Part 15
_Lockjaw, or Tetanus._—Afflicts man, horses, and dogs. The _Bacillus tetani_ is the most deadly of all known bacteria. It enters the body by wounds. It was discovered in 1884 by Nicolaier.
_Influenza, or the Grip._—Caused by one of the smallest-known bacilli; discovered in 1892 by Canon and Pfeiffer. Infection spreads by the scattering about by air-currents of the dried nasal and bronchial secretion of those suffering from the disease, and its portal of entry is by the nose and bronchial tubes.
_Pneumonia._—Caused by a coccus which grows in pairs and small chains. It enters the body by means of the respiratory tract. It is present in the saliva of twenty per cent. of healthy persons. Proved by Frankel in 1886 to be the cause of this disease.
_Bubonic Plague._—In 1894 Kitasato and Yersin isolated a small bacillus in a large number of cases and proved it to be the cause. It enters the body by means of wounds of the skin, and through bites of fleas from infected rats, which are said to be one of the chief factors in spreading this dread malady.
_Yellow Fever._—The cause of this disease is still under discussion.
Such are a few of the infectious diseases which we can readily attribute to the presence of definite micro-organisms in respective cases. But strange as it may seem, the most typical of all infectious diseases, small-pox, scarlet fever, measles, and hydrophobia, have as yet not yielded up their secrets. This is possibly due to the minute size of the micro-organisms concerned, which make it beyond the power of the best microscope to demonstrate them. In this connection it has recently been shown by Roux and Nocard that in the case of the disease known as pleuro-pneumonia of cattle the causative agent is so very small as just to be barely visible. Again, it is quite possible that these diseases may be caused by living things we know nothing about, which may be quite dissimilar from the bacteria.
INFECTION—ITS PROCESSES AND RESULTS
In the foregoing list of diseases associated with specific bacteria, attention has been drawn to the common modes of infection, or, as they are technically called, “portals of entry,” and it now remains to touch upon the main factors, processes, and results following upon the entry into the body of such disease-producing microbes.
It is a well-known fact that the normal blood has of itself to a considerable extent the power of killing germs which may wander into it through various channels. Likewise the tissue cells of the body in general show similar action depending upon the different cell groups, state of health, general robustness, and period of life. The germ-killing power varies in different individuals, though each may be quite healthy. Considered as a whole, this power possessed by the body against germs is known as “general resistance.” And when by any means this power of resistance is lost or diminished, we run grave risks of incurring disease.
Granted a case of infection, let us now trace up briefly what occurs. Between the period when the bacteria gain a lodgment and that in which the disease assumes a noticeable form, the patient simply feels out of sorts. It is during this stage that the blood and tissues are deeply engaged in the attempt to repel the attacks of the invading microbes.
With varying speed the germs multiply throughout the body generally, or may be at first localized, or even, as in lockjaw, remain localized throughout the entire disease. Multiplying in the tissues, they generate in increasing amounts their noxious poisons, which soon cause profound changes throughout the body; the patient becomes decidedly ill, and shows now the signs of an unmistakable infection.
Does the body now give up the fight entirely? No; on the contrary, the white blood-cells, the wandering cells, and the cells of the tissues most affected still carry on an unequal fight. From the lymphatic glands and spleen, armies of white cells rush to the fray and attempt to eat up and destroy the foe, but possibly in vain; the disease runs its course, to end either in death or recovery.
How, then, in cases of recovery, are the microbes finally overcome?
This question involves many complex processes which at present are by no means thoroughly understood, but we will concern ourselves with the simple principles.
It has been previously mentioned that once the bacteria get a good foothold the body is subjected to the action of generated poisons, which are known as toxins. They give rise to such symptoms as loss of appetite, headache, fever, pains and aches, and even a state of stupor or unconsciousness. In addition to the active warfare of the white blood-cells, groups of cells throughout the body, after recovering from the first rude shock of the toxins, begin to tolerate their presence, then effect a change in the chemical constitution of the toxins, and finally elaborate substances which antagonize the toxins and destroy their action altogether, thus lending aid to the warrior cells, which at last overcome the invading microbes. Recovery is brought about, and a more or less permanent degree of immunity against the special form of disease ensues.
Now if we could use these antagonizing substances, or, as they are called, antitoxins, upon other men or animals sick with a similar disease, would their bodies be at once strengthened to resist and finally overcome the disease? Yes, in a certain majority of cases they would, and this is exactly what scientific observers have noted, worked out, and have successfully applied. A new art in the healing of disease, which is spoken of broadly as serum-therapy, or medication by curative or protective serums, has thus been discovered.
The first observers in this new field were Pasteur and Raynaud in France in 1877–78, and Salmon and Smith in this country in 1886. Raynaud, by injecting serum from a calf which had had an attack of cow-pox, prevented the appearance of the disease in a calf freshly inoculated with the virulent material of the disease. Pasteur, by using feebly infective germs of fowl cholera, conferred immunity upon healthy fowls against the disease, and was able to cure those which were ill. Salmon and Smith injected small and repeated amounts of the elaborated toxins or poisons of the bacillus of hog cholera into healthy swine, and were able to confer immunity upon them.
However, it was not until Behring in 1892 announced his discovery of an antitoxin serum for diphtheria, along with an undisputed proof of its value in treatment, that the attention of the scientific world was finally aroused and stimulated to the appreciation of the great possibilities of serum-therapy.
Strange as it may seem, much opposition arose to this new method of treatment, not alone from the lay portions of the community, but even from the ranks of the medical profession itself. This opposition was due in part to misconceptions of the principles involved in the new doctrine, and in part to the falsely philanthropic prejudices of the pseudo-scientific sections of both parties. But by the persevering work of the enthusiastic believers in serum-therapy, positive conviction has now replaced misconception and prejudice in the minds of the majority of its former opponents.
The accumulation of statistical evidence, even where all allowance is made for doubtful methods of compilation, shows that the aggregate mortality of diphtheria has been reduced fully fifty per cent. since the introduction of antitoxic treatment by Behring in 1892.
Since the method of preparation of the commercial diphtheria antitoxin illustrates the general principles involved in the search for the production of curative or protective serums for infectious diseases in general, a summary of the steps in its manufacture will now be given.
A race of diphtheria bacilli, which has been found to yield a poison of great virulence in alkaline beef broth, is grown for a week or ten days in this medium. The toxin is then separated and its virulence exactly determined. It is preserved in sterile receptacles for immediate or future use. The next step is the inoculation of a suitable animal with the toxin. Of all animals the horse has been found to meet nearly every requirement. Such an animal, in a state of perfect health, receives an injection of twenty cubic centimetres of toxin, along with ten or fifteen of standard antitoxin, beneath the skin of the neck or fore-quarters, upon three separate occasions at intervals of five days. After this it receives increasing doses of toxin, alone, at intervals of six to eight days, until, at the end of two months, it is able to stand with little discomfort doses of such strength that if given in the first stage these doses would have quickly caused death.
At this period the horse is bled to a small extent, and its serum tested to ascertain if prospects are good for the production by the animal of a high grade of antitoxin. If satisfactory progress has been made, the injections are continued for another month, when, as a rule, the maximal degree of antitoxic power in the serum will have been attained.
The horse is now bled to the proper extent, the blood being received in a sterile jar and placed in an ice-box. Here it coagulates, and the serum separates from it. When the separation of clot and serum is complete, the latter is drawn off, taken to the laboratory, and standardized. This being finished, an antiseptic fluid is added to preserve the serum from decomposition. It is then bottled, labelled, and sent out for use.
In similar fashion tetanus antitoxin is prepared; and quite recently Calmette has produced an antitoxic serum for use in snake bite, by injecting horses with minute increasing doses of snake venom. His experiments have given some remarkable results, not only in laboratory work, but also in cases of actual snake bite occurring in man. Thus bacteriological scientists, after years of laborious work, in the face of much criticism and severe denunciation, may confidently announce that they have in their possession a magic key to one of nature’s secret doors. The lock has been turned. The door stands partly open, and we are permitted a glimpse of the future possibilities to be attained in the great fight against disease.
PREVENTIVE MEDICINE
The following are some of the diseases which have been remarkably controlled through preventive medicine:
_Small-pox._—While not a scourge of the first rank, like the plague or cholera, at the outset of the century variola was one of the most prevalent and dreaded of all diseases. Few reached adult life without an attack. To-day, though outbreaks still occur, it is a disease thoroughly controlled by vaccination. The protective power of the inoculated cow-pox is not a fixed and constant quantity. The protection may be for life, or it may last only for a year or two. The all-important fact is this: That efficiently vaccinated persons may be exposed with impunity, and among large bodies of men (_e.g._, the German army), in which revaccination is practised, small-pox is unknown. Of one hundred vaccinated persons exposed to small-pox, possibly one might take the disease in a mild form; of one hundred unvaccinated persons so exposed, one alone might escape—from twenty-five to thirty would die. To be efficient, vaccination must be carried out systematically, and if all the inhabitants of this country were revaccinated at intervals small-pox would disappear (as it has from the German army), and the necessity for vaccination would cease. The difficulty arises from the constant presence of an unvaccinated remnant, by which the disease is kept alive. The Montreal experience in 1885 is an object-lesson never to be forgotten.
For eight or ten years vaccination had been neglected, particularly among the French-Canadians. On February 28, 1885, a Pullman car conductor, who came from Chicago, where the disease had been slightly prevalent, was admitted into the Hôtel Dieu. Isolation was not carried out, and on the 1st of April a servant in the hospital died of small-pox. Following her death the authorities of the hospital sent to their homes all patients who presented no symptoms of the disease. Like fire in dry grass the contagion spread, and within nine months there died of small-pox three thousand one hundred and sixty-four persons. It ruined the trade of the city for the winter, and cost millions of dollars. There are no reasonable objections to vaccination, which is a simple process, by which a mild and harmless disease is introduced. The use of the animal vaccine does away with the possibility of introduction of other disorders, such as syphilis.
_Typhus Fever._—Until the middle of the present century this disease prevailed widely in most of the large cities, particularly in Europe, and also in jails, ships, hospitals, and camps. It was more widely spread than typhoid fever and much more fatal. Murchison remarks of it that a complete history of its ravages would be the history of Europe during the past three centuries and a half. Not one of the acute infections seems to have been more dependent upon filth and unsanitary conditions. With the gradual introduction of drainage and a good water supply, and the relief of overcrowding, the disease has almost entirely disappeared, and is rarely mentioned now in the bills of mortality, except in a few of the larger and more unsanitary cities. The following figures illustrate what has been done in England within sixty years: In 1838 in England twelve hundred and twenty-eight persons died of fever (typhus and typhoid) per million of living. Twenty years later the figures were reduced to nine hundred and eighteen; in 1878 to three hundred and six of typhoid and to thirty-six of typhus fever. In 1892 only one hundred and thirty-seven died of typhoid fever and only three of typhus per million living!
_Typhoid Fever._—While preventive medicine can claim a great victory in this disease also, it is less brilliant, since the conditions which favor its prevalence are not those specially relating to overcrowding as much as to imperfect water supply and the contamination of certain essential foods, as milk. It has been repeatedly demonstrated that, with a pure water supply and perfect drainage, typhoid fever almost disappears from a city. In Vienna, after the introduction of good water, the rate of mortality from typhoid fever fell from twelve per ten thousand of the inhabitants to about one. In Munich the fall was still more remarkable; from above twenty-nine per ten thousand inhabitants in 1857 it fell to about one per ten thousand in 1887. That typhoid fever in this country is still a very prevalent disease depends mainly upon two facts: First, not only is the typhoid bacillus very resistant, but it may remain for a long time in the body of a person after recovery from typhoid fever, and such persons, in apparent good health, may be a source of contamination. With many of the conditions favoring the persistence and growth of the bacillus outside the body we are not yet familiar. The experience in the Spanish-American War illustrates how dangerous is the concentration together of large numbers of individuals. But, second, the essential factor in the widespread prevalence of typhoid fever in the United States, particularly in country districts, is the absence of anything like efficient rural sanitation. Many counties have yet to learn the alphabet of sanitation. The chief danger results from the impure water supplies of the smaller towns, the local house epidemics due to infected wells, and the milk outbreaks due to the infection of dairy farms.
The importance of scrupulously guarding the sources of supply was never better illustrated than in the well-known and oft-quoted epidemic in Plymouth, Pennsylvania. The town, with a population of eight thousand, was in part supplied with drinking-water from a reservoir fed by a mountain-stream. During January, February, and March, in a cottage by the side of and at a distance of from sixty to eighty feet from this stream, a man was ill with typhoid fever. The attendants were in the habit at night of throwing out the evacuations on the ground towards the stream. During these months the ground was frozen and covered with snow. In the latter part of March and early in April there was considerable rainfall and a thaw, in which a large part of the three months’ accumulation of discharges was washed into the brook not sixty feet distant. At the very time of this thaw the patient had numerous and copious discharges. About the 10th of April cases of typhoid fever broke out in the town, appearing for a time at the rate of fifty a day. In all about twelve hundred were attacked. An immense majority of the cases were in the part of the town which received water from the infected reservoir.
The use of boiled water and of ice made from distilled water, the systematic inspection of dairies, the scrupulous supervision of the sources from which the water is obtained, an efficient system of sewage removal, and, above all, the most scrupulous care on the part of physicians and of nurses in the disinfection of the discharges of typhoid fever patients—these are the factors necessary to reduce to a minimum the incidence of typhoid fever.
_Cholera._—One of the great scourges of the present century made inroads into Europe and America from India, its native home. We have, however, found out the germ, found out the conditions under which it lives, and it is not likely that it will ever again gain a foothold in this country or Great Britain. Since the last epidemic, 1873, the disease, though brought to this country on several occasions, has always been held in check at the port of entry. It is communicated almost entirely through infected water, and the virulence of an epidemic in any city is in direct proportion to the imperfection of the water supply. This was shown in a remarkable way in the Hamburg epidemic of 1892. In Altona, which had a filtration plant, there were only five hundred and sixteen cases, many of them refugees from Hamburg. Hamburg, where the unfiltered water of the Elbe was used, had some eighteen thousand cases, with nearly eight thousand deaths.
_Yellow Fever._—The cause of this disease is still under discussion. It has an interest to us in this country from its continued prevalence in Cuba, and from the fact that at intervals it makes inroads into the Southern States, causing serious commercial loss. The history of the disease in the other West India islands, particularly Jamaica, indicates the steps which must be taken for its prevention. Formerly yellow fever was as fatal a scourge in them as it is to-day in Cuba. By an efficient system of sanitation it has been abolished. The same can be done (and will be done) in Cuba within a few years. General Wood has already pointed out the way in the cleansing of Santiago.
_The Plague._—One of the most remarkable facts in connection with modern epidemics has been the revival of the bubonic plague, the most dreaded of all the great infections. During the present century the disease in Europe has been confined almost exclusively to Turkey and Southern Europe. Since 1894, when it appeared at Hong-Kong, it has gradually spread, and there have been outbreaks of terrible severity in India. It has extended to certain of the Mediterranean ports, and during the past summer it reached Glasgow, where there has been a small outbreak. On this hemisphere there have been small outbreaks in certain of the South American ports, cases have been brought to New York, and there have been to November 1st twenty-one cases among the Chinese in San Francisco. Judging from the readiness with which it has been checked and limited in Australia, and in particular the facility with which the recent outbreak in Glasgow has been stamped out, there is very little risk that plague will ever assume the proportions which gave to it its terrible reputation as the “black death” of the Middle Ages. As I have already mentioned, the germ is known, and prophylactic inoculations have been made on a large scale in India, with a certain measure of success.
_Tuberculosis._—In all communities the _white plague_, as Oliver Wendell Holmes calls it, takes the first rank as a killing disease. It has been estimated that of it one hundred and twenty thousand people die yearly in this country. In all mortality bills tuberculosis of the lungs, or consumption, heads the list, and when to this is added tuberculosis of the other organs, the number swells to such an extent that this disease equals in fatality all the other acute infective diseases combined, if we leave out pneumonia. Less than twenty years ago we knew little or nothing of the cause of the disease. It was believed to be largely hereditary. Koch discovered the germ, and with this have come the possibilities of limiting its ravages.
The following points with reference to it may be stated: In a few very rare instances the disease is transmitted from parent to child. In a large proportion of all cases the disease is “caught.” The germs are widely distributed through the sputum, which, when dry, becomes dust, and is blown about in all directions. Tubercle bacilli have been found in the dust of streets, houses, hospital wards, and much-frequented places. A single individual may discharge from the lungs countless myriads of germs in the twenty-four hours. Dr. Nuttall estimated from a patient in the Johns Hopkins Hospital, who had only moderately advanced consumption, that from one and a half to four and a third billions of germs were thrown off in the twenty-four hours. The consumptive, as has been well stated, is almost harmless, and only becomes harmful through bad habits. The germs are contained in the sputum, which, when dry, is widely scattered in the form of dust, and constitutes the great medium for the transmission of the disease. If expectorated into a handkerchief, the sputum dries quickly, particularly if it is put into the pocket or under the pillow. The beard or mustache of a consumptive is smeared with the germs. Even in the most careful the hands are apt to be soiled with the germs, and in those who are dirty and careless the furniture and materials which they handle readily become infected. Where the dirty habit prevails of spitting on the floor, a room, or the entire house, may contain numbers of germs. In the majority of all cases the infection in tuberculosis is by inhalation. This is shown by the frequency with which the disease is met in the lungs, and the great prevalence of tuberculosis in institutions in which the residents are restricted in the matter of fresh air and a free, open life. The disease prevails specially in cloisters, in jails, and in asylums. Infection through milk is also possible; it is doubtful whether the disease is transmitted through meat. So widespread are the germs that post-mortem examination has shown that a very large number of persons show slight signs of the disease who have never during life presented any symptoms; in fact, some recent investigations would indicate that a very large proportion of all persons at the age of forty have somewhere in their bodies slight tuberculous lesions. This shows the importance of the individual predisposition, upon which the older writers laid so much stress, and the importance of maintaining the nutrition at its maximum.