Essays In Pastoral Medicine Part 14

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 circ.u.mstances. 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 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 a.s.sert 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.

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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 pa.s.s 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 appet.i.te 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.

Addison's Disease always ends suddenly. This is a rare affection, described by Addison, an English physician, some fifty years ago, which develops in individuals whose suprarenal capsules are degenerated. The suprarenal capsules are little bodies of half-moon shape which lie above the kidneys. {156} Their degeneration produces a great lowering of blood pressure. The patient becomes intensely weak, muscular movement becomes impossible, intellectual processes cause great fatigue, and finally blood pressure becomes so low that fatal collapse ensues from lack of blood in the brain. The external symptoms of these cases is a pigmentation, that is, a very dark discolouration of the skin, which develops rather early in the disease. The tongue especially becomes a very dark brown. Areas of pigmentation also occur where the skin is irritated,--at the wrists from the irritation of the coat sleeves, at the edge of the hair from the irritation of the hat.

Dr. S. Weir Mitch.e.l.l, in his _Autobiography of a Quack_, has described one of these cases very strikingly. The hero of the tale is found dead one morning by the nurse in the hospital, after he has been feeling quite as well as usual for some time.

It must not be forgotten that patients who are burned extensively very frequently die shortly after the accident. A burn that involves more than one-half of the body, no matter how superficial the burning may be, will always have a fatal termination. Deep burns in one part, unless it is some very vital part, are not so serious as extensive superficial burns. Patients with extensive burns frequently remain in encouragingly good condition for several days, and then have a sudden change for the worse. Sometimes death takes place in coma. Sometimes it takes place as the result of a perforation of the duodenum. These perforations of duodenal ulcers may take place as late as a week to ten days after the burn. They are always followed by symptoms of peritonitis and the condition of intense prostration which this brings on. Such cases need to be prepared for the worst after the first acute symptoms of the burn have subsided, when a certain amount of peace of mind is restored.

Cirrhosis of the liver not infrequently causes sudden death. Cirrhosis is an affection in which a large part of the liver substance proper degenerates, and its place is taken by connective tissue. It is typically a disease of people of alcoholic habit. It occurs in those who are engaged in the sale of spirits, though the alcoholic absorption does not take place {157} through the skin, but in a much more direct way. It is most frequent in people who take strong spirits on an empty stomach. Those who are much exposed to changes of temperature are especially liable to form such habits. It is found most frequently in the drivers of wagons and cars, in policemen, and in sea-captains, sailors, and the like. When cirrhosis causes sudden death, it is nearly always by hemorrhage. The hemorrhage takes place from the oesophagus, some of the large veins of which have become dilated until the thin walls are unable to retain the blood. The dilatation is due to interference with the venous circulation in the liver.

Of late years pathologists and medical men, especially those who are interested in children's diseases, have devoted considerable time to the study of certain cases of sudden death, which have long been very mysterious. Infants often die while in apparent good health without any adequate reason that can be found, even on the most careful autopsy. Children of an older growth sometimes die suddenly as the result of some slight shock or fright, or they die after the administration of a few whiffs of chloroform, given to help in the performance of some simple surgical operation, or they die at the beginning of some infectious fever which they ought to be able to withstand without any difficulty. A distinguished pathologist at Vienna, Professor Paltauf, who was the coroner's physician of the city and had a large number of these sudden deaths to investigate, found that in most of the cases one abnormal condition was constantly present. This consisted in an enlargement of the lymph glands all over the body. The lymph glands in the neck were involved, also the tonsils and lymphoid tissue at the back of the throat, the series of lymph glands in the groin, and, finally, there was a hypertrophy of the lymphoid tissue that occurs all along the intestinal tract. This condition of hypertrophy of lymphoid tissue has come to be known as the lymphatic diathesis or const.i.tution. It is nearly always accompanied by a distinct hypertrophy of the thymus gland. The thymus gland is an organ which occurs in the upper part of the thorax of the child, but which atrophies and practically disappears after the age of two years. In these cases it is from twice to three {158} times its normal size in the infant, and in older children it is persistent--that is, retains its primary size, though in the ordinary course of nature it should atrophy. This lymphatic diathesis undoubtedly has considerable to do with the sudden deaths which occur in these patients. What the exact connection is we do not as yet definitely know. Unfortunately, moreover, this lymphatic const.i.tution gives no sure sign of its existence before the occurrence of the fatal termination. Enlargement of the glands of the neck and of the groin, with some enlargement of the tonsils, occurs in delicate children without necessarily being symptoms of the lymphatic diathesis. The enlargement or persistence of the thymus can be better recognised, and doctors now seldom fail to notice it. Where any suspicion of such a condition exists in children of from eight to sixteen or seventeen years of age, proper precautions must be taken to prevent sudden fatal termination of any even mild disease without due preparation.

Undoubtedly many of the cases of sudden death under chloroform and ether in children and young persons are due to the existence of this lymphatic diathesis.

Diseases, like tuberculosis and cancer, that run a long but a.s.suredly fatal course, usually terminate unexpectedly. The tuberculous patient particularly will almost surely be planning for next year the day before he dies. This condition of euphoria, that is, of sense of well being, was recognised as a.s.sociated with tuberculosis as far back as we have any history of the disease. Hippocrates pointed out as one of the symptoms of consumption the _spes phthisical_ or consumptive hope.

If the patient has been very much run down, death may take place from thrombosis of some of the arteries. If the thrombosis takes place in the brain, consciousness will be lost, and the patient will often die without recovering it. Patients often develop tubercles in their brain as the result of a spread of the disease beyond the lungs, and then, as a rule, death will take place in the midst of a paralysis, which may be accompanied by loss of consciousness that lasts for several days or a week or more.

Cancer patients also die suddenly, or at least unexpectedly, at the end. Very often in them, as in tuberculosis, {159} thrombosis plays an important role in the fatal termination. In cancer of the stomach, peritonitis from perforation of the stomach may close the scene. The fatal termination in cancer of the uterus is often brought about by the development of uraemic symptoms. The new growth in the pelvis involves the ureters, prevents the free egress of urine, and so causes the retention in the system of poisonous substances that should be excreted. Cancer in other parts of the body often causes death by metastatic cancers, that is, offshoots of the original cancer which occur in other organs. Usually these are in the liver, but sometimes they are in the brain, and sometimes in the bones that surround the spinal cord. In the course of their growth they cause pressure symptoms upon the nervous system, and this leads to death. If patients become very much weakened, as is not infrequently the case, thrombosis occurs, and portions of the clots may be shot into the pulmonary veins, and cause death in this way.

Two affections which are quite common, one of them usually involving no danger at all, sometimes cause sudden death. They are varicose veins and a discharging ear. Varicose veins are the enlarged veins which occur on the limbs of a great many elderly people. If these people become run down in health and then exhaust themselves by overwork, the circulation through these enlarged veins is sometimes so impeded that clotting--thrombosis, as it is called--occurs. If a portion of the clot becomes detached, and is carried off into the circulation, a so-called embolus, this may cause sudden death, either by its effect upon the heart, or more usually upon the lungs.

Middle-ear disease causes death, either by producing an abscess of the brain, or by causing thrombosis of some of the large veins within the skull. The dangers involved in a discharge from the ear are now well recognised. Insurance companies refuse to take risks on the lives of persons affected by chronic ot.i.tis media, as it is called scientifically. Such persons may run along in perfect good health for years without accident, but a sudden stoppage of the flow may be the signal for the formation of the brain abscess, with almost inevitable death.

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Certain severe forms of the infectious fevers are very often fatal.

These forms are popularly known as black fevers, that is, black measles, black scarlet fever, etc. These fulminant forms occur especially in camps, barracks, orphan asylums, jails, and the like, where the hygienic conditions of the patients have been very poor, and where the resistive vitality has, as a consequence, become greatly lowered. The black spots that occur on such patients are really due to small hemorrhages into the skin. The hemorrhages are caused by a lack of resistance in the blood-vessels and by a change in the const.i.tution of the blood that allows it to escape easily from the vessels. Where such cases occur, patients should be fully prepared for the worst As a rule, the mortality is from 40 to 70 per centum.

Acute pancreat.i.tis is a uniformly fatal disease, though fortunately it is rare. It occurs much more frequently, however, than used to be thought. It occurs in persons over thirty who have been for some years addicted to the use of alcohol. The symptoms of the disease are severe pain in the upper left zone of the abdomen, that is, above and to the left of the umbilicus. This is accompanied by nausea and vomiting.

Collapse ensues and death takes place on the second to the fourth day of the affection. This disease may have important medico-legal bearings. Some slight injury in the abdomen, as from a blow or a kick, may precipitate an attack in predisposed individuals. Accusation of murder may result. The mental att.i.tude of the physician and the clergyman with regard to such cases must be very conservative. No opinion as to possible culpability should be ventured.

Cholelithiasis, that is, stone in the bile duct, may not only cause severe pain, but may lead to rupture of the duct and a rapidly fatal termination. Owing to the practice of wearing corsets, gall-stones occur much more commonly in women than in men. Twenty-five per centum of all women over 60 years of age are found to have gall-stones. While these cases suffer from intense pain they are very seldom fatal. But it must not be forgotten that a fatal issue can take place either from collapse and stoppage of the heart, because of the intensity of the pain, or from perforative peritonitis.

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The perforation of a gastric ulcer may cause symptoms which rapidly place the patient in a condition in which the administration of the Sacraments is very unsatisfactory. Gastric ulcers occur especially in young women, usually in those who follow some indoor occupation. Its favourite victims are cooks, though laundresses, seamstresses, and even clerks in stores, suffer from it much more than those engaged in other occupations. It occurs by preference in anaemic or chlorotic women. Sometimes, however, as in the case of cooks, the patients may seem to be in good health. Acute pain in the stomach region, followed by symptoms of collapse, should in such persons be a signal for the administration of all the Sacraments. Fatal peritonitis soon brings on a state of painful uneasiness ill adapted to the proper dispositions for the Sacraments.

Two diseases that are fortunately very rare, but which are almost uniformly fatal, deserve to be mentioned here. In both of them the symptoms of the disease are manifested through the nervous system.

They are teta.n.u.s and hydrophobia. Teta.n.u.s occurs as a consequence especially of a wound which has been contaminated by the street dirt of a large city, or the refuse of a farm. It follows deep wounds such as are made by a hayrake or a pitchfork; or seared wounds, such as are made by a toy pistol. A serum for the treatment of the disease has been discovered, but unfortunately the first symptom of teta.n.u.s is not the first symptom of the disease, but the preliminary symptom of the terminal stage of the disease, the affection of the nervous system.

Practically all cases of acute teta.n.u.s terminate fatally. As soon as a patient exhibits the characteristic symptoms, the lockjaw, the stiff neck, and the rigid muscles, all the Sacraments should be administered. In teta.n.u.s, as a rule, consciousness is preserved until very late in the disease. In severe cases, however, a convulsive state of intense irritability develops in which the slightest sound or effort brings on a series of spasmodic seizures. Patients must be prepared, then, early in the disease, if possible.

Rabies or hydrophobia is a disease which claims a certain number of victims every year in our large cities. {162} Its symptoms are the occurrence of fever and disquietude, with spasmodic convulsions of the muscles of the throat whenever an attempt is made to swallow. These symptoms come on from three to fifteen days after the bite of a mad dog. Unless the Pasteur treatment has been taken shortly after the bite of the animal was inflicted, no treatment that present-day medicine possesses is able to affect the course of the disease, and patients nearly always die. Their preparation, then, is a matter of necessity as soon as the first a.s.sured symptoms of the disease show themselves. [Footnote 4]

[Footnote 4: One cannot help but add a word here as to the cause of the disease, because clergymen can by their advice do something to remedy the evil which lies at the root of the infliction.

Hydrophobia is due to stray dogs. In practically every case the fatal bite is inflicted by some animal that no one in the neighbourhood claims. Bites by pet dogs are rarely fatal. If clergymen would use their influence to suppress the dog nuisance we would soon have an end of hydrophobia.]

Alcoholic subjects are very liable to unexpected death from a good many causes. Patients suffering from delirium tremens, for instance, may die suddenly in the midst of a paroxysm of excitement. Such a termination is not frequent, but it has occurred often enough to make it the custom, at asylums for inebriates, to warn friends who bring patients of the liability of such an accident. It is not so apt to happen during a first attack of delirium tremens as during subsequent attacks. It is most frequent among those whose addiction to alcohol for years has caused repeated paroxysms of delirium tremens. The cause of the sudden death is usually heart failure. This term means nothing in itself, but it expresses the fact that a degenerated heart finally refuses to act. Alcoholic poison in the circulation has led to fibroid degeneration of the muscular elements of the heart and made them incapable of proper function, or at least has greatly hampered their action, and the heart ceases to beat.

It must be borne in mind that chronic alcoholism makes a number of serious organic diseases run a latent course. The patient is apt to attribute his symptoms to the after effects of the abuse of alcohol.

Unless the doctor who is called in makes a very careful examination, serious kidney disease or even advanced pneumonia may not be discovered. Alcoholic subjects bear pneumonia very badly, and the preliminary {163} symptoms of the disease are often completely concealed by the symptoms due to the patient's alcoholism. Other infectious diseases, as typhoid fever, tuberculosis, and even various forms of meningitis, may run a very insidious course and give but very slight warning of their presence. The result is that these diseases are very frequently fatal in alcoholic subjects.

Old inebriates bear operations badly, and the mortality after any operation in such subjects is distinctly higher than in normal individuals. One reason for this is that considerably more ether or chloroform is required to produce narcosis in alcoholic subjects than in ordinary individuals. Ether and chloroform are very irritant to the kidneys. The kidneys are p.r.o.ne to be affected more or less in old alcoholic subjects. Death from oedema of the lungs or from some form of pneumonia is not infrequent in these post-operative cases, and gives as a rule but little warning of its approach.

It is clear, then, that alcoholic subjects must be prepared with special care whenever disease is actually present or an operation is to be performed. Too great care can scarcely be exercised in their regard. What would seem overcaution will save many a heartburn to friends and priest, for it is in alcoholic subjects especially that some of the saddest cases of unexpected death without preparation occur.

JAMES J. WALSH.

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XIII

THE MOMENT OF DEATH

It not infrequently happens that a priest reaches a patient who has just died. Conditional absolution, baptism, or other spiritual ministration might have been offered if there were signs of life, but the heart and lungs are still, "the patient is dead," and the priest leaves the place without doing anything. Yet the patient may not really be dead.

Our knowledge of the precise time the soul leaves the body is very imperfect. There is, we are aware, a close connection between the vital functions of the body, taken together or singly, and cellular activity. If the cells are not destroyed, a vital function sometimes may be restored after its cessation, but if the cells are destroyed up to a certain extent, the vital function is not recoverable. For example, if the various bodily cells of a patient dead from diphtheria are examined microscopically, it will be found that the diphtheria toxin has disintegrated the nuclei of these cells. What number of cells proportionate to the whole in, say, the heart should be destroyed before the vitality of that organ is lost, is not clearly known. Where the cells are intact, or nearly so, mere absence of respiration, or of even the heart movement, are not absolute proof of death. Numerous cases are found in medical records of persons that had been lying under water for many minutes, up to even an hour, but who were restored to life by patient and skilful efforts; and of late remarkable restorations after what was practically death, under anaesthesia and otherwise, have been reported. The technique consists chiefly in rhythmical compression of the heart, commonly after surgical exposure of that organ, with artificial respiration, and, in Crile's method, peripheral resistance is {165} employed to raise the blood pressure. Ludwig in 1842, experimented in cardiac ma.s.sage, and Professor Schiff at Florence was the first to apply the method to human subjects. Kemp and Gardner, in the _New York Medical Journal_, May 7, 1904, described various methods used in attempting resuscitation.

Professor W. W. Keen of Philadelphia has collected the records of the chief cases of resuscitation after apparent death (see _The Therapeutic Gazette_, April, 1904), and some of these are the following: Dr. Christian Igelstrud of Tromso, Norway, in 1901, was operating upon a woman, 43 years of age, for cancer. During the operation, which was a coeliotomy, she collapsed and her heart ceased beating. After the usual means for resuscitation had been ineffectively tried, her heart was laid bare. Igelstrud took hold of the heart with his hand and made rhythmic pressure upon it. In about one minute the heart began to pulsate. The patient was discharged from the hospital five weeks afterward.

Tuffier (_Bull, et mem. soc. de chir._, 1898, p. 937) in 1898 had a patient whose heart stopped after an operation for appendicitis. The surgeon had left the operating room, but he returned, laid bare the heart, pressed it rhythmically, and after two minutes it began to move again. The patient breathed regularly, his eyes opened, the dilated pupils contracted, and he turned his head. After the opening over the heart had been closed, however, he died.