Essays In Pastoral Medicine Part 13

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 excrement.i.tious 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 cla.s.s for examination in order that they might have the opportunity of studying normal urine, only to find to his painful surprise that alb.u.men was present and that he was the subject of latent Bright's disease. In these cases it is {138} impossible to foresee results. They const.i.tute a large number of the cases in which patients, seemingly in good health, succ.u.mb 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 cla.s.s 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 const.i.tuents of the blood into certain loose tissues of the body. This is easily recognised, and const.i.tutes 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 const.i.tutes 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 hoa.r.s.eness 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 s.p.a.ce 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 p.u.b.erty.

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 p.r.o.ne 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 succ.u.mb 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 a.s.surance 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 pa.s.sing 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 a.s.sured that there is no danger of death. This a.s.surance 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 a.s.surance 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 a.s.sociated 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 a.s.sumes 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.

There may even occasionally be slight losses of power in the hand or foot that point to the occurrence of small hemorrhages in the brain, that is, slight preliminary "strokes."

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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 a.s.sistance 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, a.s.sured 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.

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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 cla.s.ses 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.

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XII

UNEXPECTED DEATH IN SPECIAL DISEASES

Besides the general systemic conditions in which sudden death may occur without antic.i.p.ation, 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 p.r.o.ne to make the prognosis of pneumonia much more unfavourable than under ordinary circ.u.mstances.

Deteriorated conditions of the blood, anaemia, chlorosis--such as occurs so commonly in young women--is p.r.o.ne 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 inst.i.tutions, 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.