important affection as regards its
prognosis. From 15 to 20 per centum of sufferers from the disease die;
that is to say, about one in six of those attacked by the disease will
not recover. It is a little more fatal in women than in men. It is
especially serious for the very young and the old.
Healthy adults in middle life very rarely die from the disease. The
prognosis of any individual case, it has been well said, depends on
what the patient takes with him into the pneumonia. Serious affections
of important organs nearly always cause fatal complications. If the
heart is affected before the pneumonia is acquired, then the prognosis
is very unfavourable, and a fatal termination is almost inevitable. If
the kidneys are seriously diseased beforehand, death is almost the
rule. Pneumonia developing during the course of pregnancy is fatal in
more than one-half of the cases. At one time it was suggested that
premature delivery of pregnant {151} pneumonia patients might save at
least the mother's life. Experience in Germany, however, has shown
that, far from making the prognosis more favourable, the induction of
premature labour makes the outlook a little worse for the patient.
Previous affections of the lungs, emphysema, or tuberculosis, are
prone to make the prognosis of pneumonia much more unfavourable than
under ordinary circumstances.
Deteriorated conditions of the blood, anaemia, chlorosis--such as
occurs so commonly in young women--is prone to make the outlook in
pneumonia more serious. Pneumonia of the upper lobes of the lungs is
more apt to be followed by complications, and is therefore more
serious than pneumonia of the lower lobes. Secondary pneumonia--that
is, inflammation of the lungs which develops as a complication of some
other disease--is much more unfavourable than primary pneumonia which
develops in the midst of health. The amount of lung involved is of
course a serious factor in the prognosis. If the whole of one lung is
consolidated, or if considerable portions of both lungs are thus
affected, the prognosis becomes extremely unfavourable.
In persons of alcoholic habits the result of pneumonia is always to be
dreaded. The more liberal has been the consumption of alcohol, as a
rule, the less hope is there of a prompt, uncomplicated recovery.
Stimulants are of the greatest importance in pneumonia, and the less
the patient has taken of them before the development of his pulmonary
affection the more effective are they when the crisis of the disease
comes. The less the alcohol that has been taken habitually before the
development of pneumonia, the more surely will it do the work expected
of it during the course of the pneumonia. It must be borne in mind
that cases of pneumonia that occur in institutions, asylums,
hospitals, and the like, and in crowded quarters in tenement houses or
lodging houses, have a distinctly worse prognosis than those treated
in private houses, and the priest must accordingly be more on his
guard and give the Sacraments early.
In pneumonia, as in typhoid fever, so-called walking cases always have
a serious prognosis. They occur in very strong patients who resist,
not the invasion of the disease, but its {152} weakening influence,
and keep on their feet for several days, despite the presence of
symptoms that require them to be in bed. When a patient walks into a
doctor's office in the third or fourth day of a pneumonia with most of
one lung consolidated, exhaustion of the heart and of the nervous
system, under these unfavourable conditions, will usually have made
his resistive vitality very low. Such cases should be given the
Sacraments early, while in the full possession of their senses.
Conditions sometimes develop rather unexpectedly in which the
administration of the Sacraments becomes unsatisfactory, because of
the collapsed state of the patient.
This same advice holds with regard to walking cases of typhoid fever.
Where strong patients suffering from the disease have insisted on
being around on their feet for from six to ten days at the beginning
of the affection, the prognosis becomes very unfavourable.
Complications, such as hemorrhage or perforation of the intestine,
occur about the beginning of the third week, and often prove fatal.
All typhoid fever patients should receive at least the Sacraments
necessary to give a sense of security to the priest and their friends
during the course of the second week, even though they may seemingly
be in excellent condition. When typhoid fever is fatal the
complications occur suddenly, often without much warning; and if
intestinal perforation, for instance, takes place, the peritonitis
which develops makes the patient's condition very unsuitable for the
reception of the Sacraments in a proper state of mind.
Typhoid fever patients sometimes die suddenly in collapse when they
are convalescent. The toxine of the typhoid bacillus often affects the
heart, and causes what is called cloudy swelling of its muscular
fibres. This decreases very notably their functional ability. Any
sudden exertion, even sitting up in bed, may cause the heart to stop
under such circumstances. The modern custom in hospitals is not to
allow typhoid patients to sit up in convalescence until the head of
the bed has been raised gradually for several days so as to accustom
the heart to pumping blood up the hill to the brain. Priests must be
careful, then, when they call to see convalescent typhoid patients,
not to permit them to sit up {153} to greet them. The doctor's
directions in this matter should be followed very carefully.
This sudden fatal collapse may occur after any of the infectious
diseases. It is seen not infrequently after diphtheria. It occurs more
rarely after scarlet fever, and even after some of the milder
children's diseases. In rheumatism, especially where a heart
complication has occurred, this rule with regard to sudden movements
is extremely important Rheumatism is itself not a fatal disease, yet
there are certain cases in which very high temperature sets in, causes
delirium, and death ensues at times before the patient recovers
consciousness. Where rheumatic patients show a tendency to run high
temperatures, that is, 104 deg. or higher, it is well to be prepared for
this emergency.
Appendicitis is very much talked about in our day; but the fatal
affection represented by the new word is no more frequent than it was
half a century ago, or, for that matter, twenty-five centuries ago.
People died of inflammation of the bowels and peritonitis then; and as
the appendix was not known as the origin of the trouble, the fateful
name was not the spectre that it is now. Practically all abdominal
colic--and this means 90 per centum of all the acute pain which
follows gastro-intestinal disturbance in young or middle-aged
adults--is due to appendicitis. It comes on, as a rule, in the midst
of good health. It is very treacherous, and when the patient is
apparently but slightly ill, a sudden turn for the worse may assert
itself, and an intensely painful and prostrating condition develop.
Where symptoms of appendicitis are present, it is the part of safety
to have the patient receive at least the Sacraments of Penance and the
Holy Eucharist. When peritonitis develops, vomiting is the rule. Hence
the advisability of prompt administration of Holy Communion. Extreme
Unction can be given with some satisfaction, even during the disturbed
period which follows a beginning peritonitis. For the peritonitis that
sometimes results from appendicitis there is no hope of recovery
except by operation. Operation, to be successful, must follow the
perforation of the appendix not later than by a few hours.
{154}
Early pregnancy, that is, the first eight to ten weeks of gestation,
is sometimes complicated by a set of symptoms the most prominent of
which are sudden very acute pains in the lower part of the abdomen,
followed by intense prostration, and then by the symptoms of internal
bleeding,--namely, a soft pulse, pallor with cold extremities, sighing
respiration, and marked tendency to faintness. When symptoms like
these occur during the first three months of pregnancy, they signify,
almost without exception, rupture of an extrauterine gestation-sac.
Except where operation can be performed at once, these cases are
almost invariably fatal. Extrauterine pregnancy occurs with greatest
frequency in women who, having had one or more children, then have a
period of five or more years without children, followed by pregnancy.
Undoubtedly, extrauterine pregnancy, the knowledge of which is the
result of medical advance in very recent years, and appendicitis,
which is the growth of the last twelve years, were prominent factors
in the production of many inexplicable deaths in history. These were
not infrequently set down as due to poison.
Acute indigestion in elderly people is sometimes followed by sudden
death. Observations in this matter have somehow become much more
frequent of late years, and many of the so-called cases of heart
failure belong to this group. The important nerve trunk that carries
nervous fibres to the heart bears fibres to the digestive tract, the
oesophagus, the stomach, the intestines, the liver as well, and also
to the larynx and lungs. There is a certain intercommunication between
the impulses which pass along these various nerve fibres. Intense
irritation of the nerve endings in any one of these organs may be
reflected back upon the heart. Curiously enough the nerve fibres to
the heart that run in this trunk are many of them inhibitory; that is
to say, they lessen the function of the heart or cause it to stop
beating entirely. If an intense nervous irritation is set up in the
stomach, reflex nervous impulses may cause the heart to stop
completely and never resume its work.
Typical cases of this kind often occur during the first cold days of
the winter time. Elderly people come to their meals cold and chilly,
yet with appetite increased by the bracing air. They sit down at once,
take a larger meal than usual, and then develop severe gastritis
during the night. This is {155} relieved by purging and vomiting, and
the pain yields to the administration of morphine. Their condition
improves and all danger seems past, when, on sitting up suddenly the
next day, or, if left alone, getting up to get something for
themselves, they collapse and are dead before help can come to them.
Deaths like this sometimes occur in dysentery also, the reason being
the intense nervous reflex from the irritated intestinal nerve endings
which exerts its influence upon the heart nerves.
Certain diseases practically always end in sudden death and must be
taken special care of by the priest for this reason. Aneurism, for
instance, is one of these. An aneurism is a widening or dilatation at
some point of an artery. The most important aneurisms occur in the
arch of the aorta, that is, in the large curved artery which comes
directly from the heart itself and of which all the other arteries are
branches. Aneurisms develop, according to the expression of a
distinguished American physician, in the special votaries of three
heathen divinities, Vulcan, Bacchus, and Venus,--that is, in those who
have worked too hard, in those who have drunk too hard, and in those
who have devoted themselves too much to the pleasures of the flesh.
The most important factor of all is, however, the contraction of
venereal disease, especially of that form known as syphilis.
The termination of aneurism cases is usually by rupture with profuse
hemorrhage. Death takes place in a moment or two. Aneurisms often
cause intense pain, which is sometimes thought to be rheumatic in
origin. If the aneurism, in its enlargement, meets with bony
structure, it produces absorption of the bone by pressure upon it and
so finds a way even through the bone to the overlying skin. This
process is always intensely painful, and shortly after the aneurism
appears at the surface the pressure upon the skin causes it to become
thin and the aneurism may rupture externally.