Chapter 12

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 anaemia; 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 deg.F. to 104 deg.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._