Part 16

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 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 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 hour_ after 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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XIV

THE PRIEST IN INFECTIOUS DISEASES

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 term _Infectious_ commonly 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 called _cocci_, 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 a _parasite_ when it can live in animal tissues. It is a _saphrophyte_ when it can exist outside animal tissues. If a parasite cannot exist outside animal tissues, it is an _obligatory parasite_; if it can, it is a _facultative 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 the _specific_ cause 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, and _vice 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's _Conquest 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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PRUSSIA.--With compulsory vaccination and compulsory revaccination at the age of 12.

HOLLAND--With compulsory vaccination of children before entering a school.

AUSTRIA.--Without compulsory vaccination.

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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.