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 OMALLEY.
{168}
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.
{170}
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.
{171}
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.
{172}
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.
{175}
[Illustration: ]
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.
{176}
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 docent _Tann. 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 [Greek text], 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.