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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.
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 Mitchell, in hisAutobiography 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 constitution. 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 constitution 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 assuredly 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 associated with tuberculosis as far back as we have any history of the disease. Hippocrates pointed out as one of the symptoms of consumption thespes phthisicalor 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 rôle 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 otitis 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 constitution 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 pancreatitis 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 attitude 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 tetanus and hydrophobia. Tetanus 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 tetanus 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 tetanus 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 tetanus, 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 assured 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 prone 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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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 massage, and Professor Schiff at Florence was the first to apply the method to human subjects. Kemp and Gardner, in theNew 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 (seeThe Therapeutic Gazette, April, 1904), and some of these are the following: Dr. Christian Igelstrud of Tromsö, 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 mém. 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.
Prus (Wiener klin. Woch., no. 21, 1900, p. 486) by the same method started contractions of the heart after 15 minutes in a man that had hanged himself. The effort at resuscitation was made two hours after the suicide had been discovered, but the recovery did not go beyond imperfect movements of the heart, which gradually ceased.
Maag (Centralbl. f. Chir., 1901, p. 20) reports the case of a man who under chloroform anaesthesia ceased breathing and whose heart stopped. After 10 minutes the patient was pulseless, without respiration, cyanotic, and cold. The heart was exposed and compressed rhythmically; it was restored to action, and he began to breathe. He remained alive for 12 hours, seemingly asleep; then he died.
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Starling and Lane (Lancet, Nov. 22, 1902, p. 1397) were operating upon a man 65 years of age. The heart and respiration ceased. Lane put his hand into the abdominal incision and squeezed the heart through the diaphragm. After twelve minutes of artificial respiration the lungs and heart began to act. The patient afterward was discharged from the hospital cured.
Sick (Centralblatt f. Chirurgie, Sept. 5, 1903, p. 981) reports a very remarkable case. A boy of 15 years of age died upon the operating table.Three quarters of an hourafter the heart had ceased to beat it was laid bare. The flaps did not bleed, the pericardium was bloodless, the heart was motionless, relaxed, and cold. After a quarter of an hour, during which the heart was compressed, and artificial respiration was kept up, that is, one hour after what any physician would call death, the heart was beating and respiration was restored. Two hours later the boy became conscious and complained of great thirst and dyspnoea. He remained in this condition for twenty-seven hours, and during that time his speech was indistinct but intelligible. He then died.
Dr. George W. Crile, of Cleveland, Ohio, reports the case of a woman whose heart movement and respiration had ceased for six minutes. She was restored completely, even without exposing the heart. Dr. Crile uses an inflated rubber suit on the patient to raise the blood pressure by peripheral resistance—he does not expose the heart. He had another case, a man 38 years of age, who "died during operation, was resuscitated, and died again two hours later."
Two Hungarian labourers, whose skulls had been crushed in the same accident, were brought into Dr. Crile's clinic in a dying condition. The heart of one of these men ceased beating as he was brought into the operating room. After nine minutes the surgeons began to work upon him to resuscitate him. They succeeded, but he lived for only 28 minutes.
They then examined the other man and found him dead. Just 45 minutes after this second patient had been brought into the operating room the effort to resuscitate him began. As he had not been observed while the physicians had been engaged with the first man, they do not know when his heart{167}had ceased to beat, but he certainly was dead in the opinion of skilled observers. They resuscitated him so well that he moved his head away from the operator who was relieving the depression of the skull, but he died again in 34 minutes.
These cases are not what is commonly called conditions of suspended animation. All the patients would have been pronounced dead by any physician, and if they had been left untouched, they surely never would have been revived.
There have been about thirty attempts made by surgeons to restore patients who were dead in the full acceptance of the term as used at present. Four of these attempts resulted in complete success, others in a partial recovery, and many were without positive result. The number of complete and partial resuscitations, however, are enough to justify a priest in giving conditional absolution or baptism within an hour, or even two hours, after a patient has to all appearance died, especially in accident cases. We do not know when the soul enters the body, and there is the same doubt as to the moment when the soul leaves the body. In these latter cases we should give the patient the benefit of the doubt.
AUSTIN ÓMALLEY.
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The subject of infection is complicated, and the medical doctrine concerning it is far from certainty despite the multitude of facts presented by bacteriologists, chemists, pathologists, and clinicians. Before the days of bacteriology the termInfectiouscommonly was applied to diseases produced by no known or definable influence of any person on another, but wherein common climatic or other widespread conditions were thought to be chiefly instrumental in the diffusion. The contagious disease was one transmitted by contact with the patient, either directly by touch, or indirectly through the use of the same articles.
Now we know that many diseases called infectious are caused by micro-organisms, and we group others under this class because we hold theoretically that they have their origin in microbes not yet isolated. Hence we define an infectious disease as one which is caused by a living pathogenic micro-organism, which enters the tissues from without, and is capable of multiplying therein. These micro-organisms have a time of incubation during which a poison is made in the tissues, and this brings about the intoxication we call the disease.
Infection is a general term that includes contagion; and contagious diseases are infective diseases that may be transmitted directly or indirectly from patient to patient.
The pathological micro-organisms with which we shall deal in this article are (1) the Schizomycetes or Fission-Fungi, which are microscopical organisms that multiply by fission, and are commonly known as Bacteria; and (2) a few Protozoa, which are animal micro-organisms.
The bacteria are classed with plants because, like plants,{169}they derive nourishment from both organic and inorganic material. They have no seeds or flowers, but many of them are reproduced by spores. They consist of cells, single or grouped, which when spherical are calledcocci, when rod-shaped,bacilli, when spiral,spirilla. There are various subdivisions of these groups. We do not know whether bacterial cells have nuclei or not.
A micro-organism is aparasitewhen it can live in animal tissues. It is asaphrophytewhen it can exist outside animal tissues. If a parasite cannot exist outside animal tissues, it is anobligatory parasite; if it can, it is afacultative saphrophyte. Similarly the saphrophytes are classed as obligatory saphrophytes and facultative parasites. Pathological micro-organisms have very complicated products which are in large part poisonous.
Bacteriologists require seven conditions to prove a micro-organism thespecificcause of a given disease, and all these conditions have been fulfilled for anthrax, diphtheria, and tetanus. The specificity has been satisfactorily settled for glanders, malaria, tuberculosis, actinomycosis, gonorrhoea, and malignant oedema. It has been practically settled for typhoid, influenza, the Madura disease, and the bubonic plague; and incompletely defined for leprosy, relapsing fever, and Malta fever.
There are certain diseases which are not called specific, because they may be produced by various micro-organisms. These are pneumonia, osteomyelitis, septicaemia, pymaeia, endocarditis, meningitis, erysipelas, angina Ludovici, broncho-pneumonia, and similar maladies. Cholera and dysentery also might be grouped with these, as cholera appears to be produced by various vibrios and dysentery by different amoebae.
There are other infective diseases, in which we have not yet found the causative micro-organism, but we presume its existence. These are: rabies, syphilis, yellow fever, dengue, typhus, mumps, whooping-cough, smallpox, measles, scarlet fever, and others among the exanthemata.
Malaria and similar diseases are caused by plasmodia, which are protozoa and not bacteria.
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The priest is almost as frequently exposed to the danger arising from contagion as the physician is, and a priest that often ministers to the sick is liable to grow imprudently indifferent to danger. For one priest that is too much afraid of disease we find a hundred that have not sufficient dread.
No matter what medical science may say to the contrary, many priests hold that they have often left smallpox cases, for example, without disinfecting themselves, and that they have not spread the disease. This is a very rash assertion. It is absolutely certain that smallpox has been communicated to susceptible persons by those coming from patients ill with that disease merely passing the susceptible man on the street. The number of persons that will not take smallpox when exposed to it is very large. In Washington in 1895, during an epidemic of smallpox, 187 persons, to my personal knowledge, were exposed to one group of 39 smallpox patients without taking the disease. The unharmed had been present in sick-rooms or had even nursed the patients, not knowing that the disease was smallpox. In this epidemic eight persons lived in the same rooms with, or visited frequently, two patients that afterward died of virulent smallpox, and none of the eight took the disease. One of these eight, however, went into a dramshop, had one glass of beer and left immediately, and in fourteen days afterward (the average time of incubation) we took the barkeeper to the smallpox hospital. This barkeeper had not been exposed to smallpox except by contact with the man mentioned here. There were about 60 cases of smallpox in that epidemic, and we traced every one to direct or indirect contact with one initial case.
If we were infected by every exposure to contagious disease the world would be depopulated. It is true that you cannot give some persons diphtheria if you actually put the Klebs-Loeffler bacillus into their mouths, and nurses and physicians in consumptive wards have the tubercle bacillus in their nostrils without ill effect. So for many diseases; but it unfortunately remains true that there are susceptible persons everywhere who will at once take a disease when they are exposed to it.
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Immunity changes in the same person. Starvation, fatigue, loss of blood, unsuitable diet, exposure to heat, cold, and moisture, and other influences lessen the power of resistance to infection. Men vary almost as do the lower animals as regards infection. The quantity of tetanus toxin that will kill 400 horses will not bother a hen; Algerian sheep and the white rat are not affected by anthrax, but other sheep and the brown rat are very susceptible; a hog will not take glanders, man and a horse will; men, cattle, and monkeys have tuberculosis, dogs and goats do not; white men with few exceptions are susceptible to yellow fever and malaria, negroes are practically immune; negroes readily succumb to the fatal sleeping sickness, white men are almost immune; and similar differences are observable in the same race or family.
The question of immunity to infectious disease is very difficult to make clear because it is so technical, and it is only a theory at best. The poison of an infectious disease kills by splitting and destroying the nuclei of the body's cells. The toxic products of the micro-organisms seem to become chemically united with certain molecules of the body cells and to inhibit the normal function of these molecules. According to Erlich's theory there are other molecules in cells which neutralise toxic molecules, and when the neutralising molecules appear in excess the patient recovers. These neutralising bodies are called antitoxins.
Some antitoxins are always present in cells, and where the normal quantity of these is used up in neutralising toxins, other antitoxic bodies are formed, until finally the excess of these is thrown off into the blood serum. After they are called into being by the excitation of some toxic products, like those of the typhoid bacillus for example, the antitoxins remain in the blood for years, ready to neutralise at once any influx of fresh infection. In other diseases, like diphtheria and pneumonia, they are soon lost,—hence the recurrence of such diseases. The acquired antitoxin lasts after smallpox, vaccinia, yellow fever, scarlet fever, measles, typhoid, mumps, and whooping-cough; it is very transient after pneumonia, influenza, diphtheria, erysipelas, and cholera.
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In serum therapy antitoxins are artificially excited into being in the blood of beasts. This artificially prepared antitoxin is injected into the blood of, say, a diphtheria patient, and the poison is at once neutralised, instead of leaving the patient to make his own antitoxin and letting him perhaps fail in the effort.
The antitoxin produced in the contest of the body cells against some diseases will not only neutralise the toxin of a particular disease, but it will also neutralise the toxin of a second disease. By vaccinating a person we inoculate him with vaccinia or cowpox. His body cells make an antitoxin which neutralises the toxin or virus of cowpox, he recovers from this light disease, and the antitoxin now remaining in his body prevents for years another successful inoculation with cowpox. It does more: in 90 per centum of cases it will prevent successful infection with smallpox.
Smallpox (the pocks, pokes or pockets of matter,—opposed to the great pox or syphilis) has been known from very early times—probably even from 1200 B.C. The name "small pokkes" was first used in England in 1518. The disease was brought to America in 1507.
It may be communicated from the sick to the healthy (1) by persons suffering with the disease; (2) by bodies of persons that have died of smallpox; (3) by infected articles; (4) by healthy third persons; (5) by the air, to persons living even at some distance; (6) by inoculation. The poison enters the body by the mucous membrane of the nose, mouth, or respiratory tract, and probably through the mucous membrane of the stomach and through the broken skin.
Patients can communicate the disease probably during the period of incubation (from 5 to 20 days after exposure to the disease—commonly about 14 days); and certainly from the initial stage until no trace is left of the final skin-desquamation. The infection is most active during the formation and duration of the pocks. The mildest smallpox in one person can cause malignant smallpox in another, andvice versa. The mortality in the unvaccinated is between 40 and 50 per centum.
A typical case of confluent smallpox at its height is the{173}ugliest disease in appearance and stench and almost in substance, known to medicine. Anyone liable to infection by it, or likely to carry it to others, who says he is "not afraid of it," has either never seen it and he is talking childish nonsense, or he has seen it and he is a fool.
The face is a bloated mass of corruption; the eyes are swollen shut; the nose, cheeks, lips, and neck are puffed out enormously; the mouth is a large sore, ulcerous, and spittle trickles from it ceaselessly. The fever is up to 103 or 105 degrees; there is an unquenchable thirst, a vile stench, sleeplessness; often delirium is the only relief, and there is one chance in two of a disfigured recovery. Tobacco, alcoholic liquor and a walk in the fresh air will not disinfect the visitor to such a disease. Years ago I investigated in the laboratory the popular notion that tobacco is a disinfectant. I found that bacteria, the diphtheria bacillus and swarms of others more delicate, will grow as well in the presence of a large piece of "Navy Plug," as when tobacco is absent. Chewing tobacco, whiskey, a walk in the fresh air as disinfectants, the Sioux medicine-man's powwow, the hind leg of a rabbit as a charm, are all in the same category.
The first and chief protection against smallpox is vaccination. Vaccination does not always prevent infection by smallpox, but it does prevent it in more than 90 per centum of exposures to the disease. Welch reported in 1894 that the death-rate in one series of 5,000 cases of smallpox was 58 per centum in the unvaccinated, and 16 per centum in the vaccinated, but the vaccinated took the disease in less than 10 per centum of the exposures. During the Franco-German War in 1870-1871, the Germans who had a million vaccinated men lost 458 soldiers from smallpox while a great epidemic of smallpox was existing in Germany; the French, who were indifferent to vaccination, during the same time lost 23,400 men from this disease alone. In the United States, where there is no compulsory vaccination except such attempts as school boards make, there were between July and December, 1903, 13,739 cases of smallpox; in Germany, where there is a compulsory{174}vaccination law, there was no smallpox at all, during the same time, except 14 cases in two seaports, Bremen and Kiel, whither the infection had been brought from without.
Before 1874 there had been no compulsory vaccination law in Germany except for the army. In 1871, 143,000 Germans died of smallpox. Since the law went into effect in 1874 the disease has been stamped out, until there was between July and December, 1903, only one death from smallpox in Germany.
The chart on page 175 will show very graphically the effect of vaccination upon smallpox.
In October, 1898, smallpox was endemic in Puerto Rico; in December, 1898, it was epidemic; in January, 1899, it was all over the island and spreading rapidly. In February, 1899, compulsory vaccination was begun and carried out for only four months, when 860,000 vaccinations had been made in a population of about 960,000 people. The death-rate from smallpox dropped from 621 a year to 2.
During the century preceding Jenner's discovery of vaccination, according to Neimeyer's calculation 400,000 people died of smallpox each year in Europe. Bernouilli, a trustworthy statistician, says that during that same century, "Fully two-thirds of all children born in Europe were, sooner or later, attacked by smallpox, and on an average one-twelfth of all children born succumbed to the disease."
Early in the sixteenth century 3,500,000 people in Mexico had smallpox (Prescott'sConquest of Mexico). In 1707, in Iceland, 18,000 of the population of 50,000 died of smallpox; and in 1891, 25,000 persons in Guatemala died of this disease. In 1875 there were anti-vaccination riots in Montreal, and as a consequence most of the younger inhabitants of that city were not vaccinated. In 1885, smallpox was brought in from Chicago; 3,164 persons died of the disease; of these 2,717 were children under ten years of age, and thousands had the disease.
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Vaccination may render one immune to smallpox for many years, but if the disease is epidemic it is well to renew the vaccination after about eight years. In normal vaccination, where the lymph has been derived from a reliable source, on the third or fourth day pale red papules develop at the point of inoculation, and about the tenth day these have become pustules. The vesicles dry gradually, and between the fourteenth and twentieth days the scab falls off, leaving a pitted scar. About the fifth day an aureola of inflammation forms around the pocks, from a quarter of an inch to two inches in extent, and the inflamed area may be somewhat sore. A shield should be kept over the vaccination spot for two days, and this is then to be replaced by a piece of sterile gauze held in place by narrow strips of sticking-plaster above and below the inflamed area. Sometimes hives and other rashes occur in vaccination, but they are unimportant.
Where there is a very sore arm or other trouble, the cause may be a pre-existing unhealthy condition, like scrofula for example, or the patient has scratched the pocks, or infected them from his clothing, or the vaccine lymph was unsterile. A careless and dirty vaccinator might infect an arm with pus organisms. If good glycerinated lymph, not too fresh or too old, is used, there is seldom any trouble; but in any case all the annoyance that may come from vaccination is infinitesimal when compared with the smallpox it averts.
We may take a smallpox case as a typical contagious disease in which the priest is to give the last Sacraments; and the disinfection and other precautions observed in such a visit will serve for any other very contagious disease. For only typhus and one or two other maladies are the precautions so elaborate as those needed in smallpox.
There is a dress, called "Dr. Hawes' Antiseptic Suit," and in time of epidemics a priest should have one of these suits, or one made after it as a pattern—they can be obtained in the shops for two or three dollars. They cover the entire person, even the shoes, and they make unnecessary the changing of clothing and the disinfection of the exposed parts of the body. The hands of the priest may be left bare after fastening the sleeves of the suit about the wrists, or he may wear surgeon's thin rubber gloves. In visiting a patient that has any of the contagious diseases mentioned in this chapter, the priest should never touch{177}his own face with his hands after he has entered the sick-room until he has washed them in a bichloride of mercury solution.
A ritual should not be taken into a smallpox room, because a book cannot be disinfected without rendering it useless. The priest should memorise the prayers and ceremonial, or write them out on paper which can be burned in the hospital or the patient's house.
The priest may be obliged to administer baptism, to hear confession, to give the Viaticum and Extreme Unction. Before going to visit a smallpox patient let him find out from the physician in attendance whether the patient can receive the Viaticum, whether he can swallow it or not, whether he can open his mouth enough to take it. Ask also about the possibility of vomiting. Only a very small particle is to be brought in the pyx.
The leather cover for the pyx should not be taken into a smallpox room. Set the pyx inside a corporal, wrap the corporal in paper, and put this package into the pocket of the Hawes suit before entering the room.
As to the use of a stole,—the moralists say "graviter peccatur ab eo qui sine urgente necessitate sine ulla sacra veste unctionem administrat." There is a grave necessity here for doing away with the stole because of the difficulty in disinfecting it, unless you have one made that can be put into boiling water for ten minutes before you leave the patient's house.
The oil-stocks should contain only as much oil as is necessary for the single occasion, because what remains, with the cotton, should be burned in the patient's house.
Do not remain in the room longer than you must unless you have had smallpox. If there is any prayer or ceremonial that can be omitted, by all means leave it out. Lehmkuhl says that the penitential psalms and the litanies may be omitted. Baptise by the short form.
St. Alphonsus Liguori (Theol. Mor., lib. 5, tr. 5, n. 710) tells us there is no obligation to anoint both eyes and both ears, "si adsit periculum infectionis," but danger of infection is not materially increased by anointing both sides.{178}Lehmkuhl adds, "excepta dispensatione Sedis Apostolicae addatur unctio pedum." When the feet are to be anointed do not touch the bed-clothing,—tell the nurse to uncover the feet.
St. Alphonsus (loc. cit.,n. 729) speaking of extreme unction has these words: "Pastor ratione officii tenetur sub mortali dare lis qui petunt, nisi justa causa excuset: etiam tempore pestis, modo possit absque periculo vitae; cum eo non teneri docentTann. Dian.," etc. If you have not had smallpox you certainly risk your life by going into the room of a smallpox patient, and the danger of infection is greater in typhus; but suppose a pastor were inclined to take advantage of the excuse, he would be obliged at any risk to go into such a room to hear confession or to baptise, and if he hears confession he may as well stay for the anointing.
If you anoint a patient that has confluent smallpox you probably can not wipe away the oil, because the skin will be pustular. Wipe the oil-stock carefully; then all cotton used should be wrapped in paper and burned in the paper before you leave the house. After anointing, you had better wash your hands carefully in water in which a bichloride of mercury tablet has been dissolved—do not use soap and do not put the bichloride in a metal vessel. Wash your hands thus before you leave the sick-room.
If the patient can receive the Viaticum let him lie on his back, and you should drop the Host into his mouth without touching him with your hand. St. Alphonsus says: "non licet tempore pestis porrigere Eucharistiam medio aliquo instrumento … sed manu danda est" There is no need of an instrument. If there are any crumbs left in the pyx make the patient take them. St. Alphonsus says this may be done, and it would be almost certain infection to take them yourself if you have not had smallpox recently. Let as little ablution water as possible be given to the patient.
When you leave the room, put the pyx, oil-stocks, corporal, and stole in a pan of water and boil them for ten minutes. This will disinfect them thoroughly and will not injure them in any way. Then take off the Hawes suit as near the street-door as possible and wet it with bichloride{179}solution. Wash your hands again in the bichloride solution and rinse off the bichloride; take the pyx, oil-stocks, corporal, and stole and leave immediately. Do not touch the door-knob when going out—let some one open the door for you—and do not shake hands with any one.
Typhus fever is now rare in America, but there was an outbreak in New York City in 1881. This was the fever that killed multitudes of Irish emigrants about the middle of the nineteenth century. It is called also spotted fever, camp, jail, ship, and hospital fever, and it has many other names. The name typhus is from, a smoke or fog, and it indicates the befogged, stuporous condition of the patient. Typhoid fever is so called because it has some resemblance to typhus.
The specific cause of typhus is unknown, but the contagion develops and reproduces itself in the body of the patient. It is thought that the contagion exists in the secretions and excretions of the body and in the exhalations from the lungs and skin. The infection can certainly be carried by clothing, dust, furniture, conveyances of all kinds, and dead bodies, and it remains active for months. It may be transmitted through the air for short distances, not nearly so far as the air will carry the contagion of smallpox. In well-ventilated rooms there is less danger of infection, and a typhus patient should have at least 1,500 cubic feet of air space. The contagion may be transmitted in all stages of the disease and during convalescence.
Physical weakness, anxiety and worry, improper food, and poverty, are disposing conditions for infection by typhus. The mortality is about 10 per centum—much less than that of smallpox.
In giving the last Sacraments to a typhus patient exactly the same method should be followed as that observed for a smallpox patient. Keep as far from the patient as possible. After you touch him in anointing or in giving other Sacraments step away from him to say the necessary words. Do not stand between him and an open fireplace, window, door, or ventilator.
Relapsing fever, or famine fever, caused by Obermeier's{180}spirillum, is sometimes associated with typhus. It has a mortality that can go up to 14 per centum in unfavourable circumstances, but the disease is not more contagious than typhoid under hygienic surroundings. Wash the hands in bichloride solution after visiting a case, and do not touch the door-knob or things in the room.
Rabies (called also hydrophobia in man) is a rare disease. It is communicable by inoculation, but it is very doubtful that the disease has been communicated from man to man. The saliva from a person suffering with rabies if injected into a warm-blooded animal will cause rabies, and on that account it is prudent to use care in touching such a patient in administering the last Sacraments. The virus might enter through an abrasion on the priest's hand.
There is a false hydrophobia observed in excitable persons that have been bitten by a dog thought to be mad. The dog that has genuine rabies grows sullen, it hides in comers, and it snaps at everything presented to it A sticky, frothy mucus drivels from its mouth and its eyes become red. It will run straight ahead, snapping at anything it meets; it swallows small stones, chips, and similar objects; it does not avoid water. It howls, grows lean, and its hind legs and lower jaw become paralysed.
In man there is a premonitory stage; a furious stage, which lasts from about a day to three days; then a final paralytic stage. It is well to wait for the paralytic stage before anointing the patient, because in the other stages the slightest touch causes violent spasms. Confessors should note that the virus of rabies excites the sexual centres.
Scarlatina or scarlet fever first appeared in North America in Massachusetts in 1735. It is especially an April disease here. One attack commonly makes the person immune for life. It is a disease of children, but it attacks adults, and it is fatal among children old enough to receive the last Sacraments. Some epidemics are very malignant; and in such times all the precautions mentioned in speaking of the visitation of smallpox patients should be observed. The contagion is spread just as that of smallpox is spread, except that it is not carried through the air so far.