Part 24

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.

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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 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.

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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.

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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 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.