SEVEN AVOIDABLE DISEASES

MALARIA FEVER.

Malaria, in its various manifestations, has ever constituted the
principal obstacle to the civilization of all tropical and semi-tropical
countries, and as a consequence vast tracts of the richest and fairest
portions of the world have remained uncultivated and unredeemed from
their primitive savage state. Recent investigations have shown that this
disease can be easily prevented if the matter is taken up intelligently.

Malaria is a disease produced by a parasite belonging to the very lowest
order of animal life--the _Plasmodium malaria_, which is conveyed from
man to man by that genus of mosquitoes called the Anopheles. The parasite
attacks and destroys the red cells of the blood, and produces a poison
that causes the symptoms characteristic of malaria.

_Course of the Disease._--The most common and well-recognized symptoms of
malaria are those that occur in that variety of the disease which is
known as malarial or intermittent fever. In this type the patient--who
may or may not have at intervals for some days noticed chilly sensations,
a feeling of fullness in the head, and general bodily depression--is
suddenly seized with a chill followed by a high fever and subsequent
profuse perspiration; after these symptoms subdue, which generally
requires several hours, the patient returns to a practically normal
condition and feels, on the whole, well until the next attack occurs.
These chills-and-fever paroxysms occur at various intervals depending
upon the character of the parasite inducing them, the most common form
being that which produces a chill every day. In some instances the malady
comes on more insidiously, there being no marked chills but only
periodical elevations of temperature.

In the more chronic forms of the disease the unfortunate victim is
frequently subjected for years to attacks of fever coming on at irregular
intervals, the patient being more or less of an invalid throughout the
course of the disease. In other instances the brain becomes affected,
producing very alarming symptoms; and in quite a proportion of cases the
malady ultimately terminates in chronic Bright's disease.

_Treatment of the Disease._--Most fortunately, we have in quinine, when
properly administered, a medicine that in practically all instances acts
as a specific in this affection; but it should be used only on the advice
and under the directions of a physician. In the more chronic forms of the
disease, combinations of arsenic, with such tonics as nux vomica, iron,
and small doses of some of the preparations of mercury, produce permanent
cures where quinine has failed. It is of the utmost importance that
attention be given to the treatment, as, so long as the patient remains
with the parasites in his blood, so long is he a menace to his friends
and neighbors.

_Mode of Infection Through Mosquitoes._--The most brilliant triumph in
modern medicine, and one of the most creditable achievements of human
ingenuity, has been the absolute demonstration that malaria is carried
from man to man by means of the Anopheles mosquito, and that the disease
can, in nature, be produced in absolutely no other way. This is not a
theory, but it is a fact which has been demonstrated in its every detail
beyond dispute, and we are now happily in a condition to reject our
venerable notions concerning bad air, miasma, etc.

     Before describing the method by which infection takes place, it is
     well to say a few words concerning the mosquito that acts as a
     carrier of the disease, which may be easily differentiated from
     other similar gnats. The malarial mosquito has a body which is
     placed parallel to and almost on the same plane with the front
     portions of the insect, and as a consequence, when at rest on walls
     or other objects, the back of the body sticks out almost or quite
     at right angles with the surface upon which it is resting. The back
     portion of the common mosquito forms an angle with the front part
     of its body, with the effect that both ends of the insect point
     toward the object upon which it rests. There are still other
     differences that clearly differentiate the malarial from the common
     mosquito, but the one given ordinarily serves to distinguish
     between them. The malarial mosquito is pre-eminently a house-gnat,
     being scarcely ever seen in the woods or open, but may be
     found--oftentimes in great numbers--in all malarial localities,
     lying quietly during the day in dark corners of rooms or stables.
     This mosquito practically never bites in the day, but will do so
     in a darkened room, if a person will remain perfectly quiet; their
     favorite time for feeding is in the early parts of the night and
     about daybreak--all of which accounts for the fact, long observed,
     that malarial fever is almost invariably contracted at night. The
     malarial mosquito bites and then goes back to some dark corner
     where it remains quiescent for forty-eight hours, at the end of
     which time it again descends to feed. Contrary to the general
     opinion mosquitoes bite many times, and frequently remain alive for
     months--the malarial mosquito particularly living in cellars and
     attics oftentimes throughout the entire winter.

     If one of these mosquitoes bite a person with malaria, the
     parasites are sucked in along with the blood and pass into the
     stomach of the gnat, making their way ultimately into the body
     substance; here the parasites undergo a series of multiplications,
     a single one of them sometimes producing as many as ten thousand
     young malarial parasites. After the parasites have developed fully,
     which requires eight days in warm weather, they make their way to
     the venom-gland of the mosquito and there remain until it bites,
     when they are injected into the body of the individual attacked
     along with the poison.

     After getting into the human blood, each parasite attacks a
     red-blood cell, bores into it, and grows at the expense of the cell
     until it reaches maturity, at which time it divides up into from
     seven to twenty-five young parasites which are liberated and each
     in turn attacks a new cell. This process goes on until a
     sufficient number of parasites are produced in the individual to
     cause the symptoms of malaria, and the new subject of the disease
     thereafter becomes a source of danger to others in the vicinity
     through the intervention of still other malarial mosquitoes.

_Malaria Avoidable._--From the foregoing it is seen that the proper way
to avoid malaria is so to screen houses that mosquitoes cannot enter
them. Persons in malarial districts should not sit on open porches at
night, and should be careful to sleep under properly constructed nets. If
this be done, there is absolutely no danger of anyone ever contracting
the disease. It will be well observed that these precautions are not
necessary in the daytime, as the malarial mosquito rarely attempts to
bite during this period.

It should be remembered by those who have the disease that they are a
constant source of danger to people living in the vicinity, and they
should be doubly careful as long as the disease persists to avoid being
bitten by mosquitoes at night. It is furthermore their duty to vigorously
treat the disease until the parasites are no longer present in their
bodies, at which time they cease to be a menace to others.

Many children have malaria without showing symptoms, and, if allowed to
sleep without being properly covered with a net, are very apt to infect a
large number of malarial mosquitoes; the blood of children in malarial
localities should be examined from time to time, and if the parasites be
found, the children should be given the proper remedies until a cure is
effected.

Particular attention should also be directed to the fact that almost all
Negroes in malarial localities of the South harbor the parasites, though
very few of them show symptoms of their attacks. It is, therefore, very
important that they be treated properly, and their white neighbors should
see to it, for their own safety, that they do not sleep in houses
unprotected by nets.

If the precautions herein detailed were properly carried out, for even a
few months, malaria would practically cease to exist wherever this was
done, and would not recur unless individuals from other places suffering
from the disease were to come into the districts where the Anopheles
mosquito is present, and so give it to the gnats--to be by them
recommunicated to humanity.


TUBERCULOSIS.

Of all the enemies of mankind, tuberculosis, in its various forms, takes
the first rank. Of protean manifestations, occurring in almost every part
of the body and producing diseases of the brain, of the nerves, of the
bones, of the skin, and of all of the internal organs--pre-eminent is the
terrible malady we call consumption, which is tuberculosis of the lungs.
It has been estimated that one-seventh of all the people born into the
world die as a result of this malady in some one of its various forms,
and it is probable that one person out of every three dying between the
ages of fifteen and sixty years, succumb to this disease. As a result of
the labors of thousands of patient, self-sacrificing investigators--many
of the most distinguished of whom have died of this disease while
carrying on their work--the peculiarities of this affection are now
fairly well understood, and if we were to apply the knowledge which we
now possess in our attempts to free ourselves from its ravages, there is
no question but that within a comparatively short period of time the
disease would practically cease to exist.

_Character and Course of the Disease._--Tuberculosis is produced by a
minute vegetable parasite known as the _Bacillus tuberculosis_, a germ
which not only occurs in the human being, but is widely distributed among
the lower animals. Tuberculosis of the lungs (to restrict ourselves to
this most important manifestation) generally comes on insidiously, there
being usually no definite period from which the sufferer can date the
onset of the malady. In the early stages there is usually loss of
appetite and a pronounced feeling of weakness followed by a slight cough;
the latter symptom frequently leads patients to erroneously believe that
their trouble began with a bad cold, when as a matter of fact, the
catarrhal trouble of the throat and bronchial tubes was originally
produced by the germs of tuberculosis--there being no such thing as a
cold changing into consumption. As the disease progresses the patient
complains of fever and chills, these symptoms being oftentimes
periodical, and lead to the belief that the trouble is malarial fever:
this mistake is very common, and whenever such symptoms appear a good
physician should be immediately consulted. The patient also suffers from
exhausting night-sweats in many instances, though this is not invariable.
A rapid loss of flesh is one of the earliest and most common symptoms.
The symptoms above enumerated continue and grow worse, and in quite a
proportion of the cases there is, in addition, spitting up blood, which
in some instances may be so pronounced that it becomes a distinct
hemorrhage. In the more rapid or "galloping" forms of the disease the
patient frequently dies within a few weeks or a month or so, while in the
less severe types the malady may persist for many years before death
occurs.

_Treatment._--The treatment of tuberculosis by drugs has proven an entire
failure, but a large number of persons afflicted with this disease will
recover, if placed under proper hygienic conditions.

The patient should be put on a porch or in a tent, whether it be winter
or summer, and kept in bed at absolute rest as long as there is any
fever, and should be fed in abundance with good, wholesome food. While
this treatment appears simple it should always be carried out under the
directions of a physician, as it is only possible for those having a
thorough knowledge of the subject to give such directions as would lead
to a rapid cure of the patient.

_Modes of Infection._--Hereditary tuberculosis, notwithstanding a popular
idea to the contrary, is very rare, but there is no question that those
persons in whose family tuberculosis exists are much more prone to
contract the disease than others. In just what manner the germ of
consumption gains entrance to the human body, we are more or less
uncertain, but there are reasons for the belief that in many instances
they pass in by means of the inhaled air; there is no doubt that in a
small percentage of cases the bacillus gains entrance to the body through
an abrasion of the skin or of some mucous membrane; finally the bacteria
are often taken in with the foods that we eat, or by putting objects
upon which the germs are present into the mouth, or eating with hands
which have been contaminated and not washed. Of the foods that contain
the germs of consumption, milk is unquestionably the most common, as
there can be no question that fully 25 per cent. of our cows have this
disease, and under such circumstances their milk is usually infected with
the bacillus that produces the malady; meats, likewise, often contain
germs of this disease, but, as they are usually cooked, no harm, as a
rule, results.

Of quite as much importance as the introduction of the germ into the body
is the resisting power of the individual at the time when this occurs,
since the disease can make no progress unless the tissues have become
susceptible through lowered resistance. All things then that have the
effect of lowering the vitality of the body act as predisposing causes to
consumption; such, for example, as _WANT OF PROPER FOOD_, _LACK OF
SLEEP_, _IMPROPER CLOTHING IN COLD AND WET WEATHER_, _AND LIVING IN DAMP
AND IMPROPERLY VENTILATED HOUSES_; excesses, _PARTICULARLY THE TAKING OF
ALCOHOL_, conduce to the development of the disease--long-continued
inebriety being beyond doubt the cause that most frequently leads to
consumption. It is a common error that alcoholic stimulants tend to ward
off consumption, and it is absolutely certain that these substances not
only do not act in a curative way in those who have already contracted
the disease, but are positively detrimental. In order then to avoid
consumption--and this is particularly of importance for those in whose
family there is a predisposition to the disease--the individual should
live soberly, should try at all times to obtain a reasonable amount of
good food, should sleep a sufficient number of hours, and should be
clothed properly, particularly in the winter. Those who devote their time
and energy to the performance of their work--being careful of course not
to labor excessively--are much more apt to escape consumption than those
who do otherwise. It is particularly of importance that those who have a
tendency towards consumption should early learn, and throughout life
practice, the habit of _BREATHING THROUGH THE NOSE_: if this rule be
followed a large percentage not only of the germs of consumption, but
other bacteria as well, are filtered out during their passage through the
nose and do not reach the lungs. Cleanliness is also of much
importance--a bath taken each morning in moderately cold water being
conducive to health, not only as regards consumption but other diseases
as well. It is of course necessary that dwelling houses should be kept
thoroughly clean.

     _Advice to Diseased Persons._--In all cases where a person observes
     in himself, or in those for whom he is responsible, the symptoms
     already detailed, it is his duty to at once consult an intelligent
     physician, and if it be found that tuberculosis is present, every
     precaution should be taken by the diseased individual to prevent
     the further spread of the malady. _IN SUCH A CASE THE SPUTUM THAT
     IS CONSTANTLY BEING COUGHED UP CONTAINS MYRIADS OF THE GERMS,_ and
     it is of the utmost importance in order to prevent other persons in
     the neighborhood from being infected that this _SPUTUM BE
     DESTROYED_. The patient should at all times carry about with him
     either a small receptacle into which the sputum can be
     expectorated, or a large cloth which would answer the same
     purpose, and in either case the sputum should be burned; if this be
     impracticable, it should be placed in some good antiseptic, such as
     a saturated solution of carbolic acid or a 1-to-1,000 solution of
     corrosive sublimate in water. The patient's handkerchiefs should be
     thoroughly boiled, and his clothing should receive like treatment.
     Every precaution should at all times be observed in order to
     prevent the sputum getting onto the furniture or floors, as, under
     such circumstances, it quickly dries and being broken up into small
     particles is carried by means of the air to other parts of the
     house.

     The patient should always remember that the quicker he is placed
     under proper treatment the more the chances of ultimate recovery;
     in the early stages almost all of the cases of this kind are
     curable, but later this is not often accomplished.


TYPHOID FEVER.

Of all of the infectious diseases prevalent in the United States, typhoid
fever is one of the most common and fatal. As a result of its ravages a
vast amount of invalidism, suffering and financial loss is brought about
each year, and a frightful mortality results. It has for some time been
recognized that typhoid fever is among the most preventable of all
diseases, and if our people would bestir themselves and carry out the
comparatively simple rules that are necessary for its prevention, the
scourge would, in a short time, practically cease to exist among us.

_Character and Course of the Disease._--Typhoid fever, enteric fever, or
abdominal typhus, is an infectious disease believed to be caused by a
specific bacterial germ known as the _Bacillus typhosus_. It develops, as
a rule, quite slowly, the first symptoms being loss of appetite,
headache, and a marked fatigue on slight exertion. These symptoms
gradually grow worse, fever develops, and the patient oftentimes suffers
with chilly sensations; the temperature gradually rises, and in the
course of from a few days to a week reaches a height of 102 degrees, 103
degrees, 104 degrees, or 105 degrees F. In many cases no symptoms exist
that indicate trouble with the bowels, but in the severe forms of the
disease diarrhoea generally comes on during the first week and continues
throughout the course of the disease.

During the second week the symptoms above detailed continue, becoming
often more severe, and there develops great nervousness and delirium.
About this time there are frequently observed over the chest, abdomen and
thighs, minute reddish spots resembling flea-bites; these spots last for
a few days and then pass away and are followed by a fresh crop in other
situations. During this period of the disease inflammation of the
bronchial tubes frequently comes on, and now and then pneumonia develops.
Bleeding from the bowels is an occasional highly characteristic symptom
of the second week. When the disease follows a normal course, the
symptoms during the third week begin gradually to abate; the fever
lessens, and the patient, though much emaciated, gradually returns to a
normal condition.

     Unfortunately, however, the disease does not always pursue this
     favorable course, for, in quite a proportion of instances, the
     symptoms increase in severity during the second or third week, the
     patient becomes profoundly prostrated, the delirium deepens, and
     death occurs. The hemorrhage from the bowels, in some instances, is
     so severe that death is produced even in comparatively early stages
     of the affection.

     In many instances, through indiscretion, usually as a result of
     eating solid food, patients who are apparently on the road to rapid
     recovery, relapse, and the disease repeats the course already
     detailed.

     It is of importance to remember that now and then so-called walking
     cases of typhoid fever occur, the disease in these instances being
     characterized by the fact that the symptoms are so slight that the
     sufferer does not feel it necessary to go to bed. However, in these
     mild cases, fatal hemorrhage from the bowels is as frequent as in
     the severer types, and as a consequence the patient should receive
     careful attention. Moreover, it is of importance to remember that
     from this mild form of the affection the most malignant varieties
     of the disease may be contracted.

     The mortality in typhoid fever varies from five to twenty per
     cent., depending upon the character of the disease and the nature
     of the nursing and treatment that the patient receives.

_Modes of Infection._--It is clear that typhoid fever is the result of
the entrance into the body of some minute form of germ-life, whether this
be the bacterium generally supposed to induce the disease or not. This
contagion is beyond question a living something which multiplies with
great rapidity under proper conditions, and, escaping from the bodies of
those infected with the disease, in one way or another, reaches other
individuals. It is beyond question true that the virus passes from the
body of those infected by means of the urine and feces, and it is likely
that the secretions from the mouth and nose frequently contain the germs
that cause the fever.

As the germs are certainly extraordinarily minute, a very small amount of
any of these excretions might produce the disease in healthy individuals
if it were to get into their bodies through water, milk, or any uncooked
food, or if it were to find lodgment about the nose or mouth, or get upon
the hands of other persons. It should also be remembered that the virus
may easily get upon cooking-utensils, drinking-cups, bed-linen, and other
articles with which we are constantly brought into close contact, and
that the disease might be transmitted in this way. It is also true that
the malady may be carried from place to place by insects, particularly
flies; the latter may readily get enough infectious material upon their
legs in various ways, and then, crawling over the food, leave the deadly
poison deposited upon it.

_Treatment of Typhoid Fever._--As soon as the symptoms appear, a
physician should be called and his directions faithfully and carefully
followed out. Nothing in this disease is of more importance than careful
nursing, and it is absolutely necessary that the patient receive only
liquid diet until the physician permits other food.

Wherever possible then, patients with typhoid fever should be completely
isolated, since, if this is not done, other members of the family are
almost sure to contract the malady--a result which almost everyone has
seen who has had any experience with the disease. Wherever possible
patients should be sent to a hospital, but where this cannot be done they
should be placed in an outhouse, if practicable, or in an isolated room,
which should be thoroughly disinfected after the patient's recovery. No
one should visit a typhoid-fever patient, except when compelled to do so,
and we should be particularly careful to prevent children from coming in
contact with them, as it has been shown that they contract the disease
much more readily than grown people. It is also of importance that
persons should not sit for any length of time in the sick room, and,
above all, under no circumstances, should cooking and eating be done
there. The room in which the patient is placed should be furnished only
with those things absolutely necessary, and it is particularly desirable
that carpets and curtains should be removed. It is well to wash the floor
each day with some antiseptic solution.

Those persons who come in contact with typhoid fever should wear outer
clothing which can be easily washed and boiled. After touching the
patient, or any of his clothing, the hands should be at once thoroughly
scrubbed in an antiseptic solution. Of course, under no circumstances,
should the nurse eat or drink from the same vessels that the patient
does.

None of the excretions from persons afflicted with typhoid fever should
ever be emptied until thoroughly disinfected with creo-carboline or
strong lime-water, and under no circumstances should these be poured out
in the neighborhood of springs or wells. Towels, handkerchiefs, and
clothing that comes in contact with the patient should be thoroughly
disinfected before being sent to the laundry. This is best accomplished
by thorough boiling, but in cases where this can not be at once carried
out, it is advisable to use some chemical antiseptic; of these, perhaps
the best is creo-carboline, which may be employed in a 1-500 solution in
water; where this solution is not obtainable, a 5-per-cent. solution of
carbolic acid in water will answer. It should also be remembered that the
water in which typhoid-fever patients are bathed necessarily becomes
infected, and this should always be thoroughly disinfected before being
emptied. These precautions should be carried out for some time after the
patient has recovered, as it is well known that persons, under such
circumstances, for some time frequently contain the poison in their
evacuations.

     After the patient recovers, the room should be disinfected with
     formaldehyde gas obtained from the substance known as "formalin."
     This gas may now be obtained from the formalin without the use of
     heat in the following manner: When everything is ready, and the
     room properly sealed, thirteen ounces of permanganate of potash to
     each quart of formalin are placed in a large vessel, the room being
     closed immediately after the two substances are put together; it is
     important that the permanganate be placed in the vessel first. When
     this method is employed a quart of formalin should be used to each
     one thousand cubic feet of air-space in the room. As the gas, by
     this process, comes off with great rapidity, it is not necessary
     to keep the room closed more than about four hours. This method is
     to be advised for the reasons that it acts more quickly than the
     older one, and there is never danger of fire.

     In cases where houses are too open to permit of disinfection by
     means of gas, the sick chamber should be thoroughly washed with a
     solution of corrosive sublimate, carbolic acid or some other good
     disinfectant.


HOOK-WORM DISEASE.

It has been only recently recognized that a large percentage of the
invalidism and a great number of the deaths yearly in the southern
portion of the United States are caused by a very small intestinal
parasite known as the _Necator americanus_, or hook-worm. This parasite
has unquestionably existed over the area just named since the advent of
the Negro--recent investigations having shown that the worm is in all
probability of African origin. This hook-worm disease is probably the
most common of all the serious diseases prevalent in the South, and as it
is easily curable, and can be readily prevented, there is no matter which
should be of greater interest to the people in the infected regions,
especially those who live in villages or on farms.

_Character of the Disease._--The animal parasite called hook-worm closely
resembles, externally, the pin-worm which so often occurs in children.
The female, which is larger than the male, measures somewhat more than
half an inch in length, and has the thickness of a knitting-needle; the
male is between a quarter and three-eighths of an inch in length as a
rule. The parasite possesses around its mouth a row of minute plates
somewhat resembling hooklets, by means of which it grasps hold of the
mucous membrane of the intestine and bruises it sufficiently to cause the
blood to flow; with this blood the parasite nourishes itself. At the same
time the worm injects into the tissues a poison which has much to do with
the symptoms that occur in the disease that it produces.

These worms are usually present in great numbers, there being as a rule
from 500 to 2,000 of them, and as they unquestionably live at least eight
or ten years, the unfortunate victim suffers for a long period of time as
a result of their presence. While living in the intestines the females
lay enormous numbers of eggs which pass out with the feces, and under
suitable conditions of temperature and moisture there develops within
each of them, within from two to three days, a minute snake-like embryo
which bursts through the shell of the egg and passes into the neighboring
earth. Here the embryos live for considerable periods of time, and,
ultimately, may infect other individuals, or those from whom the eggs
were passed. There are at least two ways by which these embryos gain
entrance into the human body. Some do so by getting into drinking-water
and being swallowed; but, extraordinarily, they most frequently penetrate
through the skin. When this happens the parasite, in passing through the
skin, produces the disease known as "ground-itch." The vast majority of
the victims of this affection are children with whose skin the embryo
comes in contact while they go barefooted during the summer months.

_Course of the Disease._--Having entered through the skin, the embryos of
the hook-worm, moving by a circuitous route finally reach the intestines,
and, grasping hold of the mucous membrane with their saw-like teeth, they
begin to suck blood and grow until they reach the size of the adult worm
in about a month or six weeks. Depending upon the number which have
gained entrance, and the susceptibility of the individual, there now
begins to develop symptoms of profound anæmia; the skin of the child
becomes very pale, and assumes a sort of yellowish hue, and in cases
where there is a severe infection, the victim begins to suffer with
shortness of breath and dropsy. When this occurs the patient sometimes
dies, but more commonly death results from contracting some other
disease, which, under ordinary conditions, would produce no serious
results. One of the most unfortunate effects of this malady is that when
children become infected they cease to grow, and frequently retain the
appearance of early youth even after they have reached full maturity in
years. These unfortunates are generally incorrectly regarded as
dirt-eaters. The symptoms frequently last over a period of many years, as
in the intestines of these victims the worms that originally infect them
live certainly eight or ten years, and during this period it is beyond
question true that additions to the original number are frequently
received.

_Diagnosis and Treatment._--There is no disease that can be
diagnosticated with more ease and certainty; the eggs are present in the
feces in great numbers, and by means of a microscope they can always be
detected. In all cases where the disease is suspected, a half-teaspoonful
of the feces of the person supposed to be infected should be placed in a
bottle and sent to a competent microscopist for examination. This is done
free of charge at the laboratories of most State Boards of Health in
those parts of the country where the malady exists. Whenever an
individual shows the symptoms above detailed, an intelligent physician
should at once be called. We have medicines that act as specifics, and
the disease can always be cured in a very short period of time.

_Preventive Measures._--Of course the best method of preventing this
disease is to administer to those already infected the proper medicines,
and cause the expulsion from the intestines of the worms that lay the
eggs.

The indiscriminate scattering of the feces around the stables, so very
common in many districts, should be absolutely forbidden. Around the
house where individuals have lived who have the disease every care should
be taken to prevent contact with the earth in the neighborhood of places
where the ground might have become infected. It would be advisable for
children and others to wear shoes for at least a year after the last
individual having the disease was cured; and as a precautionary measure
it should be insisted upon that properly constructed privies or
water-closets should be at every house, and that they should be used by
everyone in whom there is a possibility that the disease exists.


DIPHTHERIA AND ITS TREATMENT.

Loeffler's discovery in 1884 of the germ of diphtheria, and its relation
to the disease of the same name, established the specific infectious
nature of this malady, and demonstrated beyond a doubt that membranous
croup is not ordinarily an independent affection, but is almost always
simply diphtheria of the wind-pipe. The discovery of antitoxin, some time
later, reduced the mortality of diphtheria from an average of 30% to 10%
in ten years; its use has also shortened the course of the disease, and
decreased greatly the frequency of the paralytic conditions that not
uncommonly follow this malady.

_Character and Course of Diphtheria._--Diphtheria is an affection caused
by a bacterial microbe which produces a poison that acts locally upon the
tissues invaded, and also, as a result of its introduction into the
general circulation, brings about more or less profound effects on the
entire system.

The period of incubation is from two to ten days. The onset is generally
characterized by a rise of temperature from 100°F. to 104°F., chilliness,
headache, and pain in the back and limbs. Albuminuria is common. The
glands of the neck often become swollen. In mild attacks a slight sore
throat is all that is complained of. In the majority of cases the disease
attacks the throat and tonsils, and is characterized locally by the
appearance of a membrane, which is usually gray or yellowish-white,
elastic, and adheres tightly to the surface upon which it lies. At
times, however, the membrane is soft and pliable, and is easily separated
from the tissue; such cases are frequently diagnosticated as follicular
tonsillitis. A bad cold is occasionally the only symptom of the disease.
The diagnosis should always be confirmed by bacteriologic examination. In
some instances the wind-pipe is primarily attacked, but when the disease
affects this part of the throat it is generally a consequence of the
extension of the membrane downward from the region of the tonsils. In the
former case the diagnosis is somewhat difficult, as cultures taken from
the throat may not show the presence of diphtheria bacilli, though
material that is coughed up may contain myriads of the germs; in this
phase of the disease interference with respiration is the symptom most to
be feared. The mucous membrane of the nose, eyes, ears and generative
organs, may be affected. Wounds are also liable to become infected with
this organism. In rare instances the membrane may extend down into the
bronchial tubes and lungs, and has been found on post-mortem examination
covering the inside of the stomach.

As complications we may have broncho-pneumonia, acute Bright's disease,
inflammation of the internal structures of the ears, bleeding from the
nose, inflammation of the valves of the heart, and sometimes paralysis of
this organ, with death; the last named sequel of diphtheria comes on
during convalescence, usually from two to four weeks after the subsidence
of local symptoms, and is due to inflammation of the nerves that control
the heart. Much less commonly paralytic conditions of the palate, throat,
eye muscles and the nerves of taste occur, and under rare conditions,
paralysis of the lower extremities. Paralysis of some kind follows in
from ten per cent. to fifteen per cent. of the cases, and appears with
equal frequency after the mildest as well as following the most severe
cases.

_Mode of Infection._--The germs of diphtheria may be carried in articles
used by persons with the disease, or they may be communicated by direct
contact. The micro-organism is found in the secretions from the mouth,
throat, or nose, and in particles of detached membrane. Bedding,
utensils, etc., used in the room where a patient has diphtheria, are
liable to carry the germs if taken from the sick-room, and consequently
should be always properly disinfected before being removed. Milk-bottles
carried into the sick-room, or handled by persons caring for the patient,
should never be returned to the dealer without being disinfected. Cats,
and less frequently dogs, may contract the disease and convey it to those
with whom they come in contact. Unrecognized mild cases are a frequent
means of spreading the disease, as also is a too early release of
patients after recovery. It is a much safer method of procedure to
require at least two negative examinations before releasing a patient
from quarantine, as during convalescence the germs may be entirely absent
on one day and a few days later be quite abundant. The bacilli may remain
in the throat from a few days to several years after the disease is
apparently entirely well, and under such circumstances the persons
carrying them become quite as great, if not a greater, menace to those
with whom they came in contact as they were during the height of the
disease. A thorough disinfection of the room and everything used about
the sick person should be carried out after the patient is released.
Complete isolation should be observed during the illness, and as long as
the bacilli remains in the throat.

_Treatment._--Diphtheria antitoxin is the specific treatment of this
malady, and should be given early in the disease. The chances of recovery
decrease in proportion to the length of time existing between the onset
of the affection and the time of administration of the drug. Antitoxin
may be repeated in six hours after the initial injection if improvement
is not noticed, but ordinarily twenty-four hours should elapse between
doses. It is well to remember that it is safer to give too much antitoxin
than too little. The initial curative dose varies from 2,000 to 5,000
units, according to the age of the patient and the severity of the
disease. When a case is seen late it is often advisable to begin with a
large dose,--it being good practice under such circumstances to use at
once as much as 10,000 units or even more. The average case requires from
the beginning to the end of the treatment a total of from 10,000 to
20,000 units, but occasionally 50,000 or even 100,000 units may be
necessary. There are very few risks in giving antitoxin. In a series of
50,000 cases treated with it only two deaths occurred sufficiently early
after the injections to warrant the belief that this unhappy result was
produced by the drug. It is worth remembering that asthmatic cases bear
the administration of antitoxin very poorly; a marked and sometimes
serious embarrassment of respiration, with cyanosis, unconsciousness, and
general collapse may follow its use, but recovery is usual in such cases.

     A condition known as anaphylaxis or hypersensitiveness, which at
     present is being much studied, may sometimes occur in the human
     being. This hypersensitiveness is manifested by the extraordinary
     peculiarity that any number of doses of antitoxin may be given
     provided they are administered within a period of less than ten or
     twelve days. On the other hand a single minute dose may induce this
     state after the period named, and, as we never know whether a
     patient is going to develop it or not, it becomes a question as to
     the safety of giving a second injection after ten or twelve days
     have elapsed following the administration of the initial treatment.
     As it is true that this hypersensitiveness once established in
     animals may continue throughout life, it becomes a question as to
     whether or not it is quite safe to administer antitoxin to an
     individual who has had the drug given him at some prior time, and
     we are not as yet in a position to definitely determine the risks
     that are involved in such a procedure. There is no reason to doubt
     that this hypersensitiveness is much less marked in man than in the
     lower animals, and there can be no question that it much less
     commonly develops, but notwithstanding this it would be the part of
     prudence to avoid a second administration of the drug after the
     interval referred to in all instances where this seems possible.
     Anaphylaxis is thus seen to bear an important relationship to what
     is commonly called the "immunizing treatment" to prevent
     diphtheria, which consists in giving a moderate dose of antitoxin
     to a person immediately after exposure to the disease. Under such
     circumstances a degree of immunity is undoubtedly secured, but this
     passes off in the course of a few weeks, and the patient then
     becomes just as susceptible as he was before. Should he now
     contract diphtheria, we would be confronted with the possibility
     that the treatment by means of antitoxin might possibly produce
     serious and even fatal results.

     Occasionally rashes occur several days after the inoculation, but
     such disturbances are insignificant except for the immediate
     discomfort experienced. Antitoxin concentrated by the Gibson method
     has reduced to a considerable extent the number of cases in which
     rashes occur.

Treatment other than by antitoxin is symptomatic. Where the disease
occurs in the wind-pipe, it may be necessary to pass a tube into its
upper opening to allow the patient to breathe, and in other instances the
wind-pipe is itself opened from the outside in order to permit a
sufficient amount of air to enter the lungs to maintain life.

It is of the utmost importance that patients be kept in bed until all
danger of complications has passed. Death from heart-failure several
weeks after the diphtheria in the throat is well, is not an uncommon
result of the disease, and is especially prone to follow even the
slightest exertion. Patients under such circumstances have been known to
die from raising themselves up in the bed.


CEREBROSPINAL MENINGITIS.

Meningitis, or spotted fever, is one of the most terrible and fatal of
all diseases, every case proving fatal in some local epidemics.

Although the cause of the disease has been known for a number of years,
the exact method by which the germ that produces it spreads from man to
man was until quite recently entirely unrecognized, and even now it
cannot be said that the whole matter has been demonstrated.

_Character and Course of the Disease._--Cerebrospinal meningitis is
produced by a minute vegetable (bacterium), the _Micrococcus
intracellularis_. This germ does not appear to occur normally in any of
the lower animals, nor has it been found in the outer world, and is
therefore to be regarded as distinctly a human parasite. It is very
fortunately a germ of low vitality, as it develops only at about blood
heat, and when expelled from its normal dwelling-place in the human body
it dies very quickly.

     The accompanying illustration shows how these bacteria appear under
     the microscope; the drawing was made from fluid taken from the
     spinal canal of a patient suffering from cerebrospinal meningitis.
     These germs get within the skull and spinal canal, and produce
     violent inflammation of the coverings of the brain and cord; these
     membranes are called "meninges," hence the name "cerebrospinal
     meningitis." Within a short time after their entrance pus is
     produced, and the condition becomes practically one of abscess
     around the brain and spinal cord.

In almost all cases the disease is preceded by a slight catarrhal
condition of the nose and throat, the symptoms being those of an
ordinary cold. The symptoms that point to the covering of the brain being
attacked come on with great suddenness; there is usually a chill,
followed by intense headache, vomiting, restlessness, with great dread of
noises and bright light; in many cases reddish spots appear beneath the
skin, and these are usually tender on pressure. In some cases the muscles
of the neck become very stiff, and contract so that the head is drawn
backward. The temperature is somewhat irregular, but is always above
normal in the beginning, and sometimes goes very high; the pulse as a
rule is normal, or but little accelerated. After the patient remains in
this condition for a period varying from a few hours to several days, he
generally becomes unconscious, and in a comparatively short time dies. In
some cases the symptoms after starting off very violently quickly
subside, and the patient makes a comparatively rapid recovery. In other
instances the disease begins more mildly, the patient having more or less
of the usual symptoms, but not so severely as is ordinarily the case; in
such cases the patient may die, after lingering weeks or months; or may
make a protracted recovery, frequently with partial paralytic conditions
that permanently remain.

     Unfortunately we possess no specific for this disease. Recently
     there has come into vogue a treatment by a serum supposed to have
     antitoxic power against this disease, but its exact value is, as
     yet, by no means settled; it must be used early if any good is to
     be expected from it. In addition to the antitoxin all that can be
     done is to keep the patient quiet with anodynes, and to minister to
     his comfort in every way possible. Ice applications to the head
     sometimes alleviate the intense headache. As the disease is
     practically an abscess around the brain and cord, perhaps the most
     rational treatment would be to open up the skull and let the pus
     drain away.

_Mode of Infection._--As this disease is one that is due to a specific
germ it is obvious that it cannot exist without the presence of this
organism; the malady is therefore infectious, and must necessarily be to
a certain extent contagious, notwithstanding the fact that it is
generally thought not to be so. The reason that the affection has not
been thought to be contagious may be explained by the following facts:
Recent investigation has shown that in many, if not all, instances of
this disease, the germ may be found in the nose and throat, where, as
has already been explained, it sets up a condition resembling an ordinary
cold. In all probability the infection takes place in the nasal cavity
first, and the germ ultimately finds its way to the coverings of the
brain. Now there is every reason to believe that in many, and probably in
a great majority of instances, the germ goes no further than the mucous
membrane of the nose, and the patient merely has as a consequence what he
considers an ordinary cold. It is clear, however, that if another
individual, who was very susceptible to this germ, should contract the
disease from this person, he might have the meningeal form of it. In
other words, it is probably true that the vast majority of people who are
attacked by this organism simply get colds as a consequence, and only now
and then does a person get meningitis as a result. This explains why the
disease does not ordinarily appear contagious.

The facts above stated are of much importance in combating the spread of
this disease. People who are exposed to those having meningitis should be
exceedingly careful not to get upon their persons any of the secretions
that come from the patient, and during periods of epidemics those who
observe a bad cold coming on should promptly consult their physicians,
and do everything to prevent the development of all catarrhal conditions
in their noses.

During epidemics persons with colds should be very careful not to allow
other people to become infected from them. As cold and wet are
undoubtedly predisposing causes to colds it is well for everyone to shun
such exposure during periods when meningitis is prevalent; debilitating
influences, such as alcoholic excess and lack of sleep, should also be
avoided.


HYDROPHOBIA.

This disease, as it occurs in man, is practically always conveyed by the
bite of some animal, the dog being the usual offender. The poison is
present in the saliva of the diseased animal and is transmitted through
wounds made by its bite.

As observed in the dog, there are two types of the disease,--one the
"furious," the other the "paralytic."

     _In the furious type_ the animal first appears to be restless and
     somewhat excited. He seeks dark places and apparently prefers to be
     by himself. In this stage of the disease the dog's appetite is good
     and may be excessive; he responds to orders although his attention
     can be attracted only for a moment at a time. As the malady
     progresses the animal becomes more and more restless, and develops
     a desire to tear those things about him into pieces. There is
     described a peculiar bark at this stage of the disease; instead of
     ending as it ordinarily does, it is prolonged and terminates in a
     higher pitched note simulating a cry. This is supposed to be very
     characteristic at this stage of the affection. The appetite
     gradually diminishes, food is refused, and swallowing becomes
     difficult. As the symptoms gradually progress the dog shows signs
     of delirium and begins to wander. As a rule, he goes about with his
     tail hung, mouth wide open, and with a wild look in his eyes,
     biting as he goes, anything that happens to be directly in his
     path; seldom does he turn aside to disturb anything or anybody. In
     the later stages of the disease paralysis generally develops,
     beginning in the hind legs and soon involving the body. If the
     animal be now carefully observed it will be seen that he cannot
     swallow. There is no dread of water, as the name "hydrophobia"
     implies, and as is commonly thought, the animal often attempting to
     drink, but owing to the paralysis of the muscles of the throat this
     is impossible. Inability then to swallow either water or solid food
     is one of the surest and most reliable signs of rabies. Weakness
     becomes very marked, and the animal finally lies down in a stupor
     and dies. The entire course of this type may last from six to ten
     days; generally it is four or five.

     _The paralytic type_ of the disease occurs in fifteen or twenty per
     cent. of the cases. The onset is, as a rule, the same as that
     observed in the furious type. Instead, however, of the dog
     beginning to wander, as previously mentioned, the animal becomes
     paralyzed, the paralysis first affecting the muscles of the jaw,
     later of the tongue. As is the case in the furious type of the
     disease, the animal loses the power to swallow both solids and
     liquids, but has no fear of water. The mouth remains wide open, the
     tongue protruding, and an abundant amount of thick saliva exudes.
     The animal remains quiet, does not attempt to bite any animal or
     individual. Death occurs on the second or third day of the disease.

_Precautions._--When an individual is bitten by an animal either supposed
or known to be rabid, the wound should be immediately cauterized with
some caustic, preferably concentrated nitric acid. This should be applied
without fear because it is safer to use too much than too little. In case
this is not available any strong caustic may be used. Punctured wounds
should be laid open with a knife and the surfaces freely cauterized. It
should not be forgotten that the slightest scratch from the tooth of a
rabid animal may lead to the development of hydrophobia in man, and it
therefore behooves all persons bitten by dogs to take every precaution
possible. Even though the animal at the time may appear to be healthy,
some strong antiseptic should be applied to the wound, and the animal
carefully watched until all possibility of his having the disease has
passed. Many persons have died from slight wounds inflicted by animals
appearing at the time to be perfectly well.

Attention should also be directed to the fact that wounds where the teeth
of the animal pass through the clothing are not so dangerous as those
where no such protection intervenes. Bites about the face and head are
much more frequently followed by rabies than those inflicted on the
extremities, and, of course, where wounds are deep the chances of
infection are much greater; where injuries of the latter kind are
inflicted it is practically out of the question to thoroughly cauterize
them, and the patient should immediately receive the Pasteur treatment.
It is probable that if thorough cauterization be not done within five
minutes that it cannot be relied on to prevent the development of the
disease; where there is any doubt the only safety lies in the Pasteur
treatment. Where a person is bitten by a dog supposed to be rabid the
animal should be caught, if possible, and kept carefully isolated for at
least ten days; should it appear well after the expiration of this period
no fear need be felt as to the results of its bite, but if it should die
the head should be cut off, packed in ice, and sent to some laboratory
for examination.

_Under no condition should the animal be killed, as the best possible
proof of the harmlessness of its bite would lie in its continuing to
live._

_Treatment._--Since the epoch-making researches of Pasteur, laboratories
have been installed in various parts of the world for the purpose of
making a vaccine by means of which it is possible, by gradual
immunization, to prevent the development of hydrophobia in persons bitten
by rabid dogs. This is done by a series of injections of a weak virus
prepared according to the directions of Pasteur. _It should always be
remembered that no harm can come from the treatment whether the patient
was bitten by a rabid dog or not, and that in all cases of doubt no
hesitation should be felt in resorting to it._