After effects of scarlet fever and measles.

In themselves, these diseases may not be severe, children often having mild attacks of scarlet fever, called scarletina, and apparently suffering only from a cold, but exposure, by which a cold is developed either during or after the disease, may lead to serious troubles. Inflammation of the kidneys often occurs, which may develop into chronic Bright's disease and ultimately cause death. Inflammation of the ear is another incident of scarlet fever, in which abscesses are formed, resulting not infrequently in permanent deafness.

The consequences of measles are not so serious usually, and a more common after effect is trouble with the lungs or bronchial tubes. Pneumonia, croup, and bronchitis very often follow measles, due, as already indicated, to exposure before the body has regained its normal condition. In both scarlet fever and measles the eyes are apt to be affected, and it is very important in both diseases to keep the patient in a darkened room and to forbid use of the eyes in reading or other close work. On account of the complications following scarlet fever and measles, as well as for their greater death-rate, these diseases are more serious than the other two included in this discussion,—whooping cough and chicken pox.

Preliminary symptoms.

The beginning of each of these four diseases is much the same, and the symptoms are likely to be mistaken for those of an ordinary cold. In all of them, the first indication of illness is redness and itching on the inside of the nose and throat with snuffling and discharging from both eyes and nose. Sometimes the throat is affected, and the patient complains of sore throat. Then the cheeks become flushed, headache may follow, and fever begins, so that the patient is in a sort of stupor, unwilling to do anything and glad to lie in bed. In severe cases vomiting may accompany or precede the outbreak of fever.

At the outset, the probable reason for the similarity of these four diseases as well as their likeness to a common cold is that the germs responsible for all of them enter the body through the nose and throat and begin their attack upon the membranes there. The action of the germ is followed by the formation of poisons or toxins which are distributed by the blood through the body, causing the fever and what are known as "general symptoms." At the beginning it is not possible to determine to which particular germ the distress of the patient is due, and probably the continued prevalence of these diseases is chiefly owing to the fact that in the early stages and in mild cases throughout, the sufferer is allowed to be at large with every opportunity for spreading the disease.

Contagiousness.

If, whenever a child has a cold accompanied by a fever, the mother would promptly put him in bed in a room by himself, keeping the other children of the family away from the sick room and the invalid under restraint until all possibility of transmitting the disease is over, the number of cases would be greatly diminished. Unfortunately, there seems to be a general impression that such precautions are useless, and that sooner or later every child must have these children's diseases. This is a mistaken notion, and the table already referred to is sufficient evidence to prove the error of this way of thinking.

All these diseases are affections of the whole body, caused by poisons generated by germs, for which so far scientists have found no antidote. The reason is plain. The germ itself is not known, and no animal has been discovered on which scientists can experiment. If we could only produce measles in a rabbit, for instance, we could very soon detect the germ and would no doubt be able to procure an antidote to the measles poison. But this has not been done, and therefore in measles and in the other diseases mentioned we can only hope that the sick person will be able to generate in his own body sufficient antidote to secure his own recovery. Physicians therefore are almost helpless in treating these diseases. They keep the patient in bed in order that all his strength may be kept for fighting the disease. They insist on ventilation in abundance, so that oxygen may be applied to the lungs in large quantities in order to neutralize the poison. They advise sponge baths in cold water and alcohol to allay the fever, and they prescribe nourishing, easily digested food, such as milk, eggs, fruit, and plenty of water to drink. In the hope of diminishing the chances of infection, particularly in measles and scarlet fever, they recommend antiseptic sprays for the nose and throat and antiseptic ointments, such as carbolized vaseline for the skin when peeling or desquamation is going on.

Quarantine for scarlet fever.

Scarlet fever, while the most violent, is also the shortest lived, in the majority of cases not more than three or four days, although the full period of recovery is much longer. The peculiarity of this disease lies in the abundant peeling which takes place usually from the entire body and particularly from the hands and feet; in fact, in a number of cases where the disease is light, the peeling from the hands and feet is the only positive proof that the malady has been scarlet fever. During this process of peeling contagion seems most active; therefore, although recovery seems entire so far as the fever is concerned, the patient should remain strictly isolated during this time. It is a slow process, lasting from two to five weeks, and is very tiresome for the child who feels perfectly well; yet, in the interests of other children, the child must be kept strictly at home until at least a week after the last sign has disappeared. It is also for the child's own sake very desirable to observe this quarantine, since it is during this period of recovery that most of the complications of scarlet fever occur, and if the patient is kept under observation, either in his sick room or on some porch where atmospheric exposure is not too great and where the child is certain to eat nothing harmful, the chances for avoiding lung troubles and digestive disturbances are minimized.

There is such a striking difference in the severity of cases of scarlet fever that the name "scarletina" was for a long time applied to mild cases with the feeling that possibly it represented an altogether different disease. At the present time the disease is more intelligently diagnosed, and while there is vast difference in the severity of the sickness, it is all the same thing. Of the ordinary cases, about 5 per cent terminate fatally; that is, in a village or a community where a hundred cases occur, there would be five deaths. If the epidemic, however, is of the severe form, a larger percentage of deaths occur, often reaching 20 per cent of those affected. It has been noted that as an epidemic progresses, the disease becomes more serious, and a death-rate of only 5 per cent may, in the course of an epidemic lasting several months, gradually increase to one of 20 or 25 per cent. For this reason strong efforts ought to be made to stamp out an epidemic while it is in the first stages.

Besides the possibility of contagion from the skin as it comes off, to prevent which the antiseptic ointment is used, contagion also occurs through clothing used in the sick room. In fact, the contagiousness of scarlet fever is probably as malignant as any other infectious disease. It has been observed that a year after a case of scarlet fever in a house, the unpacking of a trunk or the unrolling of a bundle would set free the contagion and would result in new cases of the disease. The writer learned recently of a family in which a child had died of scarlet fever and some of its clothing had been packed away in the attic. A younger sister grew up, married, moved away, and some twenty years after the death of the child, came back to her former home on a visit with her own little girl. The grandmother, visiting the attic, found the clothing packed away so long before, gave it to her grand-daughter to wear, and in ten days the child was dead with the same disease.

There are a number of cases where scarlet fever seems to have been carried by infected milk, and great care must be taken on dairy farms to avoid any possibility of this kind of infection. To prevent the disease being transmitted after apparent recovery, thorough disinfection should be practiced. The patient's body should be very carefully and completely and continuously covered with antiseptic ointment which prevents the distribution of the contagion in small particles of skin. The sick room, after the patient's recovery, should be thoroughly disinfected, and all bedding steamed or boiled. All the surfaces in the room should be washed with a solution of carbolic acid, 1 in 50, or corrosive sublimate, 1 in 1000.

Measles.

If the disease is measles, one may expect a general epidemic, since its power of direct contagion is nearly equal to scarlet fever, although the fatality is much less. It is unfortunate that so little pains are taken to prevent the spread of this disease and fortunate that, except in the case of very young children, the effect of the illness is only a temporary inconvenience. Curiously, however, if measles attacks savage tribes where it has been before unknown, the severity of the disease is very great. Cases are on record where measles have broken out on the frontier and whole villages were wiped out; where the insignificant measles, so innocuous in civilized communities, became a plague similar to a scourge of the Middle Ages. It apparently has been modified by its passage through generations of individuals, just as any bacterial disease germ is modified by successive transmission through the bodies of different animals. When, however, the disease breaks out in a community which has not suffered from the disease for many years, it is, on that account, likely to appear in a far more virulent form.

Characteristic eruptions of measles.

Measles, like scarlet fever and chicken pox, is an eruptive disease; that is, is accompanied with a rash, differing slightly in the three diseases of which the presence of the rash and its progress over the body is one of the distinguishing features. In scarlet fever, for instance, the rash appears first on the neck and chest or back and spreads outward to the extremities. In measles, the rash appears on the extremities, beginning on the face usually, and spreads to the chest and trunk. In scarlet fever, this rash appears as fine scarlet pin points scattered around on the reddened skin, and on the second or third day the entire body may look like a boiled lobster. In measles, the rash appears as blotches, while the skin is not flushed but retains its natural color. In chicken pox, the rash appears generally on the body first and consists of small red pimples which develop into whitish blisters about as large as a pea and well separated. They are much more distinct and separated than the rash of scarlet fever and measles, and are much more likely to be mistaken for smallpox pustules than for an ordinary eruptive rash.

One of the old-time fancies connected with these eruptive diseases is the belief that an abundant eruption is a sort of guarantee against the severity of the disease. The old nurse was careful to keep the child in bed, well covered, steamed in fact, until the eruption appeared, and it was commonly thought that nothing should be done to check the rash or to prevent its coming out. This is not sustained by later science, and the appearance of the rash, whether it strikes in or strikes out, has nothing to do with either the disease or with its severity. No possible connection can be traced between the dissemination of the poison through the system by the action of the bacteria and the appearance of the skin, which is a minor factor in the disease. It may be worth while to repeat that the greatest danger from measles consists in the possibility of lung complications, and infinite care should be taken to keep the patient shielded from drafts and free from overexertion until recovery is complete. Like scarlet fever, the skin peels off, although not to the same extent, and the small particles are capable of transmitting the disease. Probably, also, the secretion from the nose and throat will transmit the disease, so that it is the height of folly to allow a sick person to use a handkerchief, for example, and then to use the same handkerchief to wipe the baby's nose when he comes into the sick room. All dishes and clothing of every sort should be boiled or steamed, and to be rendered harmless they should be soaked in a disinfecting solution before being taken from the sick room. The room itself, after being vacated, should be disinfected and the walls washed, as already prescribed.

Whooping cough.

Whooping cough is unlike the other three diseases in that it is a nervous trouble, and probably the germ or the poison formed by the germ attacks the nervous system, and particularly one great nerve connecting the lungs and stomach. This is why the spasm of coughing is frequently followed by vomiting, and the only remedy which is of value in whooping cough is a nerve depressant which will diminish the activity of the nervous system without at the same time interfering with the strength or vigor of the patient. On account of this connection between the lungs, whose spasmodic ejection of air seems to threaten the entire collapse of the little patient, and the stomach, so alarming do the repeated fits of vomiting appear that often this feature of the disease is even more serious than the coughing, pathetic as it is with younger children. In some cases the stomach cannot retain nourishment long enough to feed the body, and the child literally wastes away unless the period of the disease runs out before the child starves to death.

It is often weeks instead of days before the disease can be recognized. Then, if it develops in its usual form, begins the coughing so characteristic of the malady and the hard straining whoop so painful to listen to. Occasionally this coughing may be severe enough to cause a rupture of a blood vessel; but ordinarily, unless the stomach is affected by sympathy, no great danger need be feared. Fresh air, moderate exercise, good food, and some mild nerve depressant is all that can be done. The disease is very contagious and is usually transmitted directly from the sick person to the well person. It may, however, be carried in clothing, particularly in handkerchiefs and towels. Like measles, if it gains a foothold in an uncivilized community, it attains the size of an epidemic or plague with very fatal results. It seems to have a great power over girls and children, particularly those whose vitality is below the normal. Like measles, one does not generally have two attacks of this disease. In the winter, and this is the time when the whooping cough is most common, it is often followed by lung troubles, such as bronchitis and pneumonia. The death-rate from whooping cough is as large as from scarlet fever and measles combined, but chiefly because the disease is common among the smallest children. It is not unusual for babies under a year old to have whooping cough, and when their vitality is low, they scarcely ever recover.

Precautions against spread of whooping cough.

Probably the disease does not become contagious until the cough starts, and there is no reason why the disease should not be arrested in the first victim, provided proper isolation is practiced. The idea of a child with whooping cough, even when he whoops only once or twice a day, being allowed to attend school and mingle with the other scholars and to distribute the disease among them seems in these days of sanitary knowledge almost criminal. As soon as the first whoop occurs the child should be put in a room by himself and kept there until the last whoop has been whooped, and no other child should be allowed to go into the room, and the nurse or mother who is in charge should be careful about contact with other children after coming from the sick room until she has changed her outer garment. A big apron with long sleeves, fitted closely around the neck, which may be slipped on and off easily, is an admirable protection. The same precautions about disinfecting dishes, napkins, towels, handkerchiefs, and bedding should be observed here as already referred to.

Chicken pox.

Chicken pox is the mildest of eruptive diseases. It has no relation to smallpox, so that the theory sometimes held, that an attack of chicken pox prevents any attack of smallpox later, is a mistake. Instances are on record where a person has had both diseases almost at the same time. The appearance of the eruption is the characteristic feature of this disease, and it is so well distinguished that there is no danger of failing to recognize it. It is not common in grown people, and while it should not arouse suspicion in children, it is so uncommon in adults that a suspected case is probably a mild case of smallpox, and should always be quarantined as such.

With children, the accompanying cold and fever is often very mild, so that the appearance of the rash is the first and only symptom of the disease. The eruption is a progressive thing, each day's crop coming to full bloom and dying out as the next day's crop develops. This is, by the way, a distinguishing characteristic of this disease, differentiating it from smallpox where the pustules are more persistent and where the breaking out is more general. The pustules are sometimes extremely irritating, and it is very hard to keep children from scratching, the results of which may leave deep scars and so should be avoided. An antiseptic ointment should be used as with scarlet fever and measles, carbolized vaseline being suitable, although sometimes a strong solution of soda is substituted. It is not common to disinfect in chicken pox to the same extent as in the other diseases, the contagion being apparently in the air rather than in clothing and short lived. In New York State, in 1908, no deaths are recorded from chicken pox, and it is because of this lack of fatal results that the disease is regarded so indifferently and no particular pains taken to prevent its spread.



CHAPTER XIX

PARASITICAL DISEASES (MALARIA, YELLOW FEVER, HOOKWORM, BUBONIC PLAGUE, AND PELLAGRA)

Malaria.

From time immemorial, malaria (or fever-and-ague) has been one of the great plagues of humanity. No advance outpost of civilization but has suffered, more or less severely, from this disease. Dickens, in one of his novels, describes graphically the disease as it existed in the early American settlements, and vividly portrays its ravages, both mental and physical, among the pioneer settlers. Certain sections of the world have been especially noted for the prevalence of this disease, making extensive regions practically uninhabitable. The vicinity of Rome, with its swampy marshes and low-lying areas, has been one of these plague spots. The jungles and swamps of the equator and the coastline of Africa and South America and the valley lands of the Mississippi River have all been noted as most dangerous districts for human beings to live in. Even in civilized communities the ravages of the disease have, under conditions most conducive to malaria, been fearful, so that only most urgent requirements of mining, manufacturing, or similar material processes have prevented the obliteration of entire communities.

The cause of the heavy death roll resulting from a bold defiance of the reputation of these localities—a defiance bravely adopted by hardy pioneers, by agents of trading companies, and by representatives of governments—has been, up to the last ten years, assigned to the water-laden condition of low-lying ground. Swamps and stagnant pools, moisture-laden air, and a hot climate have been universally considered to be the cause of the fever, and the transmission of the disease has been supposed to be due to the passage through the moist air of the germs of the disease, although the exact form and behavior of these germs was unknown. Certain specifics have been proved by experience to have some value. For instance, it has been found that planting a row of trees between the house and a pool from which malaria might come has been of aid in warding off the disease. In a number of cases a thick row of eucalyptus trees, so associated in the popular mind with this purpose that they are known as the malaria tree, have been planted as a tight hedge with apparently very useful results. Drainage or filling up the low lands has always been found to reduce the prevalence of the disease.

Many years ago the use of quinine in large doses was found to be a specific, and the writer well remembers, on the occasion of his visit to a malarial region, buying quinine at the grocery store by the ounce in the same way that one would buy spices or tea, the dose being a teaspoonful. Why quinine should prevent the daily or periodical chills characteristic of the disease was not known, or why a row of eucalyptus trees interfered with the development of the disease was not known, and people generally were content to rest with the knowledge of these facts only.

Mosquitoes and malaria.



In the year 1900, however, English scientists, working in the Roman Campagna, demonstrated conclusively that which had been vaguely suggested before, namely, that the cause of malaria is a parasite composed of little more than an unformed mass of protoplasm, not floating in the air at all, but transmitted only by the bite of a mosquito. By a series of most interesting experiments, conducted by them and by other scientists in other parts of the world, it has been definitely proved that when a mosquito bites an individual suffering from malaria, the mosquito draws up into his body, along with the blood of the bitten person, some of the malarial parasites. In the body of the mosquito, the parasite develops, requiring for a full-grown specimen about seven days; then, if the mosquito bites another person, the parasite is injected into the skin of the victim, and in the course of about a week a good case of malaria ensues.

Fortunately, only a small proportion of the number of mosquitoes in the world are capable of nourishing the malaria parasite. Under ordinary conditions about 5 per cent of all mosquitoes found are malarial, and a particular name has been given to those capable of transmitting the disease. The ordinary mosquito is known as the "culex," while the malarial kind is known as "anopheles." Figure 78 shows the characteristic attitude of the two kinds by which the one can be distinguished from the other when resting on a wall or ceiling. As will be noticed in the drawing, the culex carries his body parallel to the wall with his hind legs crossed over his back. The harmful mosquito, the female anopheles, always hangs on by her front legs and has her body at an angle of about forty-five degrees to the surface to which she clings, her hind legs hanging down. The wings of the harmless mosquito are usually mottled, while the wings of the malarial mosquito are of an even color. The details of the behavior of the parasite on its long journey from the original malarial patient through the body of the mosquito and into the body of the person bitten is full of interest to the scientist, who must, however, be provided with a good microscope to follow such minute bodies; but the methods of avoiding the disease are more pertinent to our present purpose.

While quinine is still recognized as the particular antidote for the malarial poison, efficient as we know now because it is poisonous to the parasite and not because it has any particular effect on the person, of late years more and more stress is being laid on the elimination of the mosquito. Naturally, if the mosquito can be destroyed and the transmission of the disease thus prevented, there will be no further need of quinine. The general impression that swampy land is favorable to the development of malaria is correct, but not because the damp air is itself pernicious. The significance of the damp ground lies solely in the fact that mosquitoes in one stage of their existence require water for their development. They breed only in water and always deposit their eggs in water, on the surface of which the eggs float in very small layers. The eggs hatch into larvae or wrigglers, which also must remain in water for development, and it is not until the third stage, that of the full-grown mosquito, that the animal leaves the water which was his birthplace. Obviously, therefore, if there is no water there can be no mosquitoes.

Elimination of mosquitoes.

Another pertinent fact discovered by scientific research is that the development of the malarial mosquito is confined to the vicinity of stagnant pools, because in fresh water, where fish are to be found, the eggs and larvae of the mosquito are a most acceptable fish food. One of the most practical ways, therefore, of getting rid of possible mosquitoes is to make sure that the pond always contains a number of fish. Woods Hutchinson gives the following interesting description of the way this fact was discovered:—

"It was early noted that mosquitoes would not breed freely in open rivers or in large ponds or lakes, but why this should be the case was a puzzle. One day an enthusiastic mosquito student brought home a number of eggs of different species, which he had collected from the neighboring marshes, and put them into his laboratory aquarium for the sake of watching them develop and identifying their species. The next morning, when he went to look at them, they had totally disappeared. Thinking that perhaps the laboratory cat had taken them, and overlooking a most contented twinkle in the corner of the eyes of the minnows that inhabited the aquarium, he went out and collected another series. This time the minnows were ready for him, and before his astonished eyes promptly pounced on the raft of eggs and swallowed them whole. Here was the answer at once: mosquitoes would not develop freely where fish had free access; and this fact is an important weapon in the crusade for their extermination. If the pond be large enough, all that is necessary is simply to stock it with any of the local fish,—minnows, killies, perch, dace, bass,—and presto! the mosquitoes practically disappear."



Another factor in the development of the mosquito from the egg to full-grown mosquitohood is that in the larvae stage air must be supplied, curiously enough, through the tail which projects slightly above the surface of the water as the larvae hang head downwards (see Fig. 79). If the surface of the water is covered with some impervious material, the mosquito larvae will be suffocated, and it has been found that oil lends itself most readily to this desirable purpose, applied at the rate of one ounce per fifteen square feet of water surface. The oil spreads out over the surface in a very thin film, but persistent enough to keep off the air supply from the mosquito larvae. This method, about which much has been written and said, is perhaps the one most commonly employed, and its results have been most satisfactory. In the vicinity of the city of Newark, New Jersey, for instance, is an area of about 3500 acres, 8 miles long and about 3 miles wide, practically all marshland. In 1903 ditches were dug throughout this marsh in such a way that the surface water was drained off, drying the ground so that hay can now be cut where formerly rubber boots were necessary to get onto the ground at all. The consequence has been that the mosquitoes have practically disappeared from this region, formerly frightfully infested, and the cost of the 70 miles of small ditches dug has been amply repaid by the freedom from malaria as well as from the nuisance of the ordinary mosquito.

Other campaigns have been waged, using kerosene or crude petroleum for the coating of ponds or pools. Wherever clear water exists the kerosene treatment is probably best. Where marshland is found, through which the kerosene penetrates with difficulty, drainage is a more useful method.

The size of the pools required for the development of the mosquito is very small. Thousands of mosquitoes may be formed in the amount of water contained in an old tomato can, and barrels half full of rain water or pools of water in the vicinity of an old pump or in the barnyard will afford golden opportunities for mosquitoes looking for a place to lay their eggs. While the ordinary culex requires from one to two weeks only for the complete transition from egg to mosquito, so that a pool filled with rain water and not dried up within that period will be sufficient to develop a brood, the malarial mosquito requires much longer—two or three months—for the full completion of her development. It is, therefore, a simple problem for an individual householder to search out the pools which remain filled with water for a period of two months, and either stock them with fish, drain them entirely, or coat them with kerosene. No hesitation need be felt about the result of this treatment. It will positively eliminate all malaria in the vicinity if the work is thoroughly done.

Limitation of mosquito infection.

The distance that the malarial mosquito can fly is of interest as indicating the distance which one must go from a house, hunting for available pools. All mosquitoes are unable to fly against the wind, so that, as already noted, one side of a swamp may be comparatively free from malaria, while the other side may be overrun with it, merely on account of the direction of the prevailing winds. Some mosquitoes that breed in salt marshes may be carried for miles, so that a land breeze will bring millions of the pests to seashore cottages which, with a sea breeze, are quite free from them. The anopheles has a habit of clinging to weeds, shrubs, and bushes when the wind blows, so that it is seldom carried more than about two hundred yards from the place where it is hatched. If all pools of water, therefore, within this radius are disposed of, the elimination of malaria will logically follow.

If one is obliged to be in a region where malaria is common, the disease can be avoided absolutely by protecting one's self from mosquitoes, and since the anopheles prefer the early morning and evening hours, it is at those times of the day particularly when precautions must be taken. It was once thought that the night air caused malaria, and this had some foundation in fact, because it is in the early evening that the anopheles is on the wing. By staying in the house after sundown and by carefully screening the doors and windows, one may live in a malarial country with perfect immunity. Volunteers have lived for months in the worst malarial regions in the world without a trace of the disease, the only precaution being to keep the doors and windows screened and to prevent mosquitoes from biting.

An interesting experiment was made some years ago by sending a malarial mosquito by mail from Italy to England, where an enthusiast allowed himself to be bitten by the insect. He had had no trace of malaria before, but a week after the mosquito's bite he came down with the disease. It has also been noted that in such parts of the country as Greenland and Alaska, where mosquitoes are as thick as in the far-famed New Jersey marshes, malaria does not result from the mosquito bites unless a malaria patient from other countries starts the infection.

The disease itself may be mild or severe. It takes about a week after the mosquito bites before the symptoms appear, and sometimes the attack is postponed for weeks or months. Chills are the usual accompaniment of the disease; in children under six, convulsions are more common. The chill lasts from a few minutes to an hour, and directly after the chill comes the fever, which lasts three or four hours. The attacks usually occur every other day and sometimes every two days, generally at the same time of day. When persons have lived for a long time in malarial regions, the intermittency of the chill and fever is less noticeable and the continuous character of the fever often leads the disease to be mistaken for typhoid. The intermittent regularity of the fever, however, although between attacks the temperature never falls to normal, distinguishes this type of malarial fever from true typhoid. The positive determination of the disease is possible by an examination of the patient's blood, in which the malarial parasite can readily be found. Quinine is the remedy and the only remedy, and, fortunately, it does no harm, even before the character of the disease is positively known. The chill seems to be due to the development of a new brood of parasites in the blood of the malarial patient, and in order that the quinine shall have its effect on the blood, it must be swallowed three or four hours before the time of the expected chill, and then it will probably prevent, not the next chill but the one after. If the quinine cannot be taken directly with reference to an expected chill, then it must be taken regularly, sometimes for months before the chills cease.

Yellow fever.

Yellow fever, although not common in this country, is interesting as being almost exactly similar in its mode of infection to malaria. It is transmitted through a parasite, as is malaria, and can only be passed along through the agency of another kind of mosquito, known as stegomyia. In 1899 there was a serious outbreak of this pestilence in the cities of our southern coast, and the terrors of the plague of the Middle Ages were revived for a number of months. Trains going out of the infected regions were stopped by crowds armed with guns and the passengers prevented from proceeding, lest the disease might spread. No goods or freight were allowed to pass out from the infected area, and the prejudice against intercourse with the outside world went so far that guards even forbade the carrying of disinfectants to the victims.

Like malaria, the disease is one requiring a hot climate, generally because it is favorable to mosquito growth. It is most common in the seacoast cities of the South, and is probably transmitted often by mosquitoes brought on board ship. Since Havana has been cleaned up by Americans, the danger formerly existing from intercourse with that city has ceased, although only three years ago the writer stopped in a hotel at Havana, where two persons had died of yellow fever a week before. The smell of disinfectants in the hotel was so great that not a fly or insect of any sort was visible, and no other hotel in the city could have been safer or more comfortable. It has been proved positively that yellow fever cannot be transmitted by direct contact, since, in the interests of science, volunteers have slept in beds from which the dead from yellow fever had just been removed without contracting the disease. That the infection is due only to mosquitoes is proved by the fact that later, when bitten by mosquitoes, they succumbed to the disease. It requires about two weeks for the disease to pass through its regular stages in the body of the mosquito, so that there is no possibility of its transmission for that time after the mosquito has come in contact with a yellow fever patient.

The symptoms of yellow fever are characteristic and very severe. The eyes first become bloodshot and, in the course of two days, yellow, whence the name of the disease. Severe vomiting is also characteristic, the discharge being sometimes discolored like coffee or even tar and known as black vomit. The skin appears yellow, a condition which lasts for some time and is particularly noticeable if by the pressure of the finger on the skin the blood is made to recede. Among persons previously in good health, the death-rate is about that of typhoid fever, but among those in unfavorable surroundings and among those given to the use of alcohol, the rate will be much higher. Practically, it may be expected that this disease, like malaria, will disappear from the face of the earth. When the only requirement is the destruction of the mosquitoes and when mosquitoes can be so easily killed as already explained, it is only a question of time before mosquitoes and the diseases they cause will be stamped out. In Havana, before 1901, the number of the deaths yearly was about 750. In the year after the American intervention, when Colonel Gorgas, by military command, insisted on the thorough cleaning of the houses and the general use of kerosene in all drains and cesspools, there was not one single death.

Hookworm disease.

The third parasitical disease common in some parts of the United States has received much attention during this last year and is known as the hookworm disease. It is a new discovery in medical science, and whereas the physical condition of the victim is usually a clear indication of the disease, a positive diagnosis is always obtained by the use of the microscope. Several years ago it was announced in the United States that the laziness and shiftlessness of the poor whites living in the sand lands and pine barrens of the South was due, not to any inherent cussedness but to the presence of a parasite in the intestine, known in Italy and Germany as the hookworm, the disease being called Uncinariasis.

The development of the disease is interesting. The worm, which is about an inch long and looks not unlike a bit of thread, lays eggs by the thousand in the intestinal tract of a human victim. Afterwards they pass out in the excreta and, favored by heat and moisture, develop in the soil in about three days into minute larvae. These larvae have a most extraordinary power of attaching themselves to and penetrating into the human skin and body. They may also enter the human body in a drink of water or on unwashed vegetables. In infected regions the soil becomes fairly alive with these larvae, and it is hardly possible for a child to walk barefoot outdoors without becoming infected. When the larvae have penetrated the hand or foot, they begin a long and circuitous journey through the body, moving from the extremities through the veins to the heart and thence to the lungs. From here they are carried through air cells into the bronchial tubes, thence along the mucous membrane up the windpipe and down into the stomach and finally, from the stomach, they pass out into the intestines, the goal of their long journey.

This all takes time, and probably from the time they enter the skin to the time they begin their murderous work on the lining of the intestines requires about two months. In the intestine the larvae develop into adults; but before this final stage an intermediate existence is reached, at which time they attach themselves to the mucous lining and bore into it, presumably for the purpose of making a nest in which later to lay their eggs. The burrowing parasite causes a great loss of blood, and it is on account of the resulting anaemia that the poor whites show always such incapacity, indifference, and apparent laziness. That this disease is of importance in considering the hygienic condition of the country is apparent when it is pointed out that in the southern part of the United States, chiefly in the rural districts, there are at least two million persons at present infected with the disease, and that should these hookworms be blotted out of existence, two million incapables would be changed into two million active Americans, ready to raise the southern districts to a commercial elevation which their natural resources seem to justify.

The treatment of the hookworm disease is simple, and the donation by Mr. Rockefeller of $2,000,000 is intended to be sufficient to furnish the opportunity at least for a complete cure of all the cases. It has been found that a small dose of a preparation of thyme known as thymol stupefies the parasites with which it comes in contact, so that they unloose their claws and are set free in the intestine after its use. A dose of epsom salts shortly after clears them out, and except for the loss of blood, the disease is finished. Sometimes, however, in long-continued cases the worms have penetrated so far into the membrane that the use of thymol cannot withdraw them. In fact, in autopsies, it has been found necessary to take tweezers and to use considerable force in order to pull them out.

The prevention of the disease is really the cure of the disease, an apparently simple matter, as already described. An improvement of sanitary conditions so as to make impossible further pollution of the soil should be also undertaken. Wherever the disease has prevailed in this country or in Europe, it has been because of an utter neglect and disregard of what are now known as ordinary sanitary conveniences, and the report of the Country Life Commission, although many charges were made against the conditions of living in different parts of the country, was far from telling the whole story in the matter of the shortcomings in parts of the southern states. There is, therefore, every reason why the farmer and others living in the country should be urged to make themselves comfortable with all known modern sanitary appliances. This is desirable, first, for the sake of others on whom their sins of unhygienic living might be visited, and then for their own sake, because there such sins would also have an effect to a degree tenfold more severe.

Pellagra.

Another disease peculiar to country life, and which has only within the last few years been recognized, is known as pellagra. Not yet is it even known through what agency the disease is transmitted, but it has been beyond question established that in some way corn is responsible for its spread. Apparently, spoiled corn is necessary, and while presumably the corn itself is not the agent, the parasite or organism that is responsible lives only on corn which has been spoiled. Scientists have long worked on the disease, and it would be a merely speculative pursuit, one of interest to scientists and medical men only, except for the fact that within the last few years it has broken out in this country and is increasing to a most alarming degree. The disease itself is almost hopeless when once established, physicians being yet utterly unable to grapple with it; and while in Italy, Spain, and Egypt it has been known for a century, there is still a death-rate of over 60 per cent, and these deaths occur after most horrible suffering and agony.

As in rabies, the parasite, if it is a parasite, acts through a poison which penetrates to the nervous centers, producing mental disturbances culminating in an active insanity. At the same time, the agent attacks the skin, whence its name "pell'agra," which means "rough skin," so that the body appears as if it were affected with a severe attack of eczema, large patches of skin peeling off and leaving the raw surface. In fact, in one of the Illinois hospitals, only a few years ago, some insane persons, infected with this disease, died, and because the effect of the disease on the skin was not known, the nurse in charge was accused of scalding the patients with boiling water, the appearance of the skin being the only proof. The nurse was discharged, although, without doubt, she was innocent, and the appearance of the skin was due solely to the disease. It has been estimated that there are at present in the United States five thousand victims of pellagra, with the number constantly increasing, although physicians of standing make estimates largely in excess of this.

Apparently preventive measures must consist in eliminating the possibility of the use of spoiled corn. Indications are that the disease appears only when such corn has been used, and in parts of Mexico where corn is always roasted before being used, pellagra is never known. It has been described as a disease of the poor, because the disease has flourished chiefly in districts where poverty is so extreme that corn, and spoiled corn at that, is the only food within reach. Usually, where a mixed diet with meat is possible, pellagra never appears. In other places, as in Italy, where the peasants live on a porridge of corn meal cooked in great potfuls, a week's supply at a time, and during the week exposed to dirt and flies and often spoiled before eating, pellagra is most common. Experiments have shown that in these districts, by excluding corn from the diet and furnishing a substantial fare, the disease has been banished. Unfortunately, the taint of the disease passes from parent to child and even to the third and fourth generation, and the physical deformities commonly seen in pellagrous districts are due to this hereditary taint. Dr. Babcock, Superintendent of the City Hospital at Columbia, South Carolina, after discussing the disease, sums up by saying, "Pellagra is a fact, and the United States is facing one of the great sanitary problems of modern times."

Bubonic plague.

The bubonic plague, or "The plague," as the importance of the disease has caused it to be called, is one of the oldest of known epidemics. In the third century it spread through the Roman Empire, destroying in many portions of the country nearly one-half of the people. Its immediate origin is a bacillus causing symptoms similar to blood poisoning, although in some cases, where the lungs are attacked, the disease has some of the characteristics of pneumonia.

A description of this disease is included here because, while bacterial in its nature, it is transmitted largely, if not entirely, by fleas and by a particular species of flea known as the rat flea. These fleas harbor the plague bacilli in their stomachs and inject them into the bodies of those they bite, in the same way that the anopheles or stegomyia mosquito transmits malaria or yellow fever. Elaborate experiments made in India in 1906 show conclusively that close contact of plague-infected animals with healthy animals does not give rise to any epidemic, so long as the passage of fleas from infected to healthy animals is prevented. When opportunity, however, was given for fleas to pass from one animal to another, the bacillus and the disease was generally carried over. It has also been found that while this species of fleas have their normal residence on the body of rats, they will also desert a rat for man, if the infected rat is dying and no healthy rat is in the vicinity to receive them. It is, then, obvious that to eliminate the disease, the most direct and positive course is to destroy the rats which are the home of the disease.

In India, where the plague appeared in 1896, causing about 300 deaths, it rapidly increased in virulence until in 1907 it caused 1,200,000 deaths. The ports of the Pacific coast became much alarmed, and when cases of the disease were actually found in San Francisco in 1906, the matter was so terrifying that the United States Marine Hospital Service was at once instructed to stamp out the disease if possible. This procedure was directed almost entirely against rats. Deposits of garbage on which rats might feed were removed, rat runs and burrows were destroyed and filled in, and stables, granaries, markets, and cellars where rats might abound were made ratproof by means of concrete. Rats were trapped and poisoned by the thousand, nearly a million being thus disposed of. As a result of such thorough work, the plague was stayed, and in 1909 not a single case of the disease among human beings was found, and although 93,558 rats captured were examined, only four cases of rat plague were found.

In southern California, however, the fleas deserted the rats for ground squirrels, and one county in particular, Contra Costa County, had an epidemic which caused the squirrels to die by the thousands. The attention of the scientists was thus turned to the squirrel as a host of the flea, and a warfare similar to that against the rat has been for a year past carried on against the infected squirrels. Between September 24, 1908, and April 12, 1909, 4722 ground squirrels were killed and examined for plague infection, and from June 4 to August 13, 1909, the work being continued, 178 squirrels were found to have the plague.

Now that the relation between fleas and their hosts and the transmission of the disease is known, there need be but little fear in the future of this old enemy of man again getting control and spreading without hindrance throughout a whole country.



CHAPTER XX

DISEASES CONTROLLED BY ANTITOXINS (SMALLPOX, RABIES, TETANUS)

Smallpox.

A hundred years ago, the most dreaded disease in this country or in Europe was smallpox; and even yet writers of fiction, when they desire to expose their hero to the most harrowing conditions possible, leave him in a deserted hut with a man dying of smallpox. But to the educated person of to-day smallpox is encountered absolutely without dread, since it has been robbed of its terrors by the introduction of vaccination. As far back as 1717, Lady Mary Montague, writing home to England, described the eastern method of taking smallpox deliberately, under comparatively agreeable conditions, in order that severe cases of the disease might be prevented.

Why one attack of the disease should prevent a subsequent case was not known, nor why inoculation with other virus than that of the disease itself should be efficient was not known. But the fact was thoroughly established then that in some way, in the process of the disease and recovery, there was left in the body some substance or agency which was sufficiently powerful to ward off subsequent attacks.

In 1796, Dr. Jenner discovered that a disease very similar to smallpox existed in the cow, and that if the scab from a pustule on the cow was used for inoculation instead of similar material from a smallpox patient, the resulting disease would be less severe and the protection against subsequent attacks equally efficient. Since that time, therefore, cowpox matter or vaccine has been used to develop a mild form of disease for the express purpose of preventing subsequent attacks.

This is the fundamental principle involved in all antitoxin treatment, and the only difference between vaccination and the injection of diphtheria antitoxin is that with vaccination the disease and the consequent protection is developed in the individual during the course of the disease, while with diphtheria the first attack of the disease and the resulting protective agencies are developed first in the horse and then the essential elements of the blood are introduced into the patient, thereby increasing his resistance to the disease. Smallpox, of all diseases, formerly claimed the largest number of deaths. A hundred years ago, persons marked with smallpox were a common sight. Among the Indians, whole tribes were wiped out with it. It is computed that in Europe, during the eighteenth century, 50,000,000 people died of smallpox. In England, the death-rate was 300 per 100,000. As late as 1800, Boston was visited by severe epidemics of smallpox.

Value of vaccination.

Owing to vaccination, the extent and intensity of the disease has continually grown less until to-day attacks of smallpox are not serious and the results are seldom fatal. For this reason and because of the chronic objection of uneducated persons to submit to governmental or outside restrictions, there has been, in recent years, a serious outcry against vaccination, with the result that in New York State, during the year 1908, there were in certain parts of the state epidemics of smallpox with, however, but two deaths. The disease may, however, at any time become serious, and, because of its virulent contagiousness, no objection ought to be made to reasonable requirements in the matter of vaccination.

Vaccination is usually not the cause of any serious inconvenience or illness, and, while some slight swelling of the arm may result, the protection afforded is so great in comparison with the temporary inconvenience that the latter ought not to be even considered. The protection afforded by a successful vaccination lasts usually from two to seven years, and it is understood that after ten years the protection is certainly lost, and in the presence of a smallpox epidemic one ought to be re-vaccinated after the minimum time named. Whether every person always ought to be vaccinated at intervals of five years or so is open to discussion. If one were on a desert island in a large or small community without intercourse with the outside world, vaccination would be of no value since smallpox would be impossible. There are communities where smallpox has been for years unknown, and consequently where the need for vaccination is not apparent. On the other hand, where smallpox is prevalent in the vicinity, and the disease is continually recurring, it is of the greatest importance, in order that it may be promptly suppressed, that every individual lend himself readily to vaccination.

Whatever harmful results formerly came from vaccination were due to a lack of cleanliness on the part of the person vaccinated or in the vaccination material itself. More care is now used in disinfecting the surface of the arm and in protecting the exposed skin after the inoculation. If the vaccination "takes," a certain amount of inflammation follows, the spot on the arm suppurates, the suppuration, however, disappearing at the end of about three weeks. If this does not occur, that is, if the vaccination does not take, it may be either because the vaccine was not good or because of the unsusceptibility of the person. In the largest proportion of cases, however, the difficulty is with the vaccine or with the doctor who does the inoculating, and when smallpox is prevalent in the vicinity a person should be re-vaccinated until the vaccination does take. The disease itself, while disagreeable, is not as hopeless as was formerly thought. There is no particular heroism in being physician or nurse to a smallpox patient now, inasmuch as vaccination absolutely prevents contraction of the disease, and the isolation practiced is the most serious objection from the standpoint of the attendants.

Characteristics of smallpox.

The disease first shows itself as does measles and scarlet fever, with the appearance of a severe cold accompanied with a high fever. On the second day a rash resembling that of measles and scarlet fever breaks out on the body; this preliminary rash almost immediately disappears and is followed by the real characteristic smallpox eruption, usually about the fourth day. This eruption appears first on the forehead or face and then on the other extremities, the hands and feet.

In mild cases, it is very difficult to distinguish between smallpox and chicken pox, and the only safe measure is to consider all cases of chicken pox in adults to be smallpox, as they probably are, since the former disease almost never attacks grown-up people. The pustules which form in smallpox are first hard and red, and then two or three days later they are tipped with little blisters which later fill with pus and appear yellow. About the tenth day of the eruption this yellowish matter exudes, forming the scar or scab which later dries up and falls off. Often this eruption is accompanied by excessive swelling of the face, so that the eyes become closed, it is impossible for the patient to eat, high delirium prevails, and the task of the nurse in such cases is an unenviable one. Although usually the pustules are separate and distinct, sometimes in severe cases they run together, so that the hands and face present one distorted mass of suppuration and crust.

The disease is particularly prevalent among negroes, perhaps because they are seldom vaccinated, and in recent epidemics in New York State it has been chiefly through negroes that the disease has been kept alive. The method of prevention for this disease is almost entirely vaccination. Just how the disease spreads is not clearly understood, although it is supposed that it is transmitted chiefly by clothing, dishes, and other articles in contact with the infection. These should, therefore, be thoroughly disinfected. The hope of eliminating the disease, however, comes rather in the use of vaccination. In New York State, in 1908, only two deaths from smallpox occurred, although twenty years before, with the smaller population, the number of deaths ran up into the hundreds.

Treatment of smallpox.

The actual treatment of a case of smallpox consists in little more than providing suitable food, in sponging the body to reduce the fever, and in anointing the skin to allay the irritation of the pustules. As in measles, the eyes are badly affected, and a darkened room is essential for the comfort of the patient as well as for the avoidance of permanent injury to the eyes. Carbolic acid solutions or ointments are to be used continually on the surface of the body, relieving the irritation and to some extent preventing pitting, which is a lasting mark of the disease.

Diphtheria.

Diphtheria was also formerly a much-dreaded disease, physicians standing helpless before severe attacks and in all cases unable to do more than suggest ameliorating remedies.

The disease usually begins with a cold, sore throat, and local inflammation, which develops sometimes with alarming rapidity. In the days of our grandmothers, the first thing that the anxious mother did when a child complained of sore throat was to get a spoon and look for white patches in the back of the throat. With severe cases of diphtheria which these white patches foretold, the growths of membrane would be so rapid as to obstruct the breathing, and the child—for the disease is preeminently one of childhood would be in danger of dying of strangulation. The doctor's remedy for this condition was to make an incision in the throat below this accumulation and insert a tube through which the breathing might continue. The writer will never forget having lived through a sickness and death of this sort in his family, seeing as a boy a bottleful of the membrane which the doctor was taking away after the death of the victim, and, while doubtless the size of the bottle and the amount of the membrane has been magnified by the lapse of years, it still remains to him as a terrible visitation and an inevitable cause of death.

Cause of the disease.

The immediate cause of diphtheria has been known only within recent years. Sewer air was for a long time thought to be responsible, and overcrowding or congestion in tenements was believed to be a fruitful source of the disease. Some years ago, when diphtheria had been epidemic in one of the state institutions and when experts had been called in to suppress the disease, the elaborate reports which they made dwelt on the quality of the drinking water and on the method of disposal of the sewage as if those factors would account for the disease. About twenty-five years ago, it was shown definitely that the disease was due to certain bacteria, and that while the membrane in the throat was the result of the rapid development of these bacteria, yet the mortality from the disease was not due to the suppression of the act of breathing, but to the development of a poison by the bacteria which went into the circulation of the body and produced death, just as any poison, as strychnine, for example, would do.

When once this fact was accepted, namely, that the disease was dangerous because of the poisons involved, scientists undertook to find a way to neutralize these poisons, and it was soon discovered that such neutralizing substances could be grown in the blood of guinea pigs. It was found that if a small dose of diphtherial toxin was injected into a guinea pig,—a dose small enough so that the guinea pig would recover,—it could then be given a larger dose from which it would also recover. This process might be repeated, until at the end of several weeks it could be given a dose the size of which would have been sufficient to have killed it almost instantly at the beginning, and which it could take and enjoy at the end of the series. The point was that evidently, as with smallpox, successive inoculations resulted in the formation in the body of some substance or agent capable of neutralizing the poisons of the disease, subsequently formed. The guinea pig is so small that the amount of restraining substance available made it desirable to find a larger animal, and the horse, equally susceptible to the disease with the guinea pig, was selected as the animal best suited for producing what is now known as diphtheria antitoxin.

Production of diphtheria antitoxin.

In laboratories, to-day, sound horses incapable of ordinary labor are devoted to this life-saving task, and, without serious injury or inconvenience to themselves, they develop artificially in their blood this agent which neutralizes the effect of the diphtheria germ. The blood of the horse, when removed, precipitated, and strained, contains this property which is used almost exactly as vaccine in the case of smallpox, except that in the case of diphtheria the development of the disease is so slow that it is not necessary to use this treatment until the disease has appeared. In smallpox, on the other hand, the disease is so rapid that when contracted it is too late for vaccination to be of much value. In New York State, the Department of Health furnishes this horse antitoxin free of expense to health officers to use with persons or families unable to purchase the preventative, so that no longer does any need exist for the continuance of diphtheria as a cause of mortality.

If the disease is early recognized and a proper amount of antitoxin injected, that is, forced in under the skin so that it may be absorbed by the blood, the probability is that in all cases the patient will recover. It is equally useful with vaccine as a preventative of disease, and in a school, for instance, where diphtheria has broken out, it is only a reasonable precaution to use antitoxin freely to prevent infection of those exposed to the disease.

To make use of the antitoxin at the proper stage of the disease, early recognition is important, and fortunately science here can be of great service. By wiping out the throat with a sterilized swab of cotton, the bacteria present in the throat, if any, will adhere and may be wiped off onto a gelatine substance in which the germs can grow. In twelve hours, they will have developed, if present, so that with a microscope they can be positively recognized. In Massachusetts, and particularly in the city of Boston, the Board of Health maintains a laboratory with a medical expert in charge, to whom physicians may refer these smears for diagnosis. No excuse exists, therefore, in such a city for failure to recognize and prevent the further development of diphtheria, since every wise physician would take a sample of mucus from a throat in case of any irritation there, the Board of Health would furnish accurate diagnosis, and the use of antitoxin will prevent the disease.

Symptoms of diphtheria.

The disease itself acts on the human body through the formation of poisons which the bacteria generate by their growth. If the germs have secured a foothold in the upper throat, then the well-known membrane is formed and the toxins produced spread through the blood and cause headache and fever, even before any experience of sore throat is felt. The temperature rises very high, the child begins to vomit, and the pulse becomes weak, and after about seven days a large percentage of these throat cases begin to improve. The membrane breaks off, the fever declines, and the child begins to recover. If the localized attack is in the larynx, a harsh cough is one of the symptoms, and this is soon followed by a serious difficulty in breathing.

The poisons are formed, as before, in the blood, and, while a surgical operation has been performed often in the past to afford relief from the tendency to strangulation, the bacterial poisons are not affected thereby, and, while the operation might be successful, the child was quite apt to die as the result of the poisons. Now, in either case, antitoxin is administered at the very outset of the attack, with the result that the poisons are counteracted, the temperature drops rapidly, the membrane is apparently at once affected and lessened, and the child recovers at once. No greater boon to the human race in the matter of disease has ever been discovered, and it is certainly most absurd for parents to refuse the use of this wonderful antidote. Not long since, the writer found a family of four children in a home where diphtheria was rampant. The mother and two children were sick with diphtheria in its worst form, and the father refused to allow the doctor to administer the antitoxin even to those sick, much less to those who had been, up to that time, only exposed. Apparently there was no direct law requiring the administration of the antitoxin, and the physician in attendance and the health officer were obliged to stand by and wait for the death of the children, which actually happened, knowing that a dose of the antitoxin ready at hand could have been administered and the children's lives, in all probability, saved.

The diphtheria poison is so virulent that in many cases it acts on the different organs of the body, particularly on the kidneys and the heart, and the recovery from this poison may take weeks. It is very necessary, therefore, for the patient to be kept quiet, and this can best be done in bed, for at least three weeks after the crisis has passed. The nervous system is often affected, so that the child may squint or stutter or perhaps not be able to see, but these effects are usually temporary and pass away as the effect of the poison disappears.

Rabies.

Rabies is the third assumed bacterial disease which is reacted upon by the administration of an antitoxin. When it occurs in man, it is generally known as hydrophobia, although it is the same disease as that known as rabies in dogs, skunks, wolves, and other animals. The virus of the disease is in the saliva of the animal, so that when a dog bites another animal or human beings, the poison is injected into the wound made with the teeth.

The actual germ has not been found, and while there is no doubt that it originates with some specific bacterium, it is probable that the transmitted disease is due rather to the toxin of the germ than to the germ itself. The greatest number of cases, by far, are caused by the bites of dogs, and the most obvious and plainest method of preventing the disease is to prevent dogs from biting. That this is efficient in stamping out the disease has been proved by the records of cases in England and Germany. There, a quarantine on all the dogs in the country, that is, the strict enforcement of laws requiring muzzling, has eliminated the disease except on the borders of other countries where such quarantine is not enforced.

In New York State, the number of cases of rabies is increasing at an alarming rate, as determined by the examinations made on dogs' heads at the New York State Veterinary College in Ithaca. Whereas a few years ago one suspected case a month was the average number sent in, during this last year, 1909, there have been sent to the laboratory, at times, as many as five or six a day, the number being larger in the warm weather. When the disease appears in the dog, one manifestation of it is that the animal runs over large areas of country, perhaps within a radius of twenty-five or thirty miles, and in this mad race the dog may infect other dogs throughout the entire distance. It is, therefore, of small value to muzzle dogs only in a particular village, since the dogs while muzzled may be bitten by an outsider. There is no reason why the disease could not be stamped out of a state in six months by muzzling all the dogs. But muzzling the dogs in a village here or in a town there is really only temporizing with the trouble.

Hydrophobia in man requires usually from two to six weeks to develop, so that there is a long period in which to utilize preventive measures, and it is on this account that children may be sent, as happens frequently, to New York City or to Paris to be treated by what is known as "Pasteur treatment." This treatment involves the inoculation of the rabies virus which has first been passed through a series of rabbits, in the course of which the virus has become exceedingly strong. The treatment of the human being consists in successive inoculations with virus of various strengths, beginning with the weakest and ending with the most powerful rabbit virus. After this has been done, the effect of the bite of the mad dog has been neutralized, so that in most cases the disease has been robbed of its power. Of the cases treated at the Pasteur Institute in 1897, numbering 1521, there were six deaths, and these six were among those whose arrival at the Institute was so late that the treatment could not be begun in time.

Tetanus.

The fourth disease for which an antidote in the form of antitoxin has been developed is tetanus, commonly known as lockjaw. This is a bacterial disease caused by a specific germ, the peculiarity of which, in its progress, is a long-continued spasm of certain muscles of the body. The germs are commonly found in dirt, garden soil being always full of them, and whenever the skin is broken by any object, such as a rusty nail or a knife not clean, lockjaw may be the result. Rather curiously, it is particularly likely to develop after gunpowder wounds, and the number of cases of tetanus after the Fourth of July is notable. This special prevalence of the disease is so well recognized that health officers usually lay in a large stock of antitoxin about the first of July, awaiting the inevitable demand for it.

The disease is most commonly contracted from wounds which occur in the hands or the feet, although it may be the result of wounds in other parts of the body. Very often the wound may be so insignificant as to escape the attention, as a pin prick, and yet be followed by an attack of tetanus. Formerly, the universal treatment for injuries from which tetanus was feared was to firmly cut out all portions of the flesh and skin which might have been infected. Sometimes cauterization was employed, as was done also with cases of rabies, and, if it were possible to reach the virus in the wounds before it escaped into the blood, such a method of treatment would be quite reasonable, but it is quite beyond hope to prevent infection in a jagged wound by cutting out adjacent flesh, with no regard to the dissolved poison. The more reasonable treatment is to inject the antitoxin, which neutralizes the poison and prevents, or at least minimizes, the disease.



CHAPTER XXI

HYGIENE AND LAW

One of the fundamental principles of society is that each individual must, in his methods of living, conduct himself with a due regard for the rights, comfort, and health of others in the same society. A single man or a single family living alone on a desert island requires no restrictions of conduct, since there are no fellow-beings on whom his violations of good conduct might react. The inhabitants of small villages with small families on large lots are but little concerned with laws governing social intercourse, since, at best, the amount of that intercourse is inconsiderable. But, as population becomes greater, as congestion increases, and as civilization and its requirements develop, the need for law governing the interrelations of individuals becomes imperative. Such laws deal with the moral life under many phases, and the courts exist for the enforcement of such laws as the people themselves, through their legislatures, demand for their own self-protection.

One of the primitive laws found necessary, even among uncivilized people, is that against theft, and, whether committed in the barbarous tribes of Africa or on the frontier plains of the West, the act is recognized as being contrary to the greatest good of the community, and, if detected, is severely punished. As civilization advances, the code of laws found necessary becomes more and more complex, and, although use has made obedience to such laws almost second nature, it is hardly possible to-day to escape the immediate restraint of such laws for more than a moment at a time throughout any period of twenty-four hours.

Principle of laws of hygiene.

It is particularly the laws which pertain to health and hygiene which we shall consider in this chapter. The principle on which laws relating to hygiene are passed is that while nominally a person is always free to do with his own whatever he may choose, yet as a member of a community he must choose to do only that which shall not injure or affect the health or comfort of his neighbors. This principle was not at first invoked to prevent violations of laws of health, but rather to prevent the inconvenience which might come to a neighbor or to the public at large by some unreasonable though apparently legitimate use of individual property. As an example we may mention the law of New York State requiring each owner of property in the country to cut grass, weeds, and brush along the highway twice each year. Although this interferes with the right of the owner to have the land which belongs to him left as he chooses, it is legal because of the greater convenience and comfort it contributes to the larger number of persons traveling along the highway.

The state does not assume the right to interfere with the acts of individuals so long as such acts affect only their own individual well-being, but when those actions affect others, then the police power of the state may be invoked. It is on this principle that the law prohibits suicide, assuming that no man can live or die without affecting the interests of other people. This is plainly so in the case of the head of a family or in the case of a man upon whom others are dependent and whose death removes their support and causes those supported to become dependent upon the state or county. This principle has been extended so as to include the cases where a method of living, a lack of care, or even a mere appearance in public may adversely affect the health of others in the same community. If, for example, a member of a family has diphtheria or smallpox, and such a child is isolated so that no danger of the spread of the disease exists, the state would not, in general, insist upon the use of any preventive or curative inoculation; but if a child with incipient diphtheria or whooping cough goes to school where other children may be infected and the disease spread, the state, acting through its Board of Education, would have a perfect right to send the child home and prevent its enjoying school privileges until recovery from the disease.

It is on this principle that the state says that no child in New York State may attend school unless vaccinated, the law reading, "No child, not vaccinated, shall be admitted into any of the public schools of the state, and the trustees of the schools shall cause this provision of law to be enforced." This law has been questioned and brought before the Supreme Court for review, and it was held by the judges that the protection to the community implied is of sufficient importance to justify its enactment.

For like reason, other restrictions governing the control of contagious diseases is a function of the police power of the state in which the rights of the individual must yield to the greater good of the community. The writer remembers a particularly malignant case of smallpox where the efforts of the local Board of Health had been concentrated on the enforcement of quarantine, and where by the aid of policemen, day and night, it was hoped that the disease was being confined in the one house; yet, after the death of the patient, and when apparently efforts for protection might be relaxed, a wake was held in the house, in the very room of the patient, which might have resulted in the spread of the disease through the entire town. Regulations, therefore, covering the conduct of funerals and of burials should be agreed to, since they are intended to prevent the spread of disease.

Self-interest the real basis of law.

Many practices which are required by law in cities where the population is crowded are not required or are not enforced in country districts, since there the failure to carry out protective measures reacts only on those immediately concerned. Disinfection of rooms in which contagious diseases have occurred is one such provision. It rarely happens that a health officer of a country community concerns himself with seeing that a case of scarlet fever, for example, is prevented from spreading by a thorough disinfection of the rooms. That seems to be left to the good sense of the individual. It is hardly conceivable that a mother with three or four children (when one child has been sick with a contagious disease) will neglect ordinary and reasonable precautions to prevent the spread of that disease to the rest of the family.

It is inconceivable, when the small amount of trouble and expense is considered, that the parents of a family, after a case of diphtheria, will neglect to fumigate and disinfect the clothing and bedding which may be thus infected, particularly if such clothing or bedding is to be used by other members of the family; and yet instances are recorded where a child has died of scarlet fever and a year later another child, perhaps wearing some of the clothes of the previous victim, has been seized with the disease and has followed its brother or sister to the grave. Cases of tuberculosis have been known to follow each other almost year after year, as one member of a family after another occupied a room where the infection persisted, either in the carpet or furniture, which was never properly disinfected. Such cases must be left to the good sense, intelligence, and understanding of the persons concerned. The police power can never in this age take the place of an enlightened sense in the community, nor are laws, as a matter of fact, of any use except as they are sustained and enforced by public sentiment.

QUALITY OF WATER

There is another way in which the police power of the state exercises control over rural communities, and that is in the matter of food which the country generally supplies to the city. Perhaps the pollution of water, which is, after all, one kind of food, is as important as any matter covered by health laws.

In most cities to-day the pollution of streams is prohibited on two grounds, first, that the streams are public property, even though for a part of their course they may be owned individually. The sum of the parts making up the whole stream involves so many individuals as to imply public ownership, and inasmuch as one individual is limited in his uses of the stream by the principle already referred to, he cannot, even on his own land, do what he pleases with a stream or with its waters. When streams are navigable, according to the law of this country, no private ownership can exist, for the waters are controlled and owned by the federal government. This latter body, in general, does not undertake to control the quality of such waters, but there are many laws covering the quantity of water in such streams, limiting the amounts that can be withdrawn, restricting the filling up or silting of such streams, and qualifying the bridging or damming of such waterways. In small streams, such as are generally found in rural communities, the vital principle of ownership is always limited by the requirement that no owner shall so interfere with the normal quantity or quality of water in the stream as to prevent their full enjoyment by the next man downstream whose rights are equal with his own. This means, in the matter of quantity, that while one individual may water stock in a stream or may pump water from a stream for household use, he may not withdraw from the stream the entire volume to use for irrigation, nor may he, as a riparian owner, sell the water to some city near by which might take out all the water of the stream.

The quality of a stream, likewise, may only to a certain extent be interfered with. If a stream flows through a meadow, cows pastured in the meadow have a natural right to wade in the brook, and if, in so doing, a certain amount of pollution is added to the waters of the brook, no one downstream can justly complain.

If, however, a sewer is carried from barns or houses into a brook which is later used for drinking purposes, the quality of the water is affected, and such a discharge is so revolting to the senses that complaint to the courts would result in an order to find some other method of disposing of such wastes.

In New York State, the legislature has delegated to the Department of Health certain rights in the matter of the protection from pollution of the waters of the state, particularly when those waters are used for drinking purposes. Upon application from the water company, this department, having carefully inspected the watershed, will prepare a complete and elaborate series of rules, giving in detail just what an individual may or may not do on the watershed, and, when enacted, these rules have all the force of law. They are, however, like all laws, subject to the constitutional limitations, and particularly to the clause of the constitution which provides that "no state shall make or enforce any law which shall deprive any person of property without due process of law." This means that if any law prevents an individual enjoying reasonable use of his own property, or if the deprivation of such use is for the special benefit of some special community or company, then that special body must be prepared to make compensation for that deprivation, although if it were for the general good of the community of which the individual was a member, no compensation might be required.

REGULATIONS GOVERNING FOODS

Laws covering the sale of adulterated foods are of two kinds, namely, those enacted by the national government at Washington, and those enacted by the local authorities, either state or municipal. The laws enacted by the national government, which are comprehended in the recently enacted National Pure Food Law, deal particularly with the adulteration and misbranding, not only of foods, but of all sorts of medicines and liquor. Their effect, however, is limited entirely to such articles as make up interstate commerce. If an article is made and sold within the boundaries of any single state, it is not subject to the national law, nor could this national law be applied to the production or sale of any article from a farm unless that article was well enough known to be generally distributed. For example, maple sirup, widely advertised and generally sold, would be subject to the provisions of the national law. Butter and cheese, sold locally, would not be subject to such a law. It is evident, therefore, that this law does not usually apply to farm products, unless, as in the case of some sausages, for example, a widely advertised campaign has been instituted to promote their sale.