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 preËminently 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.