Ri\4S5 R7a PREVENTIVE MEDICINE AND HYGIENE PREVENTIVE MEDICINE AND HYGIENE BY « MILTON J. ROSENAU PROFESSOR OF I'REVK NTIVF. .'MKniCINF, AND lIYCilKNE, IIAUVAIil); DIKECTOlt OF TIIK SCHOOL OF PUBLIC HEALTH OF HARVARD UNIVERSITY AND THE MASSACHUSETl'S INSTITUTE OF TECHNOLOGY; FORMERLY DIRECTOR OF THE HYGIENIC LABORATORY, U. S. PUBLIC HEALTH SERVICE, ETC. WITH CHAPTERS UPON SEWAGE AND GARBAGE, BY GEORGE C. WHIPPLE, PROFESSOR OF SANITARY^ ENGINEERING, HARVARD VITAL STATISTICS, BY JOHN W. TRASK, ASSISTANT SURGEON-GENERAL, U. S. PUBLIC HEALTH SERVICE MENTAL HY'GIENE, BY' THOMAS W. SALMON, MEDICAL DIRECTOR, NATIONAL COMMITTEE FOR MENTAL HYGIENE, ETC. FOURTH EDITION NEW YORK AND LONDON D. APPLETON AND COMPANY 1921 Q^_ COPYRIGHT, 1913, 1916, 1917, 1921, by D. APPLETON AND COMPANY PltlXTED IN THE rXlTED STAT1!S or AMERICA TO MY WIFE Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/preventivemediciOOrose PREFACE TO THE EIKJST EDITION This l)0()k has been written in response to a demand for a treatise based upon in(i(h>ni i)rogress in hygiene and sanitation. Tlie work is pbiiiiii'd to iiicliide those fiehls of the medical and related seienees which form the fomidation of public health work. So far as 1 know, no other book on the subject covers the broad field considered in this volume. The prog-ress in hygiene and sanitation has been so rapid that the subject of preventive medicine has become a specialty, and its scope has become so broad that the question throughout the making of this book has been rather what to leave out than what to include. The facts here brought together are widely scattered in the literature and many of them are difficult of access : they have been collected for the convenience of the student of medicine and the physician, as well as those engaged in sanitary engineering or public health work. During twenty-three years of varied experience in public health work it has been my good fortime to have served as quarantine officer, in epidemic campaigns, in epidemiological investigations, and in public health laboratories, at home, on the Continent, and in the tropics. The fruits of these experiences are reflected in this book, which may be taken as representing my personal views gained in the field, in the laboratory, in the classroom, and in administrative offices. It is Mell-nigh impossible to prevent or suppress a communicable disease without a knowledge of its mode of transmission. This is the most important single fact for successful personal prophylaxis, as well as in the general warfare against infection; therefore the com- municable diseases have been grouped in accordance with their modes of transference'. Each one of the important communicable diseases is dis- cussed separately in order to bring out the salient points upon which prevention is based. The classification adopted is believed to be unique and should prove helpful to tJiose who are especially concerned in the prevention of infection. The book may be considered in two parts, namely, that which deals with the person (hygiene) and that which deals with the environment (sanitation). The first part includes the prevention of the communicable diseases, A'enereal prophylaxis, heredity, immunity, eugenics, and similar subjects. The second part deals with our environment in its relation to health and disease and includes a discussion of food, water, air, soil, disposal of wastes, vital statistics, diseases of occupation, industrial vii viii PREFACE TO THE FIRST EDITION hygiene, school hygiene, disinfection, quarantine, isolation, and other topics of sanitary importance, as well as subjects of interest to health officers. All the important methods used in public health laboratories are described. To have made this book in monographic style with references to authorities for every statement would have resulted in an un^^^eldy work of impractical size and form. The textbook style has therefore been adopted and citation of authorities for facts that are now well estab- lished has been regarded as unnecessary. In this respect it may seem that I have given scant credit to many workers from whose writings I have borrowed results, thoughts, and sometimes words or even sen- tences. At the end of each chapter will be found a list of references to articles or books that I have especially drawn upon, and I desire to acknowledge my obligations to these sources as well as to refer the reader to them for further study of particular subjects. I have also draAvn freely upon my own previous writings and those of my co-workers in coriipiling this book. The chapter on "Disinfection"' is based upon my book entitled : "Disinfection and Disinfections." published by P. Blaki- ston's Sons & Co., Philadelphia, 1902. I have received generous help from a number of friends and it is a pleasure here to acknowledge especially my obligation to Dr, David L. Edsall for reading and correcting the chapter on Diseases of Occupa- tions, to Dr. John F. Anderson and Dr. Joseph Goldberger for re- vising the chapters upon Measles and Typhus Fever, to Prof. George C. Whipple for reading and improving the chapter upon "Water, to Charles T. Brues for many suggestions in the section upon insect-borne diseases, and to Prof. W. E. Castle for a similar service with the section on Heredity. Dr. Charles Wardell Stiles has kindly furnished infor- mation concerning the relation of parasites to soil. I also desire to express my obligations to Prof. Arthur I. Kendall, Dr. Harold L. Amoss, Dr. Lewis W. Hackett, Prof. William D. Frost, and Miss Emily G. Philpotts. It has "been my object to give in this volume the scientific basis upon which the prevention of disease and the maintenance of health must rest. Exact knowledge has taken the place of fads and fancies in hygiene and sanitation; the capable health officer now possesses facts concerning infections which permit their prevention and even their suppression in some instances. Many of these problems are complicated with economic and social difficulties, which are given due consideration, for preventive medicine has become a basic factor in sociology. M. J. ROSEXAU BoSTOjST PREFACE TO THE FOURTH EDITION This edition has been largely rewritten and entirely reset. The fol- lowing new snbjects have been added : Public Health Methods and Measures; Relative Values in Public Health Work; A Public Health Program; Organization of Health Departments; Median Endemic Index; Housing; Rural Sanitation; Public Health Education; Public Health .Xursing: Drug Addiction, Alcoholism; Undernutrition; Sani- tary Surveys; Infant Mortality; Koch's Laws; Intelligence Quotient; Vitamins : Oral Hygiene ; Ocular Hygiene ; Personal Hygiene ; and a Laboratory Course in Preventive Medicine and Hygiene. The following diseases are discussed in this book for the first time: Vincent's Angina; Deer-Fly Fever; Leishmaniasis; Epidemic Encepha- litis; Yaws; Psychoneuroses ; War Edema. The following subjects have been rewritten : Venereal Diseases and Hygiene of Sex ; Dysentery ; Influenza ; Trench Fever ; Mental Defec- tives; Food Poisoning; Botulism; Deficiency Diseases and Goiter. More or less extensive changes have been made throughout the rest of the volume. I have received letters from many parts of the world calling my attention to errors of commission or omission. I am grateful for these suggestions and will appreciate others that may help improve the book and keep it up to date. Acknowledgment of special help is stated on page xi. M. J. ROSENAU Hakvabd Medical School Boston ACKNOWLEDGMENTS In making this l.o(.l^ 1 liavo enjoyed assistance from many friends. J am especially indebted to the i■ollo^vino• fur heli) in the subjects named : 1)K. J. 1*. Lkake, Smallpox and \aecination Dk. a. i\I. Stimson, Rabies Di{. W. A. HiNTOX, Glanders, The Wasscrmanii Eeaction Dk. F. n. Yekiioeff, Preventable Blindness, Ocular Hygiene Dr. a. W. Sellards, Dysentery Dr. E. K. Tyzzei!, Leishmaniasis Dr. a. K. Krause, Tuberculosis Dr. E. H. Place, Diphtheria, Scarlet Fever, Measles, Whooping Cough Dr. Eufus Cole, Pneumonia Dr. C. W. Stiles, Hookworm Disease Dr. B. H. Eansom, Intestinal Parasites Dr. H. E. Carter, Mosquitoes, Malaria Dr. L. 0. Howard, Flies Dr. FJarry Plotz, Lice, Typhus Fever Dr. G. W. McCoy, Leprosy, Anthrax Dr. E. H.' Creel^ Maritime Quarantine Dr. J. Broxfexbrenner, Immunity Dr. J. E. Mohler, Meat Inspection Dr. J. GoLDBERGER, Pellagra Dr. C.-E. a. WmsLOW, Ventilation Dr. Alice Hamilton, Industrial Hygiene Dr. G. C. Whipple, Sewage, Garbage and Eefuse Dr. J. W. Trask, Vital Statistics Dr. T. W. Salmon, Mental Hygiene Lieutenant Colonel C. F. Foster, Major J. E. Bayliss, Major E. E. Hume and Major G. F, Lull read and corrected the chapter on Military Hygiene. My colleagues, Dr. M. J. Schlesinger, Dr. Harry Weiss, Dr. D. L. Sisco, Dr. Benjamin White, Mr. E. W. Lamson, and Mr. A. P. Pratt, helped me see the book through the press. My efficient secretary, Miss Mae C. Moran, made the index. D. Appleton and Company have met with unusual difficulties in publishing a book of this size at this time, and I am indebted for their cooperation, especially that of Dr. J, E, Broome, HARVAKD Medical School ^' ^- ^^^^NAU Boston CONTENTS SECTION I PREVENTION OF THE COMMUNICABLE DISEASES CHAPTEn '"-*'' l^- I. DISEASES HAVING SPECIFIC OR SPECIAL PROPHYLACTIC MEASURES 1 Smallpox and Vaccination Historical Note, 1; Vaccination, 3; Vaccine Virus, 4; Methods of Vaccination, 9; Indices of a Successful Vaccination, 12; The Immunity, 14; Revaccination, 18; Claims for Vaccination, 20; Vaccination of Exposed Persons, 20; Dangers and Complications, 21; Tlie Government Control of Vaccine Virus, 24: The Unity of Cowpox a'nd Smallpox, 25; Compulsory Vaccination, 25; Inoculation or Variola Inoculata, 26; Prevalence of Smallpox, 28; Epidemiology, 29; Modes of Infection, 30; Resistance of the Virus, 31; Smallpox in the Vaccinated and Unvaccinated; 31; Isolation and Disinfection, 35. Rabies : General considerations, 38; Period of Incubation, 39; Entrance and Exit of the Virus, 40; The Relative Danger of Bites, 41; Viability, 41; Prophylaxis, 42; The Local Treatment of the Wound, 43; The Pasteur Prophylactic Treatment, 44; Diagnosis of Rabies in Dogs, 51. Vexebeal Diseases: Syphilis, 55; Gonorrhea, 67; Chancroid, 72. Venereal Prophylaxis and Hygiene of Sex: Prevalence, 73; Attitude, 75; Education, 76; Notification, 78; Continence, 79; Personal Hygiene, 79; Alcohol, 80; Prostitu- tion, 80; Segregation, 81; Medical Prophylaxis, 81; Hospitals and Clinics, 85. Pkevextable Blixdxess: , Ophthalmia Neonatorum, 87; Trachoma. 92: Toxic Amblyopia, 94; Accidents, 94. Tetanus : Etiology, 95 ; Occurrence. 97 ; Trismus Neonatorum, 99 ; Incuba- tion, 100; Resistance, 100; Prophylaxis, 102. II. DISEASES SPREAD LARGELY THROUGH THE ALVINE DIS- CHARGES 105 Typhoid Fever General Considerations, 105; Historical Landmarks, 106; Prevalence. 107: Channels of Entrance and Exit, 110; Diagnosis, 110; Bacillus Carriers, 113; Resistance of the Virus, 116; Ty- ph<)id Bacillus in Nature, 117; Modes of Spread, 118; Typhoid Vaccines, 128; Management of Case, 133; Personal Prophylaxis, 135. Paratyphoid Fever General Considerations, 136; Paratyphoid Fever and Food Poisoning, 138. xiv CONTENTS CHAPTER PAGE Choleba General Considerations, 139; The Cause and Contributing Causes, 139; Diagnosis, 141; Modes of Transmission, 142; Bacillus Car- riers, 144 ; Immunity and Prophylactic Inoculations, 145 ; Quaran- tine, 146; Personal Prophylaxis, 147. Dysenteky Bacillary Dysentery, 148; Amebic Dysentery, 150; Contrast be- tween Bacillary and Amebic Dysentery, 151. Hookworm Disease Distribution, 153; Species of Hookworm, 154; Modes of Trans- mission, 154; The Parasite, 154; Immunity, 157; Resistance of the Parasite, 157; Prevention, 158; Plan of Campaign, 160. III. DISEASES SPREAD LARGELY THROUGH DISCHARGES FROM THE MOUTH AXD NOSE 163 TUBEECtXOSIS General Considerations, 163 : The Difference between Human and Bovine Tubercle Bacilli, 165: Bovine Tuberculosis in Man.. 166; Modes of Infection, 170; Immunity, 177; Resistance of the Virus, 180; Prevention, 181; Segregation — Sanatoria, 182: Per- ' ^sonal Prophylaxis, 184; Tuberculosis in Children. 187: Bovine Tuberculosis, 188; Directions for Testing Cattle with Tuberculin, 188; The Bang Method of Suppressing Bovine Tuberculosis, 189; Organization of a Local Tuberculosis Campaign, 190; Outlook, 191. DlPHTHEEIA General Considerations, 191; Modes of Transmission, 193; Bacillus Carriers, 195: Diagnosis, 198: Resistance. 198; Im- munity, 199; The Schick Reaction, 201; The Control of Out- breaks, 202; Responsibility of the Medical Profession, 206; Pre- vention of Post-diphtheritic Paralysis, 207 ; Prevention of Serum Sickness and Anaphylactic Shock, 208; Historical Note, 209. Vincent's Angina 210 Measles General Considerations, 212; Immunity, 213; Resistance of the Virus, 214; Modes of Transmission, 215; Prevention, 217. German Measles 219 Scarlet Fever General Considerations, 219; Modes of Transmission, 220; Im- munity, 223; Prophylaxis, 223. Whoopixg-Cough General Considerations, 224 : Modes of Transmission, 225 ; Im- munity, 226; Prevention, 226; Mortality, 228. Mumps 228 Lobar Pneumonia General Considerations, 230; Types of Pneumococci, 231; Resist- ance of the Virus, 232; Modes of Transmission, 232; Carriers, 233; Immunity, 2.34; Prevention, 236; Preventive Measures, 237. Influenza General Considerations, 239; Etiology, 241; Mode of Infection, 241; Epidemiology, 241; Vaccines, 244; Administrative Meas- ures, 245. Common Colds ' General Considerations, 246; Prevention, 247; Drafts and Chill- ins, 248. CONTENTS XV CHAPTER PAGE Cerebrospinal Fever tk-nenil Considerations, 250; Epidemiology, 251; Modes of Transmission, '252; Carriers, 254; Prevention, 257. IV. INSECT-BOKNE DISEASES 259 General Coxsiderations 259 Insecticides . ' General Considerations, 266; Preparation of the Room for Funii<jatii)n, 266: The Relative EHieiency of Insecticides, 267; Sulphur, 2(i!): Forinaldehyd. 270: Pyrethruni, 271: Phenol- Camphor, 272: Hydrocyanic Acid Gas, 273; Bisulphid of Car- bon, 274; Petroleum, 275; Arsenic, 276. Mosquitoes General Considerations, 279: Life History and Habits, 280; The Destruction of ilosquitoes, 281; Malaria, 286; Yellow Fever, 295; Dengue, 303; Filariasis, 305. Flies General Considerations, 307 ; Life History of the Musca Do- mestica, 309: Life History of Stomoxys Calcitrans, 310; Flies as Mechanical Carriers of Infection, 311; Suppression, 315; Sleeping Sickness, 317; Deer-Fly Fever, 321; Pappataci Fever, 322. Fleas General Considerations, 322; Pulicides, 325; Relation of Plague to Rats and Fleas, 325. Rats a:sd Other Rodents General Considerations, 328 : Breeding and Prevalence, 329 ; Migration, 330: On Vessels, 331; Food, 331; Habits, 332; Rat- Bite Fever. 332 ; Plague in Rats, 333 ; Acute Infectious Jaundice, 335; Rat Leprosy, 337; Trichinosis, 337; Food Infection. 337; Other Parasites, 337 : Economic Importance, 338 : Suppression of Rats, 338; Squirrels and Plague, 344; Plague, 345. Ticks General Considerations, 354; Texas Fever. 356; Rocky Moun- tain Spotted Fever, 356; Japanese River Fever, 361; Relapsing Fevers, 361. Lice General Considerations, 362; Lice Bites and the Transmission of Disease, 365; Delousing, 366: Lice as a ^Military Problem, 369; -Typhus Fever, 370; Trench Fever, 376. Bedbugs General Considerations, 378; Suppression, 379. Leisioianiasis 380 Roaches 383 V. MISCELLANEOUS DISEASES 386 Infantile Paralysis General Considerations, 386; Resistance of the Virus, 389; Im- munity, 390; Modes of Transmission, 390; Prevention, 392. Epidemic Encephalitis 394 Chickenpox 395 Glanders General Considerations, 396; Diagnosis, 397; Prevention, 400, Anthrax General Considerations, 401; Resistance, 402; Prevention, 402. FOOT-AXD-MOUTH DISEASE 405 xvi CONTENTS CHAPTER PAGE Malta Fever General Considerations, 407 ; Modes of Transmission, 407 ; Goats' Milk and Malta Fever, 409; Prevention, 410. Yaws 410 Leprosy General Considerations, 411; Immunity, 413; Rat Leprosy, 414; Modes of Transmission, 415; Prevention, 418. SECTION II MENTAL HYGIENE By Thomas W. Salmon General Considerations 421 The Problems of Mental Hygiene, 422; Heredity, 424; Alcohol, 429; Other Exogenous Poisons, 433; Endogenous Poisons, 434; Syphilis, 434; Other Infections, 437; Head Injuries, 438; Men- tal Causes, 439; Experience of the World War, 442; Economic Factors, 449; Immigration, 450. Agencies Available for the Application of Preventive Medicine Hospitals for Mental Disease, 451 ; Public Health Authorities, 452; Educational Authorities, 452; National and Local Societies for Mental Hygiene, 452. Conclusion 454 SECTION III PUBLIC HEALTH MEASURES AND METHODS SOME GENERAL CONSIDERATIONS 459 Sources of Infection, 459; Modes of Transference, 460; Carriers, 462 ; Missed Cases, 463 ; Channels of Infection, 463 ; "Contagious" and "Infectious," 463; Epidemic, Endemic, Pandemic, and Prosodemic, 464; Fomites, 465. Relative Values of Public Health Work 466 A Score for Health Activities 468 A Public Health Program 469 Organization of Health Departments 470 The Median Endemic Index 472 Health Centers . 473 Housing 473 Rural Sanitation 475 Public Health Education 476 Infant Mortality 477 Public Health Nursing • 483 Nuisances . 483 Face Masks 485 Drug Addiction 486 Alcohol 487 Sanitary Surveys . 493 Management of an Epidemic Campaign 495 Quarantine 498 General Considerations, 498; Maritime Quarantine, 502; Quaran- . tine Procedures, 509 ; The Bill of Health, 509 ; The Equipment of a Quarantine Station, 510; Qualifications of Quarantine Officers, CONTENTS xvii PAGE 511; Disinfection of Ships, 511; Fumigation of Sliipp, ol.l; Cargo, 518; Foreign Inspection Service, 518; National versus State Quarantine, 51i>; Interstate Quarantine, 519. SKCTION^ IV IMMUNITY, HEKEDITY, AND EUGENICS I. IMMUNITY 523 General Considerations 523 Mecluinisni of Immunity, 527; Theories of Immunity, 528; Natural Immunity, 530; Acquired Inununity, 532; Non-Specific Immunity, 532; iMixed Immunity, 533; How Active Imnuinity May Be Acquired, 533; Bacterial Vaccines, 535; Specificity, 537; Local and General Immunity, 53!); Bacillus Carriers, 540; Latency, 542; Lowered Resistance, 542; Relation between Host and Parasite, 546; Ehrlich's Side-Chain Theory of Immunity, 647 ; Antitoxic Immunity, 553. Toxins 553 Antitoxins General Considerations, 558; Preparation of Antitoxin, 561; Method of Concentrating Diphtheria Antitoxin, 562; Mode of Action, 563. , Endotoxins 565 Standardization of Antitoxic Sera Standardization of Diphtheria Antitoxin, 566; Standardization of Tetanus Antitoxin, 568. Phagocytosis 570 Opsonins 574 Lysins 575 Hemolysis 578 Cytotoxins ..... 579 The Bordet-Gengou Phenomenon — Fixation of Complement The Wassermann Reaction, 581. The Neisser-Wechsberg Phenomenon or Deviation of the Com- plement ; . 583 Precipitins General Considerations, 585; Tests for Blood, 587. Agglutinins 589 Anaphylaxis General Considerations, 593; Examples of Anaphylaxis, 594; Experimental Anaphylaxis, 594; Specificity, 596; Sensitization by Feeding, 598; Maternal Transmission, 598; Serum Anaphy- laxis in Man, 598; Hypersusceptibility and Immunity Produced by Bacterial Proteins, 601; Relation of Anaphylaxis to Protein Metabolism, 602; Relation of Anaphylaxis to Endotoxins, 602; Relation of Anaphylaxis to Tuberculosis, 602; Relation of Anaphylaxis to Vaccination, 603; Relation of Anaphylaxis to Food "Idiosyncrasies," 604; Eczema, 604; Relation of Anaphy- laxis to Hay Fever, 605; Relation of Anaphylaxis to Drugs. Anaphylactoid Reactions, 605; Other Practical Relations of Anaphylaxis, 605. II. HEREDITY AND EUGENICS 607 General Considerations 607 Defectives, 608; Recognition, 608; Mongolianism, 608; Feeble- minded— Idiots, Imbeciles and Morons, 609 ; Prevention of Propa- xviii CONTENTS CHAPTER P\GE gation of Defectives, 611; Statistics of Defectives, 613; De- generate Families, 615. Eugenics ; 619 Pbixciples of Heredity Variation, 621; Darwin's Theory — the Survival of the Fittest, 621; Mutation, 622; DeVries — Discontinuous Evolution, 622; Weissmann's Views, 623 ; Mendel's Law, 624 ; Atavism and Rever- sion, 628; Galton's Law of Filial Regression, 629. The Cell in Heredity 629 Statistical Methods 631 Heredity versus Environment 638 Immunity Gained through Inheritance 639 III. THE HEREDITARY TRANSMISSION OF DISEASE . . . '. 640 General Considerations 640 Inbreeding, 642; The Microbic Diseases, 643; Congenital Trans- mission, 644; Hereditary Transmission of a Tendency to a Dis- ease, 644 ; Tuberculosis, 645 ; Syphilis, 645 ; Cancer, 646 ; Leprosy, 648; Deaf -Mutism, 648; Albinism, 649; Color-Blind- ness, or Daltonism, 650; Hemophilia, 651; Gout, 651; Brachy- dactylism, 652; Polj'dactylism, 653; Fragilitas Ossium, 653; Myopia, 653; Cataract, 653; Retinitis Pigmentosa, 653; Diabetes Mellitus, 654; Orthostatic Albuminuria, 654; Alcoholism, 654; Migraine, 654; Anaphylaxis or Food Idiosyncrasies, 655; Hay Fever, 655; Epilepsy, 655; Huntington's Chorea, 655; Fried- reich's Disease — Hereditary Ataxia, 656; Mental Deficiency, 658; Insanity, 658. SECTION V FOOD I. GENERAL CONSIDERATIONS 661 The Uses of Food General Considerations, 663; Caloric Value of Food, 664. Classification of Foods Physical Properties, 666; Sources, 666; Chemical Composition, 666; Composition and Function, 667. Vitamins 669 The Amount of Food Excessive Amounts, 673; Insufficient Food, 674; Famine and Pestilence, 675 ; War Edema, 675 ; Underfeeding and Growth, 676. Unbalanced Diets 676 The Deficiency Diseases General Considerations, 677; Beriberi, 678; Scurvy, 683; Rickets, 685; Pellagra, 686. Food Poisoning General Considerations, 692. Food Infections Incubation Period, 696 ; Symptoms, 696 ; Taste, Odor and Ap- pearance, 698; Kind of Food Responsible, 698; Diagnosis, 698; The Colon-Typhoid Group, 699; The Gaertner Group, 701. Botulism General Considerations, 706; Prevalence, 706; Symptoms, 708; Pathology, 710; The Bacillus, 710; Toxin, 712; Antitoxin, 715; Prevention, 716. CONTENTS xix CHAPTER PAOE Decomposed Foods Geiu'ial Consiclerations, 717; Fermontation and Putrefaction, 718; I'utrefac'tive Changes in Proteins, 719; "Ptomain" Poison- ing, 721. Adulteration of Food 725 Preservation of Foods General Considerations, 728: Cold, 730; Drying, 733; Salting and Pickling, 735; Jellies and Preserves, 730; Smoking, 737; Canning, 737; Chemical Preservatives, 741. The Preparation of Food Cooking, 749; Methods of Cooking, 751. II. ANIMAL FOODS: MILK 753 Milk General Considerations, 753; Composition, 754; Ferments or "Life" in Milk, 760; Thermal Death Point of Milk Enzymes, 761; "Leukocytes" in Milk, 762; The Excretion of Drugs in MUk, 763; The Differences between Cow's Milk and Woman's Milk, 763; Milk Standards, 764: Grades of Milk, 765; Certified Milk, 767; "Standardized" or Adjusted Milk, 768; Pveconstructed Milk, 768; The Decomposition of Milk, 768; Sour Milk and Intestinal Flora, 769; Putrid Milk, 770; Slimy or R6py Milk, 771; Alco- holic Fermentation of Milk, 771; Bitter Milk, 771; Colored Milk, 772; Adulterations of Milk. 772; Dirtv Milk— The Dirt Test, 772; Clarification, 773; Bacteria in " Milk, 774; The Germicidal Propertv of Milk, 776; Diseases Spread by Milk, 777: The Character of Milk-Borne Epidemics, 783; Dried Milk, 784; Fresh Milk Products, 785; Butter, 785; Inspection, 788; Pasteurization, 788; The Effect of Heat upon Milk, 792; The Essential Requirements for a Safe and Satisfactory Milk Supply, 793. The Bacteriological Examination of Milk Number of Bacteria, 794; Kinds of Bacteria, 796. The Microscopic Examination of Milk The Stewart-Slack Method. 797; The Doane-Buckley Method, 798; The Prescott-Breed Method, 798. Chemical Analysis of Milk t Total Solids, 798; Determination of Total Solids, 799; Deter- - mination of Fats, 800; Determination of Milk Sugar, 802; Deter- mination of Proteins, 804 ; Water, 805 ; Reaction, 806 ; Specific Gravity, 807; Field Tests, 808; Heated Milk, 808; Tests for Enzymes, and Their Significance, 808; Tests for the Adultera- tion of Milk, 810. III. ANIMAL FOODS: MEAT, FISH, EGGS, ETC .814 Meat Structure and Composition, 814; Nutritive Value, 815; Sources, 816; Recognition of Spoiled Meat, 817; Prevention, 818; Meat Preservatives, 818. Meat Inspection General Considerations, 818; The Abattoir, 820; Qualifications of a Meat Inspector, 822; The Freibank or Three-Class Meat System, 822; Emergency Slaughter, 823; Methods of Slaughter, 824; The United States jNIeat Inspection Law, 825; Ante- Mortem Inspection, 825; Post-Mortem Inspection, 826. Animal Parasites Trichinosis, 830; The Pork or Measly Tapeworm, 834; Taenia Saginata, 835; Echlnococcus Disease, 836. XX CONTENTS CHAPTER Fish Physiological Fish Poisoning, 837; Bacterial Poisons, 838; The Fish Tapeworm, 839. Shellfish General Considerations, 840; Oysters, 842: Mussel Poisoning, 843. Bob-Veal 846 Eggs Nutritive Value, 847; Classification, 848; Bacteria in Eggs, 849; Eggs and Disease, 849. Plant Foods Tubers, 851; Roots, 8.51; Fruits, 851; Carbohydrate Food Preparations, 851; How Plants May Injure Health, 851; The Nutritive Value of Plants, 850; Poisoning from Plant Foods, 856. SECTION VI AIE I. COMPOSITION OF THE AIR : 865 General Consideeations 865 Oxygen, 867: Nitrogen, 869; Argon, 869; Ozone, 869; Hydrogen Peroxid, 871; Ammonia, 872; Mineral Acids, 872; Carbon Dioxid, 872. II. PRESSURE, TEMPERATURE, AND HUMIDITY 887 Peessuee Normal Atmospheric Pressure, 887 ; Diminished Atmospheric Pressure, 887 ; Increased Atmospheric Pressure, 890. Movements of the Atjiospheee 891 Tempebature of the Aib General Considerations, 893; Methods of Recording Tempera- ture, 895. Humidity Aqueous Vapor, 896 ; Methods of Determining Humidity in the Air, 900; Relation of Humiditv and Temperature to Health, 904; The Kata-Thermometer, 907; "^Effects of Warm Moist Air, 910; Effects of Cold Damp Air, 911; Effects of ^Yarm Dry Air, 912. III. MISCELLANEOUS 914. Odobs 914 Light — Ocular Hygiene 916 Electricity 925 Radio-Activity 925 Smoke 926 Fog 929 Dust 929 IV. BACTERIA AND POISONOUS GASES IN THE AIR .... 936 Bacteria in the Aie General Considerations, 936 ; Method for Determining Bacteria in the Air, 938; Air and Infection, 939. CONTENTS xxi rllAPTEII VAOt Poisonous Gases in tiik Aik Carbon Monoxid, 941; Illuiiiinatiiiy (Jas, 1)44; Utlier Gases in the Air, 94(5. Sewer Gas General Considerations. 949; Bacteria in Sewer Air, 9.10; Ac- cidents in Sewers, 951; Illustrative Cases of Deatli by Sewer Gas, 952; Prevention of Accidents in Sewers, 954; Ventilation of Sewers, 954. V. FRESH AND VITIATED AIR 955 The Benefits of Fresh Air 955 The Effects of Vitiated Air General Considerations, 955; The Effects of Increased Carbon Dioxid and Diminished Oxygen, 957; Poisons in tlic Expired Breath, 958; Physical Changes in the Air, 960; Reinspiration of Expired Air, '963. Summary 964 VI. VENTILATION AND HEATING 966 Vextilatiox General Considerations, 966; Air Washing, 968; Recirculation, 968 ; Vitiation by Respiration, 969 ; Vital Capacity of the Lungs, 969; Dead-space' Air, 970; Factor of Safety, 971; The Amount of Air Required, 971; Standards of Purity — Efficiency of Venti- lation. 973; The Size and Shape of the Room, 975; Inlets and Outlets. 977; External Ventilation, 979; Natural Ventilation, 979; Mechanical Ventilation, 984. Heatin^g General Considerations, 984; Open Fires, 986; Franklin Stoves, 986; Open Gas and Oil Heaters, 986; Hot-air Furnaces, 986; Hot-water and Steam Pipes, 987; Electric Heating, 988; The Cooling of Rooms, 988. SECTION YII SOIL L GENERAL CONSIDERATIONS 991 Classification of Soils, 992; Surface Configuration, 993; Com- position of the Soil. 993: Physical Properties, 994; Soil Air, 996: Soil Water, 996; The Nitrogen Cvcle, 998: The Carbon Cycle, 1002. II. SOIL AND ITS RELATION TO DISEASE 1003 Bacteria in Soil, 1003; Pollution of the Soil. 1004; Dirt, 1005; Cleanliness, 1006; Influence of Soil upon Health, 1007; Diseases Associated with Soil, 1007. SECTION YIII WATEK GENERAL CONSIDERATIONS 1015 Composition, 1015; Classification. 1016; Properties, 1017; Uses in the Body, 1017;. Amount Used and Wasted, lOlS; Dual Water Supply, 1021. xxii CONTENTS SOUECES OF WATEK Eain Water, 1022; Surface Waters, 1020; Ground Water, 1032. SOUKCES AND NaTUKE OF WaTEE PoLLUTLON AND INFECTION General Considerations, 10-13; Simple Tests to Determine Sources of Pollution, 1043; Interstate Pollution of Streams. 1044: Pollu- tion of International Boundary Waters, 1045; The Care of Catch- ment Areas, 104G. II. SANITARY ANALYSIS OF WATER 1048 Standard Methods . .' 1048 Odoks and Taste General Considerations, 1050; Method of Determining Odor, 1051; Prevention and Removal of Tastes and Odors, 1054. COLOB General Considerations, 1055 ; Method for Estimating Color, 1056; Platinum-Cobalt Standard, 1056. Tuebidity General Considerations, 1057; Methods for Estimating Turbidity, 1058. Reaction" 1059 Total Solids ^ 1060 Haedness General Considerations, 1061; Methods, 1063. Oeganic Matter Free Ammonia, 1066; Albuminoid Ammonia, 1069; Nitrites, 1071; Nitrates, 1072. Chlorids 1074 Chlorin , 1075 Oxygen Oxygen Consumed, 1077 ; Dissolved Oxygen, 1079. Iron General Considerations, 1080; Iron Pipes, 1081. Lead Tests, 1082. III. MICROSCOPICAL EXAMINATION OF WATER 1084 The Sedgwick-Rafter Method, 1084; Significance of Ihe Examina- tion, 1086. Bacteriological Examination The Number of Bacteria in Water, 1087 ; Method for Determin- ing the Number of Bacteria in Water, 1089; Kinds of Bacteria in Water, 1090. IV. INTERPRETATION OF SANITARY WATER ANALYSIS . . . lOHG General Considerations 1096 Allowable Limits, 1097 ; Illustrative Analyses Interpreted, 1099. V. THE PURIFICATION OF WATER . . . 1108 Nature's Methods of Purifying Water General Considerations, -1108; Evaporation and Condensation, 1109; Self-purification of Streams, 1109; Storage in Lakes and Ponds, 1111. CONTENTS xxiii CHAPTEU PAGE Distilled Water 1112 Boiled Water 1112 Filters Slow Rand Filters, 1113; INk'oIianieal Filtora. 1122; Household Filters. 1127; Scrubbing or Roughing Filters, 1128; Screening, 112S. Storage ■ 1128 Sedimentation 1129 Chemical ]\Ietiiods of Purifying Water Ozone, 1129; Clilorinated Lime — Bleaciiing Powder or "Ciilorid of Lime," 1132; Chlorin, 1131); Permanganate of Potash, 1140; Alum or Sulphate of Aluminium, 1141; Sulphate of Iron and Lime, 1142: Metallic Iron: The Anderson Process, 1143; Cop- per Sulphate, 1143. Ultraviolet Rats 1144 VI. WATER AND ITS RELATION TO DISEASE 1147 General Considerations 1147 The Mills-Reincke Phenomenon 1148 Non-Specific Diseases Due to Water General Considerations, 1149; Goiter, 1150; Lead Poisoning, 1155. Specific Diseases Due to Water General Considerations, 1159; Cholera. 1161; Typhoid Fever, 1167; Dysentery, 1179; Diarrhea. 1180; Animal Parasites, 1181. Sanitation of Swimming Pools 1182 Drinking Fountain 1184 Ice General Considerations, 1184; Natural Ice, 1186; Manufactured Ice, 1187; Ice and Disease, 1188. SECTION IX SEWAGE DISPOSAL By George C. Whipple General Considerations 1191 Importance of Speedy Removal of Fecal Matter, 1191; Dry Earth System, 1192; Water Carriage System, 1192; Separate and Combined Systems, 1193; Quantity of Sewage, 1194; Com- position of Sewage, 1194; Ventilation and Flushing of Sewers, 1196. Stream Pollution Sewage Disposal by Dilution, 1196; Hygienic Aspects of Stream Pollution, 1198; Protection against Pollution, 1199; Funda- mental Principles of Sewage Treatment. 1200: Preparatory Processes. 1200; Purification Processes. 1204: Finishing Proc- esses, 1209; Choice of Methods, 1209; Relative Bacterial Effi- ciency of Different Processes, 1210; Management of Sewage Treatment Works, 1211; Treatment Plants as Nuisances, 1211; Nuisances Caused by Trade Wastes, 1212. Cooperative Sanitation 1212 The Rural Problem of Sewage Disposal 1213 xxiv CONTENTS SECTION X EEFUSE DISPOSAL - By George C. Whipple PAGK Genebal Considerations 1219 Incineration Plants, 1221; Reduction Plants, 1223; Feeding Garbage to Hogs, 1224; Collection of Garbage, 1224. SECTION XI VITAL STATISTICS By John W. Trask General Considerations 1225 Vital Statistics Definition, 1227; Development, 1227; Based upon Population, 1228. Population Statistics Source of Data, 1228; Nature of Census Information, 1229; Sources of Error in Census Enumerations, 1229 ; Fluctuation in Population, 1230; Estimates of Population, 1230. Marriage Statistics Marriage Rates, 1234; Factors Influencing Marriage Rates, 1234; Uses of Marriage Registration, 1234. Birth Statistics Registration in the United States, 1235; Birth Rates, 1238; Sources of Error in Birth Statistics, 1239 ; Uses of Birth Regis- tration and Statistics, 1240; Factors Influencing Birth Rates, 1241. Morbidity Statistics General Considerations, 1242; Morbidity Statistics in the United States, 1243; The Model Law for Morbidity Reports, 1245; Re- sults of Notification in Certain States and Cities, 1246 ; Source of Statistical Data, 1247 ; Nature of Information Secured by Morbidity Notification, 1251; Standard Notification Blank, 1251; Sources of Error in Morbidity Statistics, 1252; Uses of Mor- bidity Reports and Statistics, 1253; Morbidity Rates, 1254; Hospital Statistics and Sickness Insurance Records, 1255 ; Fac- tors Influencing Morbidity Rates, 1255 ; Notification of Occupa- tional Diseases, 1255; Morbidity Statistics of Military Popula- tions, 1257. Mortality Statistics General Considerations, 1259; Registration of Deaths in the United States, 1260; United States Registration Area for Deaths, 1260; Source of Data, 1261; The Standard Death Certificate, 1262; Sources of Error, 1262; Uses of Death Registration, 1266 ; Death Rates, 1267; Factors Affecting Death Rates, 1270; Inter- national List of Causes of Death, 1272. Infant Mortality 1275 Life Tables 1276 SECTION XII INDUSTEIAL HYGIENE AND DISEASES OF OCCUPATION General Considerations 1279 Some Fundamental Considerations in Prevention General Considerations, 1283; Hours of Work, 1284; Fatigue, 1284; Minors, 1286; Women, 1287; Factory Inspection, 1289; Preventable Accidents, 1290; Sedentary Occupations, 1291. CONTENTS XXV CHAPTER PAGE Diseases of Occupation Glassifk-ution of llie Oiriipatioiial Disoaaes, 121>2; Lead, 1203; Phosplioriis, i;{();}; Arsoiiic, l.Jd."); Mercury, i:U)7; Carbon Monoxid, l.SOH; llydroj^'cn Snlphid, i:{<)!): Other Industrial Poisons, l.UO; Dustv Trades, l;{i;{; Tlie Textile industries, ^•^\^)■. Wood Dust. 1319; Mininfr, l;n!»; Effects of Heat, 1321; Com- municable Infections, 1322; Caisson Disease, 1324. SECTION Xlll SCHOOL SANITATION AND PERSONAL HYGIENE General Considekations 1325 Healtli Education. 1328; School Building, 1328; Tiie School- room, 1329; The School Furniture, 1330; Posture, 1334; Recess, 1334; Lighting, 1335; Ventilation and Heating, 1336; Open Air Schools, 1337; Water-closets and Urinals, 1337; Cleanliness, 1338; Medical Inspection, 1338; The Communicable Diseases of Childhood, 1341; Closing Schools on Account of Epidemics, 1342; The Eyes, 1342; The Ears, 1343; Oral Prophylaxis, 1343; Nose and Throat, 1346; Diseases of the Skin, 1347; Nervous Diseases and Mental Defects, 1348; Chorea, 1348; Vaccination, 1350. SECTION XIV DISINFECTION I. GENERAL CONSIDERATIONS 1351 Disinfection, 1351; Nature's Disinfecting Agencies, 1353; Cleanli- ness, 1353; Antibiosis and Symbiosis, 1354; When and Where to Disinfect, 1355; Qualifications of the Disinfector, 1355; Con- trols, 1356; Disinfection Must Be in Excess of Requirements, 1356; Specificity of Germicides, 1356; Chemotherapy, 1357; The Ideal Disinfectant, 1357; Concurrent Disinfection, 1357; Ter- minal Disinfection, 1357; Penetration, 1358; Organic Matter, 1359; Time, 1359; Speed of Disinfection and Stability of Dis- infectants, 1360; Temperature, 1360; Emulsions and Solutions, 1361; Dilution, 1362; Reaction, 1362; The Mechanism of Bactericidal Action, 1362; The Choice of Germicide, 1364. The Staxdakdization of Disixfectaxts , General Considerations, 1364; Methods, 1365; Carbolic Coeffi- cient, 1366. II. PHYSICAL AGENTS OF DISINFECTION 1375 Sunlight, 1375; Ultraviolet Rays, 1375; Electricity, 1377; Pres- • sure, 1377; Burning, 1377; Dry Heat, 1378; I3oiling, 1378; Steam, 1379. III. CHEMICAL AGENTS OF DISINFECTION 1390 Gaseous Disinfectants — Fumigation Preparation of the Room, 1390; Formaldehyd Gas, 1391; Sul- phur Dioxid, 1396; Hydrocyanic Acid Gas, 1402; Chlorin, 1403; Oxygen, 1404; Ozone, 1404. Liquid Disinfectants General Considerations, 1404; Methods of Using Chemical Solu- tions, 1405; Metallic Salts, 1406; Bichlorid of Mercury, 1406; Silver Salts, 1407; Zinc Salts, 1408; Ferrous Sulphate, 1408; Sulphate of Copper, 1408; Coal Tar Creosote, 1408; Carbolic Acid, 1409; Phenol, 1410; The Cresols, 1411; Liquor Cresolis Compositus. 1412; Lvsol, 1412; Creolin, 1412; Aseptol, 1412; Asaprol, 1413; Sanatol, 1413; Solveol and Solutol, 1413; Naph- xxvi CONTENTS CHAPTER PAGE thols, 1413; Ambrine, 1413; Naphthalene, 1413; Formalin, 1414; Potassium Permanganate, 1415; Hydrogen Peroxid and Other Peroxids, 1415; Lime, 1416; Bromin and lodin, 1417; Anti- formin, 1421; Dyestuffs, 1422; Acids, 1422; Alcohol, 1423; Soaps, 142'4. Convenient Formula fob Disinfecting Solutions Bichlorid of Mercury — Corrosive Sublimate, 1425; Formalin, 1425; Milk of Lime, 1426; Carbolic Acid, 1426; Chlorinated Lime, 1426. IV. METHODS OF DISINFECTIOIST 1439 Air, 1427; Stables, 1428; Railroad Cars, 1430; Feces, 14.32; Sputum, 1434; Bed and Body Linen, 1435; Books, 1435; Cadavers, 1436; Thermometers, 1437; Wells and Cisterns, 1437. SECTION XV MILITAKY HYGIENE Genebal Considebations Comparative Loss in Campaign from Sickness and Wounds, 1441. Recbuits and Recbuiting General Considerations, 1442; The Physical Examination, 1444; Age, 1444; Character and Mental Condition, 1445; Height, Weight and Chest Measurements, 1446; Vision, 1447; Teeth, 1448; Vaccination, 1448; General, 1448; Training, 1449, Duties of the Medical Offices 1450 Equipment . General Considerations, 1451'; The First-aid Packet, 1453; Clothing, 1454. Diseases of the Soldier General Considerations, 1458; War Gases, 1459. Sanitation in Camp and on the March Personal Hygiene of the Soldier, 1459; The March, 1459; Forced Marches, 1461; Discipline and Sanitation, 1462; Sani- tary Police, 1463; Transportation, 1464. Camp Sites General Considerations, 1465; Topography, 1465; Tentage, 1467; Care of Tents, 1468. Sanitation of Babbacks and Camps General Considerations, 1469; Water, 1470; Disposal of Excreta, 1473; Disposal of Garbage, 1475. Sanitation of Teenches 1478 Hygiene in the Tropics 1479 Cold Climates 1481 SECTION XVI A LABORATOEY COURSE IN PREVENTIVE MEDICINE AND HYGIENE Schedule 1483 Vaccination, 1484; Standardization of Disinfectants, 1485; Water, 1486; Milk, 1489; Bacterial Vaccine, 1492; Vital Statistics, 1493; Diphtheria Diagnosis, 1496; Classification of Pneumococci, 1498; Meningococcus Isolation and Carrier Detec- tion, 1499; Sanitary Survey of a City or Town, 1501. Index l^Oo LIST OF ILLUSTRATIONS FicrKB PAGE 1. Vaccination scars 10 2. The course of the eruption 13 3. Vaccinia: course of the eruption 14 4. Vaccinia: course of the eruption (continued) 15 5. Course of vaccination and revaccination 19 6. Smallpox mortality per 100,000 population in Breslau ... 32 7. Smallpox mortality per 100,000 population in Vienna ... 33 8. Smallpox mortality per 100,000 population in Prussia ... 36 9. Smallpox mortality per 100,000 population in Austria ... 37 10. Chart showing relation of enforcement of muzzling law to prevalence of rabies in Great Britain 43 11. Influence of public water supplies on the typhoid fever death rate 119 12. Immediate and striking effect of purifying a badly infected water supply upon the typhoid situation 121 13. Abrupt reduction in death rates from typhoid fever incident to water purification in four American cities 122 14. Hookworms, natural size 155 15. Hookworm embryo 155 16. Chart showing the decline in the death rate from tuberculosis . 182 17. Curve of the influenza epidemic in the naval training camp at Pelham Park, New York, September and October, 1918 . 243 18. "West swab tube 256 19. Diagram illustrating the method of taking material from the nasopharynx by means of a special swab 256 20. A South African blood-sucking fly (Pangonia), illustrating long proboscis to pierce heavy fur of certain animals . . . 261 21. Example of sealing door for purpose of fumigation .... 267 22. Anopheles punctipennis 288 23. Stegomyia calopus (female) 297 24. Head of Stegomyia calopus (male) 298 25. Eggs of Stegomyia calopus 299 26. Larva of Stegomyia calopus, Eespiratory siphon of culex to the right 300 27. Pupa of Stegomyia calopus 301 28. House fly showing proboscis in the act of eating sugar . . . 307 29. Eggs of house fly as laid in a mass 308 '30, Eggs of house fly 308 31. Larvae of house fly 309 xxvii xxviii LIST OF ILLUSTRATIONS FIGURE pj^ej. 32. Puparium of house fly .- 309 33. Stable fly 310 34. Head showing proboscis 310 35. Wing of stable fly 311 36. The "little house fly" 312 37. Wing of house fly, showing how it carries dust particles . . 313 38. The Hodge fly trap on a garbage can 315 39. Tsetse fly 318 40. The Indian rat flea 323 41. The common rat flea of Europe and North America . . . 324 42. The human flea 324 43. A squirrel flea 327 44. A general scheme for testing plague rat infection, city of Manila 352 45. Isolated plague-infested center, Manila, P. 1 353 46. The Texas fever tick 357 47. Rocky Mountain spotted fever tick 358 48. Serbian barrel 367 49. Delousing plant 371 50. The bedbug , .... 379 51. Diagrammatic representation of complement fixation . . . 400 52. The cell with its various combining groups or side chains known as receptors 549 53. The toxin molecule: showing the haptophore (combining) group, and the toxophore (poison) group 549 54. The first stage of antitoxin formation: a toxin molecule an- chored to a receptor 549 65. The second stage: continued stimulation causes a reproduction of receptors 550 56. Third stage: The receptors beginning to leave the cell . . . 550 57. Fourth stage: the receptors have left the cell and float free in the blood — antitoxin 551 58. The neutralization of a toxin by antitoxin; the free receptors in the blood have united with the toxin — antitoxic immunity 551 59. Showing complement and immune body 551 60. Showing an immune body having two affinities 552 61. Diagram illustrating deviation of complement 584 62. History of the family Zero 616 63. History (condensed and incomplete) of three markedly able families 6l8 64. Wilson's theory of inheritance modified by Lock 623 65. Diagram showing the course of color heredity in the Andalusian fowl, in which one color does not completely dominate another 626 66. Diagram showing the course of color heredity in the guinea-pig in which one color (black) completely dominates another (white) 626 67. Model to illustrate the law of probability or chance .... 632 LIST OF ILLUSTllATIONS xxix FIQl'RR ■ PA«r. 68. Normal curve . . .- . . . 633 69. Curve made up of variates 636 70. Family history showing deaf-mutism 649 71. Family history showingr polydactylism 652 72. Family history showing Huntington's chorea 656 73. Family history showing feeble-mindedness 657 74. Sections through seeds of rice, wheat and corn 681 75. Curve showing thermal death point of Bacillus botulinus . 712 76. Curve showing rate of destruction of botulinus toxin . . . 714 77. Unsanitary surroundings of a cowbarn 765 78. Conditions under which it is difficult to cleanse and disinfect milk bottles and milk pails 773 79. A dark, poorly ventilated cow shed, difficult to keep clean . . 775 80. Automatic temperature recorder for pasteurizers 790 81. Strauss home pasteurizer 792 82. Trichinella spiralis. Entire life cycle in each host .... 831 83. Taenia solium, the pork or measly tapeworm 834 84. Beef tapeworm 836 85. Dibothriocephalus latus, the fish tapeworm 839 86. Portable Haldane apparatus for small percentages of carbon dioxid 879 87. Petterson-Palmquist apparatus 881 88. Wolpert air tester . . 884 89. Fitz air tester 885 90. Diagram showing absolute humidity in grains at different tem- peratures 897 91. Sling psychrometer 901 92. Eelative humidity table 902 93. Dew-point apparatus 903 94. The Kata-thermometer 908 95. Table showing the density of smoke, in accordance with the Eingelmann chart, which may be emitted from the various classes of stacks in Boston, Mass., and duration of such emission 928 96. Palmer water-spray apparatus for the collection of aerial dust . 934 97. Magnus aspirator 938 98. The double aspirator 938 99. The position of inlets and outlets and their relation to the air currents in a room 978 100. "Window ventilator 979 101. Diagrammatic sketch of various provisions for ventilation . 980 102. Fairfield system of window ventilation 983 103. The nitrogen cycle 999 104. The nitrogen cycle in diagrammatic vertical section .... 1000 105. Ground water 1032 xxx LIST OF ILLUSTKATIONS KlfitB!! . PAGE 106. Usual method of pollution and even infection of- wells . . . 1037 107. Proper construction of a well 1038 108. Popular idea of how wells become infected from surface pollution * 1039 109. Depression of the ground water level by pumping and tendency to draw near-by pollution from the soil or cesspool . . . 1040 110. In a limestone formation it is difficult to tell anything about the source of water obtained from a well 1041 111. Algae commonly found in water 1052 112. Algae commonly found in water (continued) 1053 113. Oil droplets in a diatom 1054 114. Graduated cylindrical funnel and concentrating attachment used in the Sedgwick-Rafter method 1085 115. Diagram illustrating the character of the ground water in rela- tion to soil pollution, to assist in the interpretation of a sanitary analysis * . 1098 116.' Diagram showing location of samples 1106 117. Section of an English filter bed 1114 118. The arrangement of a slow sand filter 1115 119. Diagram illustrating "loss of head" 1118 120. An ozonizer 1130 121. An installation for treating water with ozone ....... 1131 122. Asiatic cholera and the Broad Street pump 1163 123. Asiatic cholera and the Broad Street well . 1164 124. Water supply of Hamburg . 1166 125. Change in water supply 1169 126. Mean death rates from typhoid fever, 1902-1906, in 66 American cities and 7 foreign cities 1170 127. Map of Plymouth, Penn., in 1885 1173 128. Map showing water supply of Ashland, Wisconsin .... 1175 129. Inclined screen operated by water wheel 1201 130. Reinsch-Wurl screen . 1202 131. Cross section of septic tank 1202 132. Typical section of an Imhoff tank 1203 133. Chemical precipitation plant at Worcester, Mass., outlet . . 1204 134. Triple contact beds at Hampton, England 1205 135. Cross section of intermittent sand filter 1206 136. Cross section of contact bed . . 1206 137. Typical section of sprinkling filter 1207 138. Trickling filter at Birmingham, England . 1208 139. Septic tank and chemical precipitation tanks at Rochdale, England 1209 140. Intermittent sand filtration bed at Brockton, Mass 1214 141. Filter bed with sand ridged for winter operation at Brockton, Mass 1215 LIST OF ILLUSTRATIONS xxxi KUn 1!E PAGE 142. Discharge of sewage upon a filter bed at Brockton, Mass, . .1216 143. Digestion process of garbage reduction 1220 144. A simple type of garbage incinerator 1222 145. Cobwell process of garbage reduction, New Bedford, Mass. . 1223 146. Births (including stillbirths), persons married, and deaths (excluding stillbirths) registered per 1,000 population per annum, Michigan, 1871-1915 1238 147. Diphtheria — number of cases notified per annum for each death registered in Michigan, 1884-1912 1247 148. Smallpox — number of cases notified per annum in Michigan, 1883-1915 1248 149. Smallpox — number of cases notified per annum for each death registered, Michigan, 1883-1915 1248 150. Scarlet fever — number of cases notified per annum for each death registered, Michigan, 1884-1915 1249 151. Measles — number of cases notified per annum for each death registered, Michigan, 1890-1917 1249 152. Births and deaths (exclusive of stillbirths) per 1,000 population per annum registered in Mass., 1871-1911 1266 153. State statistics of original registration 1276 154. System of hoods and ventilators to carry off the fumes from the furnaces in a foundry 1281 155. Red oxid of lead and litharge being mixed in the manufacture of storage batteries 1295 156. A worker with lead oxid, showing respirator to protect himself against the poisonous dust 1298 157. Workmen exposed to zinc fumes in brass casting, causing a con- dition known as "brass-founders' ague" 1312 158. An effective dust-removing system in the boot-and-shoe in- dustry. Edge trimming 1315 159. A very dusty trade — drum with nails which combs out the small pieces of broom corn 1316 160. The stone industry . . . ^ 1820 161. Faulty posture . . . . ' 1332 162. The Heusinger desk 1333 163. Boston school desk and chair 1334 164. Device for determining carbolic coeflScients 1368 165. Arrangement of tubes in water-bath and their contents . . . 1370 166. Section through Arnold steam sterilizer 1381 167. Section through autoclave 1382 168. Bramhall-Deane steam sterilizer 1382 169. Cross section through steam disinfecting chamber .... 1383 170. Longitudinal section through steam disinfecting chamber . . 1384 171. Kinyoun-Francis steam disinfecting chamber 1385 172. Automatic thermometer 1387 173. Plan showing the method of installing the double-ended steam chamber at a national quarantine station 1388 xxxii LIST OF ILLUSTRATIONS FIGUBE PAGE 174. Flaring- top tin bucket for generating formaldeliyd by the per- manganate method 1394 175. The pot method of burning sulphur 1398 176. Large stack burner for sulphur, with 15 of the 18 pans removed to show construction 1399 177. Liquefied sulphur dioxid in tin can 1400 178. Section through double sulphur furnace 1402 179. Steam sterilizer for bedpans 1434 180. Proper and improper methods of distributing the equipment . 1452 181. The normal foot 1457 182. Shape of the U. S. military shoe 1457 183. Camp of a regiment of infantry, war strength 1466 184. Ishiji filter (Japanese model) 1470 185. Darnall siphon filter 1471 186. Construction of pit latrine 1473 187. Straddle-pit cover ! . . . 1474 188. Pit crematory 1474 189. Pit for kitchen refuse 1475 190. Urine soakage pit 1476 191. A rock pile crematory 1477 192. U. S. Army grease trap 1477 193. Improvised ice-box 1479 194. Water bag to cool water in hot countries 1480 PREVENTIVE MEDICINE AND HYGIENE SECTION I PREVENTION OF THE COMMUNICABLE DISEASES CHAPTER I DISEASES HAVING SPECIFIC OR SPECIAL PROPHYLACTIC MEASURES SMALLPOX AND VACCINATION The prevention of smallpox depends primarily upon vaccination, sec- ondarily upon isolation and disinfection. Vaccination was the first specific prophylactic measure given to man ; it produces an active im- munity to smallpox. On account of its importance and great practical value this subject will be considered in some detail, for much of the antivaccination sentiment is due to ignorance or misconstruction of the facts. Smallpox was once the most prevalent and dreaded disease in the world. Before the days of vaccination only five persons out of a hundred escaped it, and about a quarter of those who took it died. Many of those who recovered were mutilated or maimed for life. Historical Note. — The credit of giving vaccination to the world is due to Jenner, who proved through carefully planned experiments that cowpox protects against smallpox. This fact had been familiar to the farmers and folk of England as a vague tradition for a long time. A young girl who sought medical advice of Jenner, when a student at Sudbury, said, "I cannot take smallpox because I have had cowpox" ; this remark made a strong impression upon the young medical student. Benjamin Jesty, a Dorchestershire farmer, in 177-i successfully vac- cinated his wife and two sons. Plett, in Holstein, in 1791 also success- fully vaccinated three children. It was Jenner, however, who through logical and scientific methods proved that a person who has had the mild disease, cowpox, enjoys protection against the serious and often 1 2 DISEASES HAVING SPECIAL PROPHYLAXIS fatal disease, smallpox. Waterhouse and others soon repeated and cor- roborated Jenner^s experiments and helped to establish the soundness of his conclusions. Jenner made his crucial experiments in 179G, when he transferred the vaccine matter from the hand of a dairy maid (Sarah Nelms) to the arm of James Phipps, a boy about 8 years old. Sarah jSTelms scratched her hand with a thorn and "was infected with the cowpox from her master's cows, in May, 1796." Jenner transferred the vaccine virus from the eruption upon the hand of Sarah Nelms to the arm of James Phipps on May 14, 1796. A typical take followed. "In order to ascertain whether the boy, after feeling so slight an affection of the system from the cowpox virus, was secure from the contagion of the smallpox, he was inoculated the first of July following with variolous matter, immediately taken from a pustule. Several slight punctures and incisions were made on both arms, and the matter was carefully in- serted, but no disease followed. The same appearances were observable on the arm as we commonly see when a patient has had variolous mat- ter applied, after having either the cowpox or the smallpox.^ Several months afterward he was again inoculated with variolous matter, but no sensible effect was produced on the constitution." In addition to such direct experimental proof, Jenner inoculated smallpox matter into ten persons who had at some previous time con- tracted cowpox. Date of Inoculation with Smallpox 1. 1778 2. 1791 3. 1792 9. 10. 1795 6.-) 7. [■ 1797 8. J After 1782 Not stated Name Mrs. H. Mary Barge Sarah Portlock r Joseph Merret I William Smith Elizabeth Wynne Sarah Wynne William Rodway Simon Nichols John Phillips Ascertained to have had Cowpox When very young 31 years previously 27 years previously 25 years previously 1, 5, 15 years previously 10 months previously 9 months previously 38 years previously Some years previously 53 years previously In justification of such human experimentation it should be re- membered that at that time the inoculation of smallpox matter into healthy individuals was an acknowledged method of preventing that disease. Jenner himself was inoculated when a boy. The question of "inoculation" (with smallpox) as contrasted with "vaccination" (with cowpox) will be discussed presently. With such proof as this Jenner put a popular belief upon a scien- tific basis. He demonstrated that cowpox is a local and mild disease * This keen observation shows that Jenner was familiar with the modified take, recently rediscovered and now known as the immediate reaction. SMALLPOX AND VACCINATION 3 in man, that it may be readily transferred from man to man, and that it protects against smallpox. The chain of evidence was complete, but he first proved his thesis to his own satisfaction before he gave it to the world. He said himself: "I placed it on a rock where I knew it would be immovable Ijeforc I invited the public to take a look at it." Jenner presented the results of his observations to the Royal Society, of which he was a Fellow, but the paper was refused. He then published it in 1798 as a book, modestly entitled, "An Inquiry Into the Causes and Eifects of the Yariolae Vaccinae, a Disease Discovered in Some of the Western Counties of England, Particularly Gloucestershire, and Known by the Name of the Cowpox." Every student of preventive medicine should read this brief "inquiry'' in the original. It may be taken as a model of careful observation and logical presentation, showing great self-restraint and moderation of an observant, imaginative, and judicial mind. Dr. Benjamin Waterhouse, the first professor of Theory and Prac- tice of Physic in the Harvard Medical School, early became convinced of the value of Jenner's demonstration and obtained some vaccine virus on threads from abroad. On July 8, 1800, he vaccinated his son, Daniel Oliver Waterhouse, then five years old. This was the first person vac- cinated in America, so far as existing records show. After successful vaccination with cowpox his two sons and other members of his house- hold were inoculated with smallpox at the Smallpox Hospital by Dr. Zabdiel Boylston, with negative results. In Boston on August 16, 1802, nineteen boys were vaccinated with the cowpox. On November 9th twelve of them were inoculated with smallpox; nothing followed. A control experiment was made by inocu- lating two unvaccinated boys with the same smallpox virus; both took the disease. The nineteen children of August 16th were again unsuc- cessfully inoculated with fresh virus from these two boys. This is one of the most crucial experiments in the history of vaccination, and fully justified the conclusion of the Board of Health — "cowpox is a complete security against the smallpox." Thomas Jefferson helped materially to spread the new doctrine in this country, and, in 1806, in writing to Jenner, said : "Future nations will know by history only that the loathsome smallpox has existed and by you has been extirpated.'" This prophecy has by no means been ful- filled— though eminently possible. YACCINATION Vaccination may be defined as the transference of the virus from the skin eruption of an animal having vaccinia or cowpox into the skin of another animal. Vaccination, then, consists in introducing the active 4 DISEASES HAVING SPECIAL PEOPHYLAXIS principle of cowpox into the skin of a susceptible animal. For over one hundred years vaccination (from vacca — a cow) was a specific term limited to the introduction of the virus of cowpox into the skin, in order to induce vaccinia and prevent variola. In recent years, however, the term has been used in a generic sense to include the introduction of many different substances in many different ways and for many different purposes. Thus we speak of attenuated or killed bacterial cultures as bacterial vaccines; and the subcutaneous inoculation of organic sub- stances of diverse origin and nature is often spoken of as vaccination. We hear of typhoid vaccines, anthrax vaccines, staphylococcus vaccines, and we read in the literature of animals "vaccinated" with extracts of cancer and other organic substances. For distinction between a vaccine and a virus, see page 534. VACCINE VIEUS ^, Vaccine virus is the living specific principle in the matter obtained from the skin eruption of animals having a disease known as "vaccinia" or "cowpox." A^accine virus is obtained from calves, but may also be obtained from older cattle, from man, rabbits, buffalo, camels, and other mammals. Cowpox, or vaccinia, is an acute specific disease to which many animals are susceptible, namely, man, cattle, camels, rabbits, monkeys, guinea-pigs, rats, etc. The disease runs practically the same clinical course in all susceptible species. The eruption is always local and confined to the site of the vaccinated area ; the constitutional symptoms are always benign and usually slight. Vaccinia or cowpox is a benign disease; when uncomplicated, it has never been known to cause death or leave any unpleasant sequelae. After an incubation period of from three to four days the local eruption begins as a papule which soon develops into a vesicle, and later into an umbilicated pustule. Surrounding the vesicle is a red- dened, inflamed, and tender areola. The neighboring lymph glands are swollen and tender, and there may be slight fever lasting several days. The pustule dries, leaving a crust or scab, which comes away,- dis- closing a typical foveated or pitted scar. Human and Bovine Vaccine Virus. — Vaccine virus is usually ob- tained from (1) bovine or (2) human sources. Human virus is now seldom used, for the reason that the supply would not be sufficient. Upon the appearance of a smallpox outbreak it is sometimes necessary to have enough virus to vaccinate one hundred thousand or more people. Such large quantities evidently could not be obtained from man at any desired time. Another objection to the use of human virus is the possibility of transmitting syphilis, and perhaps SMALLPOX AND VACCTNATIOX 5 other dit^oasos peculiar to iiiaii. It i^ not always jjractical to select donors so as to avoid such transmission. When human seed is used the virus may be transferred directly from arm to arm; or the virus may be preserved dry in the scab; or the con- tents of the vesicle may be kept in either a dried or moist state, as de- scribed below for bovine virus. Arm-to-arm vaccination is still practiced in several parts of the world, particularly in Mexico, where it is claimed that it has the advantage of producing a better take; that the results are surer in that there are fewer unsuccessful vaccinations; and, finally, it is stated that the human virus affords a better immunity, but as to this there is no proof and some doubt. Bovine virus has been used more or less since the time of Jenner, but especially since 1866 when the Beaugency strain was discovered, and more since 1891 when Copeman showed how to purify it with glycerin. It has the great advantage of being readily obtained in any amount and when desired. It may be purified, and it further totally eliminates the danger of conveying syphilis and other diseases peculiar to man. Forms of Vaccine Vims. — Vaccine virus may be used in one of three forms: (1) fresh, (2) dry, (3) glycerinated. The fresh virus may be taken from the eruption of the calf or man and transferred directly. Thus the Institut Tacc-inale at Paris still prefers to use the fresh virus. The vesicle is squeezed at its base be- tween the blades of forceps, and some of the content is transferred from the calf directly to the skin of the arm by means of a thumb lancet or any similar instrument. The vaccinal matter may be dried, and the virus remains potent in this state a very long time, especially if kept cold and protected from light. The virus may be dried upon a splinter of ivory, bone, or other substance. Formerly physicians preserved the dried crust from a typical take. When needed, small portions of this crust were ground, moistened, and inserted into the skin. Glycerinated virus consists of vaccine pulp treated with 50 per cent, glycerin. This purifies it and hence is preferable. Vaccine Pulp and Vaccine Lymph. — A distinction is drawn between the pulp and the hinph. The pulp consists of the entire vesicle with its contents, which is scraped from the skin, and is composed of epi- thelium, leukocytes, bacteria, products of inflammatory reaction, the fluid content of the vesicle, debris, etc. The lymph is the serous fluid contained in the vesicle or which often exudes from the broken vesicle. When the eruption is produced on the skin of a calf in a large con- fluent area, the surface of the eruption is scraped away and the exuding "lymph" is placed upon points by dipping or brushing. !Most of the active principle of vaccine virus is contained in the epi- thelial cells, and this portion is largely lost when only the lymph is 6 DISEASES HAVING SPECIAL PROPHYLAXIS used. The pulp, which includes the lymph, therefore contains the virus in greater concentration, and is almost exclusively used in this country at the present time. Dry Points versus Glycerinated Vaccine Vims. — The old-fashioned dry points were prepared by applying the vaccine lymph to splinters of ivory. Bone or glass were later substituted for ivory. Bone is un- desirable because it is difficult to sterilize and may contain tetanus spores. The only advantage of the dry point is its convenience in vaccinating. One disadvantage is that the virus dried upon such points cannot easily be purified as is the case with glycerinated pulp. Further, the points are used as scarifiers and the method of scarification favors irritation and infection of the wound. Dry points practically always contain more bacteria than the glycerinated virus. For these reasons points are no longer permitted in interstate traffic in accordance with the federal regulations. The best container for single doses of vaccine virus is a capillary tube. These are easily sterilized, filled and hermetically sealed. They should be wiped with alcohol and broken with sterile gauze, and the contents can then safely be emptied by means of a small rubber bulb. "When many vaccinations are to be done, it is preferable to have the virus in bulk. The Process of Ripening or Aging. — When the vaccine virus is fresh it is said to be "green." Glycerin is added to the green pulp, and after it has acted a certain period of time the virus is said to be "aged" or "ripe." The use of glycerin for this purpose was introduced by ]\Ioncton Cope- man ^ in 1891 for the purpose of preserving ^ and purifying the virus. The glycerin acts as a differential germicide, that is, it is comparatively harmless to the active principle in the vaccine virus, but destroys the frail non-spore-bearing bacteria. In time the virus itself succumbs. Vaccine virus must, therefore, not be used while green nor when too old. Manufacturers date their products as "not reliable after" 2 months in the summer time, and 3 months during the cold season. Fifty per. cent, glycerin of the best quality is used. I have shown that no growth of bacteria, yeasts, or molds takes place in 60 per cent.* glycerin. Two to four parts of 50 per cent, glycerin are added to 1 part of the pulp by weight. The mixture is then thoroughly ground with a mortar and pestle by hand, or between glass rollers in a special mill driven by machinery. The pulp should be thoroughly broken up and a uniform suspension obtained. The amount of glycerin added depends upon the consistency and character of the pulp. The only objection 'Transactions of the International Congress of Hygiene, 1891. ^Glycerin also serves as a preservative for other " filterable viruses, as foot- and-mouth disease, infantile paralvsis, rabies, etc. ^Hyg. Lab. Bull. No. 16, U. S.'P. H. & M. H. S., 1903. SMALLPOX AND VACCINATION 7 to adding more glycerin Avoukl bo the greater dilution of the virus, and, therefore, a larger proportion of negative takes. A higher percentage than 50 per cent, of glycerin soon renders the virus inert. The time required for the virns to ripen depends upon the temperature. Most of the non-spore-bearing bacteria perish in 30 days at 15° to 20° C. Approximately the same effect may be obtained at 37° C. in a few hours. At low temperatures the glycerin has practically no bactericidal effect. The process must always be controlled bacteriologically. Vaccine virus should always be kept cold until used. The warmth of the doctor's pocket may be enough to destroy its potency in a few hours. The heat of the railroad car or post oflficc may soon render it impotent. This explains the difficulty sometimes encountered in obtain- ing potent virus during the summer months. Substances other than glycerin are used for the purpose of purifying vaccine virus. Carbolic acid (0.5 to 1.0 per cent.), in addition to glycerin, is used with success in Japan, and to a large extent in this coun- try. Potassium cyanid, brilliant green, chloroform, chlorobutanol, etc., have been tried, with less success in practice. Bacteria in Vaccine Virus. — Vaccine virus obtained from the skin always contains bacteria. However, these bacteria are, for the most part, harmless to man. They are commonly those that are found on and in the skin of the calf. The non-spore-bearing varieties are largely elimi- nated by the process of ripening. There are fewer bacteria in the typical unbroken vesicle than in the pustule or in a broken, crusty, inflamed eruption. Green virus may contain from a few thousand to over a million bacteria per cubic centimeter. The ripened, glycerinated virus con- tains much fewer, and these mostly harmless saprophytes. The number of such bacteria in the ripened virus may be taken as an indication of the care and cleanliness with which the virus has been prepared. In the LTnited States vaccine virus is required to have fewer than 50 bacteria per dose. Noguchi ^ by painstaking methods obtained a bacteria-free vaccine virus, which may be propagated in the testicles of bulls or rabbits. Human beings react to' the testicular strain in an entirely typical manner, but this method has not been found practical for propagation on a large scale. Seed Vaccine. — The seed virus may be obtained (1) from cowpox, (2) from smallpox, (3) by retro vaccination. "Spontaneous" or casual cowpox occasionally occurs; that is to say, the disease appears to arise spontaneously because its origin cannot be traced. Casual cowpox comes either from another case of cowpox or from a case of smallpox. Cattle are not subject to smallpox, but, when smallpox virus is introduced into the skin of a calf, it produces cowpox. Wour. of Exp. Med., June 1, 19L5, XXI, 6, p. 339. 8 DISEASES HAVING SPECIAL PROPHYLAXIS When smallpox is thus converted into cowpox, it remains fixed as such, and never reverts to smallpox.*' Twenty-nine separate records of success- ful modification of smallpox virus into cowpox are found in the litera- ture; also a number of negative attempts. Some of the strains obtained in this way were used to vaccinate children with typical takes and adequate protection, Retrovaccination consists in carrying the vaccine virus back from child to calf; better still, the virus may be passed from man through rabbit, monkey^ or other susceptible animal, and then again to the calf. Changing the species helps to maintain the activity of the vaccine virus for an indefinite time; furthermore, the change leaves behind cer- tain associated bacteria which may gather increased virulence by suc- cessive passage from animal to animal of the same species. Propagation. — In the propagation of bovine virus young calves are preferred, because they are more manageable, the skin is more tender, and the eruption is therefore more abundant and typical. With young animals a milk diet may be used, which simplifies the problem of dust contamination from dry feed. If hay or fodder is used, it should first be autoclaved. Either heifers or bull calves are suitable, although the former are preferred. The animals are held in quarantine for seven days, under observa- tion, to determine the absence of infections such as tuberculosis, glan- ders, foot-and-mouth disease, tetanus, fever, diarrhea or skin eruptions of any kind. Before vaccinating the calf it is carefully cleaned, and the site of the inoculation is shaved and prepared surgically,^ but without the use of strong germicidal solutions, for the reason that they are apt to destroy the action of the vaccine virus. Cleanliness and asepsis are the watchwords. The area selected is usually the abdominal wall between the tip of the sternum and the groin, sometimes including the inner side of the thigh. The usual method is to make long, superficial incisions in the skin about one centimeter apart, and the seed virus is gently rubbed into these incisions. The calves must then be kept rigidly isolated in a special room, moderately lighted, free from dust, and screened to keep out insects. The temperature of the animal is taken several times daily and the eruption at each stage of the disease is closely watched and recorded. The virus is usually taken from the animal about the fifth day. It is an advantage to take the virus early, in order to avoid contaminating infections which may occur when the vesicles maturate. Vaccine virus * It is liighly significant that casual cowpox was formerly much more com- mon when smallpox was much more prevalent. '' I used 3 scrubbings with soap and 3 tloodings with alcohol, at the Antitoxin and Vaccine Laboratory, Mass. State Dept. of Health. SMALLPOX AND VACCINATION 9 taken after the eighth day is unreliable. Jeuner's golden rule was to take the virus before the areola appeared. Virus taken after the eighth day is apt to produce unduly inflamed or abortive vesicles, called spurious takes by the early vaccinators. Only typical and entirely characteristic vesicles should be removed. Before the virus is removed, the animal is chloroformed to avoid pain, and an autopsy is done as soon after the virus is removed as practicable. If the autopsy shows any lesions indicating infections other than vaccinia, the virus is discarded. It is not wise in propagating vaccine virus to vaccinate too large an area. This favors infections by lowering resistance ; furthermore, less t^-pical eruptions are obtained than when the area vaccinated is moderate in extent. A yield of from 30 to 50 grams of pulp from one calf should satisfy the propagator. Before the virus is taken the animal is placed upon a special table, the site of the vaccination exposed and given a very thorough washing and prolonged scrubbing with soap, and an abundant flushing with sterile water. The pulp is obtained by scraping the vesicles with a sharp spoon curette. Glycerin (50 per cent.) in the proportion 1 to 4 is added at once to the pulp, and this is ground to a state of fine and uniform subdivision in a Csokar lymph mill, or simply by hand with a mortar and pestle. This glycerinated pulp is then allowed to age, and when purified by the action of the glycerin it is hermetically sealed in capillary tubes, or placed in small vials for the market. METHODS OF VACCINATION" Vaccination consists in transferring the virus of cowpox from one animal to the skin of another animal. The operation of vaccination con- sists of introducing vaccine virus into the skin. Under no circumstances must the vaccine virus be placed under the skin or subcutaneously. The operation may be compared to the transfer of a culture in a bacteriologic laboratory. Precisely similar precautions to prevent contamination must be used in both cases. Vaccination must be regarded as a surgical opera- tion. No person unfamiliar with surgical cleanliness should be per- mitted to perform this "little" operation. The vaccine virus may be introduced in one of three ways: (1) by puncture, (2) by incision, or (3) by scarification. Jenner used punctures or short incisions. Later blisters were raised upon the skin and the virus placed upon the abraded surface. The incisions w^ere then increased in number, and finally cross scratchings or scarifications were made. 10 DISEASES HAVING SPECIAL PEOPHYLAXIS Puncture.— The simplest method is shallow ohliqiie pricking of the skin with a needle moistened with the vaccine virus; this gives little chance of contamination and the eruption is typical. The disadvantage is that the virus now used is diluted with glycerin, and therefore some- what attenuated, so that a few punctures may not give an adequate take. Incision or Scratch. — The method advised and recommended is that of incision. Incision is the only method of vaccination permitted by the laws of Germany, and recommended by the Local Government Board of England. Incision, if not too deep, consists really of a series of punctures, and serves the same purpose. Incisions may be made with the point of a scalpel. I prefer to use a sterile needle. The incision or scratch should not be deep enough to draw blood, but a few drops do no harm. It is rather difficult to control the depth of the incision with a scalpel, espe- cially if it is sharp. Scratching with a needle is much more easily controlled. Two. incisions should be made about one inch long and about an inch apart. The vaccine virus is first placed upon the skin in two small droplets about an inch apart. The point of the needle is now moistened in the droplet and as the scratch is made the needle carries the virus along with it into the little wound. With the flat of the needle the virus should be gently rubbed (not ground) into the scratch. It is important not to cause any unnecessary irritation so as to avoid attract- ing infections. Scarification. — Scarification or cross-scratching should be prohibited by law. It is forbidden in Germany. The objection to scarification is that this method produces a relatively large abraded surface which is soon covered by a dry, hard crust of serum and blood, through which the erup- tion cannot pierce. The vesicles form a ring around the scarified area, leaving a central irritated wound inviting infection. Most of the cases of tetanus complicating vaccination occur in cases in which scarification was used. In this method favorable anaerobic conditions are produced under the crust or scab which forms over the abraded surface. The scarified area also leaves an unnecessary and unsightly scar (Fig, 1), Fig. 1. -Vaccknatiu.n ,Slai;.s Produced by ^Ietho;) OF Scarification. Note unnecessarv central scar. SMALLPOX AND VACCTNATIOX 11 The Point of Election. — The outer surface of ihe left arm at about the insertion of the deltoid is the most convenient for tlie operator and the patient. This is the original site selected by Jcnner, and is less liable to severe glandular complications than other points. The skin here is easily made taut during the operation by grasping the under side of the arm. Inspection of the course of the eruption is also facilitated. Flachs recommends the side of the chest at about the level of the sixth rib. in the axilla. Here the scar is not visible; but tiiis site is more objectionable than that recommended by I. IL Goldberger,* who uses the inner and back side of the arm. The leg is sometimes selected to avoid disfigurement. The vaccina- tion scar should not be regarded as a deformity. To the sanitarian a typical vaccine scar is a sanitary dimple. The leg is more exposed than the arm to traumatism^, and, therefore, to complications. Dock refuses to vaccinate on the leg unless the patient will stay in bed until the vesicle heals. With babies in diapers and with young children it is exceedingly difficult to keep these parts clean. If the leg is selected, the vaccination should be done on the calf below the head of the fibula, and not on the outer surface of the thigh. Number of Incisions. — This has an important bearing upon the probability of the take, as well as the protection. It is not wise to de- pend upon one. There is a definite relation between the number of vesicles and the degree and length of the immunity. See page IT. The German regulations of 1899 require at least four incisions, each one cen- timeter long and two centimeters apart. The Local Government Board of England directs that four vesicles should be produced, and that the total area of the vesicle formation shall not be less than one-half a square inch. ]\Iy own practice follows that of Dock, who makes not less than two incisions about an inch long and an inch apart; but in case of ex- posure to smallpox three or four such incisions are advisable. The Operation. — The skin at the site of the operation must be sur- gically clean, but need not necessarily be treated with germicides. If such are used, they must be carefully washed away in order not to destroy the activity of the virus. A thorough preliminary scrubbing with soap and water is necessary for a dirty skin. "Washing with warm water followed by alcohol is usually enough. The alcohol should be per- mitted to evaporate before the vaccine is applied and the incision is made. In general, the less the skin is irritated the less the danger of complica- tions. Xeedles are particularly handy, as they may be flamed just before the operation, and are convenient in saving time when many people are to be vaccinated. The vaccine virus is gently rubbed into the incision, not ground in, and then allowed to dry. No dressing is necessary as long as the vesicle remains unbroken, but several layers of dry sterile *y. r. Med. Jour., Dec. 25. 1020, 112, No. 6.. p. 10.35. 13 DISEASES HAVING SPECIAL PROPHYLAXIS gauze held in place by adhesive plaster do no special harm, provided they are removed before pustulation. Pads, plasters, and shields of any sort are unwise, because by retaining heat and moisture they cause softening and breaking down; in other words, they act like a poultice. The best dressing, is the unbroken skin, and then the crust (scab) which naturally forms. This permits frequent inspection and avoids undue heat and softening. If the pustule breaks or the crust comes off, or the take shows indications of secondary infection, frequent dress- ing with an active germicide is indicated. It is not good surgical technic to bind up any actively suppurating area for more than 24 hours. Painting the vesicle with tincture of iodin, cauterizing the base with silver nitrate, or the application of carbolic acid, picric acid, and other active germicides does not diminish redness or shorten the course of the vaccinal eruption. Bathing need not be omitted, nor any of the ordinary occupations, but ca-re should be taken not to soften the crust by water or sweat. Unnecessary use of the arm must be guarded against, as this increases the congestion, inflammation, and the chances of infection. INDICES OF A SUCCESSFUL VACCINATION The take must be typical and the clinical course characteristic, other- wise we have no assurance that the individual is protected against small- pox. The best indices of a successful take are: (1) the course of the eruption, (2) the general symptoms, and (3) the scar. The importance of knowing the skin lesions of vaccinia were in- sisted upon by Jenner. Every vesicle, scab, ulcer, or irritated wound is not vaccinia. Xo confidence should be placed in doubtful or atypical takes. The characteristic features of vaccination are singularly alike. The clinical course of a primary vaccination is as follows : Course of the Eruption. — The primary wound soon heals. Appar- ently nothing occurs for 3 to 4 days, which is the period of incubation. Then one or more small papules appear upon the skin where the vac- cine virus was introduced. The papule is small, round, flat, bright red, hard, but superficial. About the fifth day the summit of the papule becomes vesicular. The vesicle is at first clear and pearl-like. Umbilica- tion soon develops as the vesicle enlarges. A deep, red, and swollen areola surrounds the vesicle and grows wider as the lesion advances. This gives the picture of the "pearl upon the rose leaf" which consti- tutes the true Jennerian vesicle. By the seventh day the vesicle is full size, round or oval, flat on top, umbilicated, and contents clear. It is multilocular ; if pricked with a pin or accidentally opened only that portion of the lymph contained in the compartment opened will exude. By the eighth day it turns yellowish, the middle is fuller, following which the so-called second umbilication develops. Meanwhile the areola SMALLPOX AND VACCINATION 13 deepens, widens, and may be swollen. The skin feels hot, is painful, and the axillary glands become enlarged and tender. About the tenth day the areola begins to fade and the swelling subsides. By tlie eleventh or twelfth day the pustule rapidly dries, leaving a brown, wrinkled scab, which finally drops off about the twentieth day. It should never be removed, as it forms the best dressing. PUNCTURE PUSTULE 9TH DAY PAPULE -4"^" DAY DESICCATION 12TH0AY VESICLE 5'^**DAy CRUST IBT"OAY UMBILICATION7TMDAY FOVEATED SCAR Fig. 2. — The Cotjrse of the Eruption (Diagrammatic). The scar is at first red, finally turns white, with the pits or fovea- •tions so characteristic of true cowpox. General Symptoms. — These vary. Malaise, loss of appetite, some- times nausea and vomiting, headache, pain in the muscles of the back, and other indications of a mild febrile reaction appear about the seventh day, and soon cease. The temperature may go to 38° or 38.5° C. as the vesicle ripens. The febrile reaction bears no special relation to the size and number of the vesicles or to the areola. The regional lymph nodes become enlarged and tender about the time the pustule forms. The nitro- gen elimination increases about the tenth day for a short time. The blood changes resemble those of smallpox, an early leukopenia and sec- ondary leukocytosis. 14 DISEASES HAVING SPECIAL rEOPHYLAXIS Secondary vaccinations often run an accelerated^ milder, or modified course with shortened periods of incubation (see revaccination). Vaccination certificates should be based upon observation of the course of the take. Modified reactions in revaccinations are to be inter- preted as successful takes, but their nature should be recorded — as im- mediate, or accelerated reactions, page 18. THE IMIklUNITY The immunity appears about the eighth day of the vaccination. Layet puts the point of safety at the ninth day, Burckhard at the elev- Fi(,. 3. — VacciIv'IA. Course of the Eruption. enth. These data are based upon the early work with variolation, when persons were inoculated witli smallpox at various periods following vac- cination. Sacco got only a local eruption by inoculating smallpox on the eightli to the eleventh days, and none after that. Fig. 4. — Vaccinia. Course of the Eniption. 15 16 DISEASES HAYIXG SPECIAL PEOPHYLAXIS Taccinia protects not only against smallpox, but also against vac- cinia. Curiously enough^ the degree and length of immunity appear to be greater against smallpox than against itself. Persons who have had smallpox may often be vaccinated successfully. It is irrational to at- tempt to fix a definite time for the duration of the immunity. This varies as in other infectious processes. It is known through experiment and experience that the immunity gradually wears off. The degree of protection is usually absolute for some years, and then gradually fades. Judged by successful revaccinations, it begins to disappear in 2 years and in 10 years is almost completely gone. In this, as in other diseases, immunity is a relative term. Smallpox itself does not always protect against smallpox. Some people have two and even three attacks of smallpox.^ Such cases, however, are exceptional, and it is also ex- ceptional to have smallpox occur in an individual who has been properly vaccinated. Careful statistics collected in Japan since 1879 show quite definitely the gradual diminution of the immunit}', beginning with the second year after vaccination. Kitasato's table,^° based on 951 cases, is as follows: SUCCESSFUL REVACCINATIOX AFTER 1 year 13.6 per cent. 2 years 32.9 " " 3 years 46.6 ^J |J 4 years 57.3 5 years 51.1 6 years 63.8 Weil, in 1899, reported 72.5 per cent, of successful revaccinations after seven years, 80 per cent, after eight years, 85 per cent, after nine years, and 88.6 per cent, after ten years. German Government reports show 90 to 93 per cent, successful revaccinations after 10 years. It is commonly asserted that, if a revaccination takes, the subject was therefore susceptible to smallpox. While this is usually true, it does not necessarily follow. It is a still greater fallacy to state that, if a vaccina- tion fails, the subject is therefore immune. This view, may result in real harm. Vaccination may fail for many reasons — the operation may not have been properly done, or the virus may have been inert. Sometimes persons are unsuccessfully vaccinated three, four, or more times before a typical take is obtained.^^ A modified reaction must be regarded as evidence of immunity. Thus, the immediate reaction is a clear indication of immunity, the accelerated reaction of partial immunity. » Jenner mentions "the lady of Mr. Gwinnett, who has had the smallpox five times." — Baron's "Life of Jenner," Vol. II, p. 265. ^"Jour. A. M. A., March 25, 1911, p. 889. "One of my cases gave a history of having been unsuccessfully vaccinated five times. The' sixth attempt produced a typical primary take ^yith 21 vesicles. SMALLPOX AND VACCINATION 17 There appears to be a (lofinite relation between the immunity con- ferred and the number of vaccination scars. There is also some evi- dence that the protection is directly proportional to the area of the local eruption. This question has not been carefully studied since the data contained in the final Report of the Royal Commission on Vaccination, which is summarized in the following table: MORTALITY OF POSTVACCINAL SMALLPOX IX OF SCARS RELATION TO THE NUMBER Number Scars of 3,094 cases* (1836-51) 10.661 cases* (1852-67) 6,839 casest None ' 21.7% 39.4% 1 7.6 13.8 6.2% 2 4.3 7.7 5.8 3 1.8 3.0 3.7 4 0.7 0.9 , 2.2 * Final Report of the Royal Commission on Vaccination, 1896, paragraph 291. Dr. Thome, from data collected by Mr. Marson. t Same Report, paragraph 293. Summary of cases apart from those of Mr. Marson. One point needs emphasis : The degree and duration of the im- munity are directly proportional to the typical nature of the take. No reliance should be placed upon atypical reactions. The immunity may be renewed ; two vaccinations are usually sufficient to protect for life. The nature of the changes in the body which produce the immunity are not understood. In this sense vaccination is still an empiric pro- cedure. We now know of many analogous instances, however, where an active acquired immunity is induced by means of an attenuated virus. The immunity produced by vaccine virus does not depend upon an anti- toxin. The blood, however, contains specific antibodies, shown by the fact that the activity of vaccine virus is destroyed when mixed with equal parts of blood serum from a calf two weeks after successful vacci- nation. WHEX TO VACCIXATE The fact that the immunit}' wears off after a number of years makes it necessary to practice revaccination in order to afford a continuous protection. There is some difference of opinion as to just when it is best to vaccinate the second time. Ten years is too long a period, prob- ably, to depend upon in individual cases. One vear — advised by some — is shorter than necessary in most cases. The five-year interval of Japan 18 DISEASES HAVING SPECIAL PROPHYLAXIS is good in many respects, but probably not better than revaccination in the twelfth year obligatory in Germany. The best time to vaccinate is in the first year, at least before the second summer, and again at from ten to thirteen years. After this it is usually unnecessary to vaccinate again, unless there is particular danger of exposure to smallpox. All persons exposed directly or indirectly to smallpox should at once be vaccinated and revaccinated until only an immediate reaction is obtained — unless they have had smallpox. There are no contraindica- tions to vaccinating babies immediately after birth, but takes are some- what less likely than at six months. Vaccination is accompanied by less reaction in young infants than in children, and less in children than in adults. EEVACCINATION The clinical picture of secondary vaccinations may be quite different from the typical take following a primary vaccination. These altered reactions were known in the time of Jenner, but were lost sight of until recently rediscovered, and their significance realized from studies in anaphylaxis. Revaccinations may be divided into three groups: (1) they may run an unaltered course resembling primary takes in all respects, showing that immunity to cowpox had disappeared; (2) they may run a somewhat more rapid course in which the period of incubation is shortened and in which the height of the eruption occurs about the sixth day, this is known as the accelerated reaction; or (3) they may run a very much shortened, milder, and rapid course. The eruption may be only a small papule which does not develop into a vesicle and slowly disappears; the period of incubation is about 24 hours. This is known as the immediate reaction and resembles a cutaneous tuberculin reaction in many respects. Every gradation occurs between an immediate reaction and a primary take. These altered reactions are significant and have been studied especially by von Pirquet and are shown graphically in Fig. 5. _ _ Both the immediate and the accelerated reaction are indications of immunity and therefore should be considered as successful takes. The immediate reaction may be put to practical use in order to distinguish smallpox from chickenpox.^^ Thus, Tieche has shown that smallpox virus introduced into the skin of a person immunized by vaccination will show the typical immediate reaction ; whereas the virus of chicken- pox is invariably negative. This test can be freed of all possible danger by heating the virus to 60° C. for 30 minutes, which does not seem to affect the reaction. " See also page 395. o < O j < o ^2 P > O M UK ^•?^ 2 ^:sa K^" a s I"! ""^ o o P ^-^ >H a ^ a 3 ^ 2 Z i^ O « O U iM <j £5 d Q p=t 19 20 DISEASES HAVING SPECIAL PROPHYLAXIS CLAIMS FOR VACCINATION 1. "Duly and efficiently performed it will protect the constitution from subsequent attacks of smallpox as much as that disease itself will." " 2. It protects the individual against smallpox for a period which has not been determined mathematically for the individual, but which averages about seven years. 3. The protection may be renewed by a second vaccination. 4. Persons successfully vaccinated on two occasions are usually immune against smallpox for life. 5. Vaccination and revaccination systematically and generally car- ried out confer complete protection to a community or a nation. In other words, while the individual protection is not always lasting, the communal protection is absolute. 6. A person vaccinated once and at a later time contracting small- pox as a rule has the disease in a less serious form than unvaccinated persons (varioloid).^* The degree of favorable modification of smallpox is in inverse proportion to the period of time elapsing between the vac- cination and the attack of smallpox. 7. The beneficial effects of vaccination are most pronounced in those in whom the vaccine affection has run its most typical and perfect course. ■ , VACCINATION OF EXPOSED PERSONS The question frequently arises whether persons exposed to smallpox should be vaccinate'd. The effect of vaccination during the period of incubation of smallpox is very interesting, and may be summed up as follows : 1. Vaccination just before or during the primary fever of smallpox does not influence the disease. 2. If the vaccination is done during the last stage (9th to 14th day) of the period of incubation of smallpox, the two infections run their course side by side without influencing each other. 3. If it is done about the sixth or eighth day of the period of in- cubation the vaccination takes and may modify the severity of the smallpox. 4. Vaccination done at the beginning of the incubation period, in " "I never expected that it would do more, and it will not, I believe, do less." — Jenner. Baron's Life, Vol, II, p. 135. "The term varioloid was introduced by Thompson in 1820 to describe the mild and modified form of smallpox occurring after vaccination. The eruption in varioloid does not mature and disappears more rapidly than in variola. Yolfert, Dornbleuth, and Harden showed that one vaccination was not always sufficient protection against smallpox for a lifetime, that revaccination was necessary and that the clinical manifestations of this vaccination are as different from those of the first vaccination as varioloid is from variola. SMALLPOX AND VACCINATION 21 time to have the vaccine eruption reach maturity before the smallpox begins, will prevent or abort the disease. As we can never be quite sure just what stage in the period of in- cubation a given case may be in, it is always advisable to vaccinate exposed persons. Furthermore, little harm will be done if it is too late and the vaccine eruption is added to the smallpox. Indeed, Hanna ^'^ presents claims to the effect that there is evidence of mitigation of the severity of smallpox when vaccination is performed at any time after infection up to the day of onset and even afterward. DANGERS AND COIklPLICATIONS The alleged danger from vaccination has been greatly magnified by the antivaccinationists. However, vaccination is not always a harmless procedure; it must be looked upon as the production of an acut^e infec- tious disease, and, although the disease is always mild and benign, it must not be treated as trifling. The chief danger lies in the fact that we have produced an open wound, which is subject to the complications of any wound. Even a pin prick or a razor scratch may result in death. While the aggregate number of deaths resulting from the complications of vaccination were considerable, the Individual risk is now so small as to be disregarded, especially when proper precautions are taken. Many of the infections after vaccination occur in those in whom the regard for cleanliness is slight, and who neglect the care of the wound. In recent years, owing to the improved quality of the vaccine virus and the introduction of aseptic methods, a bad sore arm is a rare occurrence, and serious complications still rarer. The danger connected with vacci- nation is infinitesimal when compared with the benefit conferred. The following complications need consideration : Auto Vaccination. — This is usually due to scratching the virus with the finger into the nose, the mouth, the mucous membranes, or any part of the skin. When carried into the eye it may cause blindness. Physi- cians sometimes vaccinate their lips by blowing into vaccine tubes. In vaccine establishments accidental vaccination of the hand is common. Generalized Vaccination. — This is sometimes reported, but is in my experience a mistaken diagnosis. A generalized eruption of cowpox is exceedingly rare, if it ever occurs. I have seen it once in the calf after intravenous injection of a large amount of the virus, in which case there was a prolonged period of incubation. The eruption is strictly confined to the point of vaccination. Satellite vesicles sometimes develop in the immediate neighborhood, owing to the spread of the virus into minute nicks in the epithelium. ^'Public Health, July, 1910, XXIII, No. 10, p. 351. 23 DISEASES HAVING SPECIAL PEOPHYLAXIS Wound Infections, such as ulcers, gangrene, erysipelas, abscesses, lymphangitis, suppuration of the axillary glands, and other septic infec- tions are now exceedingly rare, and demand the usual surgical measures to prevent their occurrence. Impetigo contagiosa occasionally occurs and may be a serious com- plication of vaccination^ trspecially the rare bullous impetigo or pemphigus which is attributed to special susceptibility or chance infec- tion and not to the vaccine virus. (Syphilis, tuberculosis, and leprosy were formerly thought of as possibilities when human virus was used, but these are not to be feared with the use of bovine virus.) Tetanus. — Tetanus deserves a special word. This serious infection sometimes complicates a vaccination wound just as it may any wound. When we consider the many millions of vaccination, wounds, many of which are neglected surgically, it is no surprise to learn that tetanus occasionally occurs as a postvaccinal complication. Acland is acquainted with only one instance in more than five million consecutive vaccinations in England, and even in this one there was no evidence that the tetanus was in the vaccine virus. Over 31,000,000 doses of vaccine were used in the United States from 1904 to 1913 inclusive, yet only 41 authen- ticated cases of tetanus occurred subsequent to vaccination.^^ A study of these cases makes it clear that the infective principle was not in the vaccine virus, but was received ten days or more after vaccination, owing to the prolonged period of incubation (20.7 days) and the high mortality (75.2 per cent.). The pernicious method of vaccination by scarification was used in almost all cases of tetanus following vaccination. Many of the cases give a history of having the vaccination scab or crust removed in some way, thus permitting infection of the wound with a re-formation of the crust and the establishment of an anaerobic condi- tion. The fact that lack of care is an important factor in postvaccinal tetanus is indicated in the figures from the United States Army and Navy with a record of millions of vaccinations without a single case of tetanus. At the Hygienic Laboratory at Washington vaccine virus representing over two million vaccinations has been examined without finding tetanus. Special tests for tetanus are required by Federal regula- tions of every lot of vaccine virus before it is placed upon the market. In the Vaccine Laboratory of the State Department of Health of Mas- sachusetts, these tests are conducted in accordance with the Eegulations ^'^ of the U. S. Public Health Service of October 1, 1919, as follows: Samples of the virus from each calf are tested separately. Only *'J. F. Anderson: United States Public Health Keport, Reprint 289, July 16, 1915. "Edward Francis, "Laboratory Studies on Tetanus," Hvgienic Laboratory Bull., No. 95, August, 1914, U. S. Public Health Service. Also G. W. McCoy and Ida A. Bengston, Hyg. Lab. Bull. No. 115, Oct., 1918. SMALLPOX AND VACCINATION 23 ground glycerinated piil[) ki'{)i without preservative for at least 7 days at a temperature of 10° C. or higher is used for the tetanus test. This is to permit tiie destruetion l)y the glycerin of the most of the frail hat'teria. Tlie test virus must not contain pliciiol or preservative other than glvicrin. Two euhie centimeters of the virus is planted in each of four Smith fermentation tuhes, each containing at least 25 cubic centimeters of meat infusion hrotli. The::e tubes are heated to 100° C. for thirty minutes just before planting in order to expel the oxygen of the air. The tubes are incubated at .'>7° C. and inspected daily; those showing gas or growth in the closed arm are used to inoculate mice or guinea pigs with one cubic centimeter of the unfiltered broth, not less than tvi'enty-four hours after growth in the closed arm and also nine days after planting. If the animals show symptoms of tetanus, the entire batch of vaccine is discarded. Or: (a) Plant 0.25 c. c, virus in plain broth fermentation tube. In- cubate at 37° C and inject 0.25 c. c. of the growth at the end of 9 days subcutaneously into a mouse. (b) Plant 0.25 c. c. virus into fermentation tubes of glucose bouillon and incubate immediately. Inject 0.25 c. c. of the growth at the end of 9 days subcutaneously into mice. (c) Plant 0.25 c. c. vaccine virus into fermentation tubes of glucose bouillon, heat at 60° C. for one hour and then incubate. Inject 0.25 c. c. of the growth into mice at the end of 9 days. (d) Plant 0.25 c. c. vaccine virus into fermentation tubes of ordi- nary bouillon, containing a bit of sterile tissue, and inject 0.25 c. c. of the growth at the end cf 9 days into mice. (e) Inject 0.25 of the vaccine virus subcutaneously into guinea-pigs. If tetanus spores are present in the virus, one of these four methods is almost sure to detect them. The tests are made in duplicate so that a total of 2.5 c. c. of the virus is thus tested. The occurrence of occasional stray tetanus spores in vaccine virus was demonstrated by Carini.^^ Such vaccine, however, had proved en- tirely harmless in thousands of cases. Francis also showed that vaccine virus purposely contaminated with tetanus spores will not produce tetanus in monkeys, although it will produce typical "takes." Glycerin does not destroy the tetanus spore. While the occa- sional danger cannot be denied, it is plain that postvaccinal tetanus can usually be laid to improper methods of vaccination and to lack of care of the vaccination wound. To prevent tetanus complications it is important to avoid scarifica- tion and irritation, to avoid the use of shields and bandages which favor anaerobic conditions, to require the patient to use strict cleanliness, and to use vaccine virus that has been properly prepared and tested. "^Centralhl. f. BaJct., Orig. 1904, XXXVII, p. 1147. 24 DISEASES HAVING SPECIAL PEOPHYLAXIS Foot-and-Mouth. Disease. — The infection of foot-and-mouth disease has in one instance been demonstrated as a contamination of vac- cine virus.^^ It is, however, impossible to convey foot-and-mouth dis- ease to man through cutaneous inoculation. While no harm has been done to man, the contamination is undesirable, and vaccine virus is tested from time to time to assure its freedom from this infec- tion (page 406). As an illustration of how seldom complications are caused by vac- cination we have the results of Germany, where in thirteen years (1885- 1898) 32,166,619 children were vaccinated. Of these 115 died within a few weeks or months after the Operation, presumably of injuries in- cidental thereto. Of these at least 48 probably did not die as a direct result of the vaccination. The figures of recent years are still better, for it is now exceedingly rare for a death to be recorded as directly due to vaccination. Ten million vaccinations in the Philippine Islands were done under the direction of American health authorities without the loss of life or limb. Of the millions of vaccinations done in the army and navy during the World War, there is not a single record of serious result. This clearly indicates that with the use of a carefully tested virus and efficient technic, the danger is nil. THE GOVEENMENT CONTROL OF VACCINE VIRUS By the law of July 1, 1902, the vaccine virus sold in interstate traf- fic in the United States must come from a licensed manufacturer. These licenses are issued by the Secretary of the Treasury only after a careful inspection of the plant, personnel, and product by a competent government officer. The licenses are good for one year only, and are reissued only after reinspection. The government regulations require each lot of vaccine virus to be examined carefully by modern bacterio- logical methods to determine the number of bacteria, and special tests must be made to determine the absence of pathogenic microorganisms. These tests include animal inoculations, as well as cultural methods. Special tests for each lot of vaccine must be made to determine the presence or absence of streptococci, tetanus spores, the gas bacillus, and other pathogenic microorganisms, etc. The government does not guaran- tee the purity and potency of each package of vaccine virus, but through its inspections and frequent examinations of the virus on the market every confidence may now be had in the vaccine virus propagated by licensed manufacturers in this country. "Mohler and Rosenau, U. S. Dept. of Agriculture, B. A. I. Circular 147, June 16, 1909. SMALLPOX AND VACCINATION 25 THE UNITY OF COWPOX AND SMALLPOX The unity or duality of these two diseases has been the subject of much contention. Jenner originally considered cowpox to be a modified smallpox.20 The successful experiments in Germany, England, and this country, in which smallpox has actually been modified by passing vario- lous matter through calves has proved positively that we are dealing with two forms of one disease. Much of the vaccine virus used during the past hundred years was originally obtained from cases of casual cow- pox. This virus has been shown by experience and experiments to pro- tect against smallpox, which again makes it highly probable that we are dealing with one disease. See also page 8. It seems plain that the so-called casual cowpox has its origin from smallpox through accidental inoculation in milking cows by persons having or recovering from smallpox. Once started, the propagation of the modified virus from cow to cow would be comparatively simple. COMPULSORY VACCINATION Vaccination affords a high degree of immunity to the individual, and a well-nigh perfect protection to the community. To remain unvac- cinated is selfish in that by so doing a person steals a certain measure of protection from the community on account of the barrier of vac- cinated persons around him. The laws ^^ and regulations relating to vaccination in the several states of the United States show marked lack of uniformity. Compul- sory general vaccination can be said to exist by law only in Kentucky, Philippine Islands, and Porto Kico.^^ Arizona, Hawaii, Maryland, New Mexico, and North Dakota have laws requiring vaccination of children. Most states or cities have laws requiring vaccination before admission to the public schools. Decisions in the various courts in the United States have held com- pulsory vaccination to be legal. A decision of the Supreme Court of the United States (Henning Jacobson vs. The Commonwealth of Massa- ^" Smallpox is a disease subject to mutations. Since 1898 a mild form of smallpox has existed in this country with a death-rate of about 0.5 per cent. This mild form shows little tendency at present to increase in virulence. Chickenpox itself may belong to the smallpox family. The two diseases are sometimes indistinguishable at the bedside. Jenner always considered cowpox and smallpox as modifications of the same "distemper," and that in using vaccine lyjuph he was impregnating the constitution with the disease in ita mildest form instead of propagating it in its virulent and contagious form. Alastrim, kaffirpox, milkpox, etc., are aberrant forms of smallpox occurring in the tropics, and for public health purposes should be regarded as variola vera. These irregular forms of the disease need further study. ^'Kerr, J. W., "Vaccination, and Analysis of the Laws and Regulations Relating Thereto in Force in the United States." Public Healtlv Bull. 52. -^Massachusetts, in 1809, was the first state to enact -legislation relative to vaccination. 26 DISEASES HAVING SPECIAL PROPHYLAXIS chusetts, April 1, 1905) upheld in every respect the statute, the validity of which was questioned under the Constitution : "The liberty secured by the Constitution of the United States . . . does not impart an absolute right in each person to be, at all times, and in all circumstances, wholly freed from restraint. Pieal liberty for all could not exist under the operation of a principle which recognizes the right of each individual person to use his own, whether in respect to his person or his property, regardless of the injury that may be done to others." Theoretically it would be ideal if all persons submitted to vaccina- tion and revaccination voluntarily. But experience has shown that this is impractical, and, wherever tried, has failed. The best results have always been obtained where vaccination has been compulsory, and, in my judgment, this is the only present means by which smallpox may be eliminated. The world may learn a valuable lesson from the splendid results ob- tained in Germany through compulsory vaccination and revaccination. In England the "conscience clause" allows many persons to remain un- vaccinated and thereby seriously diminishes the effects of the vacci- nation laws of that land. In Minnesota the state health authorities be- came weary of the clamor against compulsory vaccination and assisted in having the law repealed. They said, in substance, to the people of the state: "Take your choice. Be vaccinated and protect yourself, or run the risk of contracting smallpox; if you get it, it is your own fault." There is now much smallpox widely distributed in the United States, among a large non-vacinnated portion of the population. INOCULATION OR VARIOLA INOCULATA [Variolation] The practice of inoculation or variolation must be carefully distin- guished from that of vaccination. By inoculation we mean the introduc- tion of smallpox virus into the skin of man. The disease thus pro- duced is usually mild, but is nevertheless true smallpox, and just as con- tagious as smallpox. This phase of the subject may be made clearer by considering small- pox as existing in three forms: (1) variola vera or true smallpox; (2) variola inoculata or inoculated smallpox; (3) vaccinia, cowpox, or modi- fied smallpox. The differences between these affections are shown in the table on the following page. Emphasis must be placed on the fact that variola inoculata, while usually a mild disease, is just as communicable as true smallpox, and those who contract the disease in this way get true smallpox, sometimes in serious or fatal form. Inoculation, therefore, protects the individual but endangers the community. SMALLPOX AND VACCINATION 27 Variola Vera Variola Znocnlata Vaccinia or Cowpox True smallpox. Inoculated smallpox. Modified and attenuated small- pox. Occurs only in man. Occurs in man and monkeys. Man, nionlceys, cattle, puineu- piKs, raljtjits, rats, camels, and many other mammals. High mortality. Milder; rarely fatal; about 1 in 500. Very mild ; never fatal. A general eruption, often confluent or liemor- rhagic. Highly contagious. A local and a general eruption, fewer .p,ustules (rarely over: 200); seldom confluent or hemorrhagic. Equally highly contagious. Period of incubation 12-8 days. 14 days. I Always local and conflned to the site of the vaccination. Not contagious — contracted only by mechanical transfer of vaccine virus. 3-4 days. Inoculation is a very old custom. It was practiced by the Chinese from time immemorial. The method was introduced into western civili- zation through Lady Mary Wortley Montagu, who learned of the method at Constantinople and had her own boy "engrafted" with successful re- sult. In 1717 Lady Montagu wrote her now famous letter to her friend Sarah Chiswell, and the practice soon became popular in England (1721) and spread to America and the Continent.^^ It was introduced into this country by Dr. Zabdiel Boylston at Boston. But the dangers were early realized and inoculation was soon replaced by vaccination. According to Plehn, inoculation is still practiced in central Africa. The method of inoculation is precisely similar to that of vaccina- tion. The matter is obtained from the vesicle or pustule of a case of smallpox. This material is then introduced into the skin by means of a puncture, an incision, or through an abraded surface. The Chinese inoculate usually by plugging the nostrils with cotton previously sat- urated with a mixture of water and pustular-crustaceous matter taken from the eruption of a smallpox patient; less commonly by blowing the crushed fresh crusts into the nostrils through a bamboo pipe. Following the inoculation of smallpox virus a local eruption appears on the fourth day at the site of the inoculation. This local eruption resembles vaccinia but develops more rapidly. Constitutional symptoms appear on the evening of the seventh or the morning of the eighth day following the inoculation. These symptoms resemble the onset of true smallpox and are rigor, headache, vomiting, and fever. The local erup- " The practice of inoculation had been published in England as early as 1714 by Dr. Timoni of Constantinople; at Venice in 1715 by Pylarini, and in the same year in London by ilr. Kennedy, a surgeon who had been in Turkey. Its adoption and subsequent ditfusion, however, were due to Lady Mary Wortley Montagu. 28 DISEASES HAVING SPECIAL PEOPHYLAXIS tion subsides on the appearance of the febrile symptoms but at the same time the general eruption breaks out. The crop is usually discrete, mod- erate in number, but runs the usual course through papule, vesicle and pustule formation. Inoculation has fallen into disuse only because we have vaccination. There are conceivable emergencies in which the practice would be justi- fied. For example, on board ship or on an island or isolated place, in the absence of vaccine virus. Under such circumstances it would be essential to inoculate ever3^body at the same time. The inoculation of smallpox will always remain for the student of hygiene one of the most interesting episodes in the develop- ment of preventive medicine. It illustrates in the clearest manner some of the fundamental phenomena of infection, susceptibility, and immunity. It was animal experimentation on a huge scale, the like of which we shall never see repeated on man as the subject. It is now a matter of regret that for the sake of science better advantage was not taken of the data. PREVALENCE OF SMALLPOX It is very difficult for us now to realize that smallpox was once much more common than measles and much more fatal. Many of those who recovered were disfigured for life, left blind, or with some other serious consequence of the disease. For centuries smallpox was one of the greatest scourges. It depopulated cities and exterminated nations. In Europe alone, where its ravages were comparatively slight, it killed hundreds of thousands yearly. In the 18th century, of which we have the best records, almost everybody had it before he grew up. Parents often exposed their children to the disease in order to be through with it, just as they now sometimes do with the minor contagious dis- eases. Smallpox was formerly a disease of children. It was called Kinder- hldttern. Since vaccination protects the child, smallpox has now be- come more prevalent among adults. The distinguished mathematician, Bernouille, estimated that 15,000,- 000 people died of smallpox in 25 years in the 18th century. It has been estimated that 60,000,000 people died of smallpox during that century. Haygarth gives an account of a smallpox epidemic in Chester, England, population 14,713. At the termination of the epidemic there were but 1,060 persons, or 7 per cent, of the population, who had never had smallpox. Many similar instances are cited in the literature. The French physician de la Condamine (1754) said that "every tenth death was due to smallpox and that one-fourth of mankind was either killed by it or crippled or disfigured for life." Sarcone (1782) estimated the SMALLPOX AND VACCTNATTOX 29 number of persons in Italy who tJufTered from smallpox as 90 j)or cent, of the population. Smallpox was introduced into the western hemisphere by the Span- iards about fifteen years after the discovery of America. In Mexico within a short period 3,500,000 persons are said to have died of the disease (Chapman). Catlin (1S41) states thai of 1-^,000,000 American Indians 6,000,000 fell victims to smallpox. In Iceland, in 1707, 18,000 perished out of a population of 50,000, that is, smallpox iilfled 36 per cent, of the total population in one year. A good example is that of Boston in 1752, population at that time 15,684. Of this number 5,998 had previously had smallpox. During the epidemic 5,545 persons contracted the disease in the usual manner, and 2,124 took it by inoculation. One thousand eight hundred and forty- three persons escaped from the town to avoid infection. There were, therefore, left in the city but 174 persons who had never had smallpox. Smallpox is still as serious as it was in former times. Thus, in five years, from 1893-1897, 346,520 persons died of smallpox in sixteen countries. Of this number Russia alone lost 275,502. These figures are the more terrible when it is realized that these lives might have been saved by the use of a simple prophylactic measure within reach of all. EPIDEMIOLOGY Few of the acute infectious diseases show such a complete indepen- dence of conditions such as race, climate, soil, age, sex, and occupation, sanitary surroundings, etc., as does smallpox. It thrives wherever the contagion is carried, and wherever it finds susceptible people. Prob- ably no one is naturally immune. The susceptibility of an unvaccinated population varies, because a smallpox outbreak leaves so many immune. This is one reason why the disease recurs in waves. The mortality varies greatly in difEerent epidemics. At times it is less than one per cent.; it frequently reaches thirty per cent, and over. From 1897-1912 the mortality in the United States varied from 0.34 per cent, to 6.2 per cent.; in 1895 it was 20.84 per cent., and following that 0.5 per cent. These differences occurred in the prevaccination era as well as now. There seem to be two distinct strains in the United States, one the classic smallpox of the text books, the other a very mild form. The epidemiology of smallpox bears no relation to improved sanita- tion, which has diminished the prevalence of plague, typhoid, cholera, and has practically subdued typhus and relapsing fever. It is evident that general sanitation could not affect contagious diseases like small- pox and measles. Smallpox spares neither the high nor the low, the rich Dor the poor, the clean nor the dirty; before the days of vaccination it 30 DISEASES HAYIXG SPECIAL PEOPHYLAXIS counted many kings, queens, and princes among its victims. George "Washington contracted smallpox in the West Indies. MODES OF INFECTION We are still ignorant of the precise mode by which smallpox is con- veyed. The view generally held is that the infection is air-borne and enters the system through the respiratory mucous membranes. It has been surmised that a local lesion may be produced in this favorable soil, the so-called "propustule," from which general infection through the blood takes place. The blood infection is marked by a sharp onset (the initial symptoms), and the skin eruption is embolic in character. The objection to this view is that a careful search at 54 autopsies in Boston by Councilman and his colleagues failed to find such a propustule. The Chinese inoculate the disease by placing variolous matter in the nostrils, but the disease so produced is said to resemble variola inoculata. The virus of smallpox is contained in the skin lesions. Of this we have experimental evidence. It is also supposed to be in the expired air. This, however, has never been experimentally proved and is doubt- ful. The disease is contagious before the eruption appears. It is even believed to be communicable during the period of incubation. Small- pox has always been taken as the type of the contagious diseases; the contagion appears to be the most "volatile" of any of the diseases of man with the possible exception of measles and influenza. This volatil- ity, however, has been over estimated, and, while probably an air-borne infection, the radius of danger is contracted. English observers have long taken the vicAv that smallpox may be blown for great distances, and they attribute the prevalence of smallpox to the windward of hos- pitals as an indication that the virus may be carried down the wind. My experience with the disease teaches me that the danger from such a source is practically nil. One may safely live next door to a small- pox hospital that is well screened and properly managed. The influence of flies and other insects, or surreptitious visiting, may account for the spread of this disease outside of hospital walls. In addition to more or less direction contact, smallpox may be spread indirectly in a great variety of ways. The secretions from the mouth and nose doubtless contain the infection, and, while suspicion has not particularly fallen upon the feces and urine, it is probable that all the secretions and excretions from the body may be infective at some time throughout the disease, or during convalescence. Toys, pencils, spoons, cups, towels, handkerchiefs, bedding, and objects of the greatest variety that have in any way come in contact with the patient may carry the infection. Under favorable circumstances the active principle may prob- SMALLPOX AND VACCINATION 31 ably live for a considerable time upon I'omites, altlu)ii;^di tbc praetieal danger from this source is not very great. Smallpox is not usually considered an insect-borne disease, but it is highly probable that a fly lighting upon a smallpox patient and getting its proboscis, feet, and other portions of its body smeared with the variolous matter, and then flying to a susceptible person, could thus readily transmit the infection. Other insects may by such mechanical transfer play a similar rule. RESISTANCE OF THE VIRUS It is generally, and doubtless correctly, assumed that the active prin- ciple of variola has approximately the same resistance to external con- ditions as vaccine virus. This assumption is confirmed by experimental evidence, which shows that the virus of smallpox is somewhat more readily destroyed than the virus of cowpox. Scientific data concerning the viability of variolous matter is meager, owing to the fact that this question can only be settled by prolonged and repeated experiments upon monkeys. Brinckerhoff and Tyzzer ^^ found that variolous virus is less resistant to desiccation than vaccine virus; that variolous virus does not pass a Berkefeld filter and is attenuated by long exposure to 60 per cent, glycerin. In general it may be said that variolous virus is killed by exposure to ordinary germicidal substances, both liquid and gaseous, in the strengths and time commonly employed. It succumbs in fact before the average non-spore-bearing bacteria. There is an exception to this statement in the case of carbolic acid and the coal-tar disinfectants. McClintock and Ferry -^ have shown that such germicides as carbolic acid, cresols, and the like do not destroy the virulence of vaccine' virus in 0.5 per cent, solutions in five hours' ex- posure.-® Noguchi found that 1 per cent, phenol has no injurious ef- fect upon emulsions of the testicular strain of vaccine virus. The in- ference is allowable that this class of disinfectants cannot be relied upon to prevent the spread of smallpox. Glycerinated virus is very susceptible to heat. SMALLPOX IN TEE VACCINATED AND UNVACCINATED The experience of over one hundred years offers convincing proof of the pronounced difference in the mortality and morbidity from small- pox in the vaccinated and the unvaccinated. ""Studies upon Experimental Variola and Vaccinia in Quadrumana," Jour. Med. Research, Vol. XIV, No. 2, Jan.. 1906, pp. 223-3.59. ^Jour. of the Amer. Public Health Assn., June, 1911 (Vol. I, No. 6), p. 418. ^ Jo«r. Exp. Med., March 1, 1918. 1 , ^i> O'0 ^O0A Of aa0A 0« ee Off p« O'O <■£ O'O sefii- O'O S6 0-0 ^s 00 €ff ff'ff -xg to /efiJ^ <W7 06 s'o 6ff 09 PP ofo . i» \90 ^PPf O'O Sf 00 ^9 O'O fP 1 l^'p ^» 1 ■ X'€ /^/i* t% OP i'O 6A. 1 fr'o 91 I'/iM '■]?^\v-\ > 9'A u '-'- llV'iV.Z 'l^'AViJl "; 1 9'0 PiPJ^ T O'O SI O'O ^l ^O'O €4. ' 9tf- AC S.2 O' 02 C o ■» (^3 ?t: ^ 32 iimiimc::::::::;::::::::::::::::::; 6'ez Hill llill mil Hill Hill Hill Hill Hill 9sn lllll Hill Hill Hill Hill Hill Hill r- 21 99Zf Ufff- 01 iiiiiiiiiiiiiiiiiiiiiiiiic::::::::::::::::::::::" 69 99 C9 I I I I 1 1 1 I I 1 1 1 I 1 1 1 11 99ffA 99 f9 77? lllll llill Hill llirr !!!!! !!!!: '"" "'". !!!" €9 iT f9ffA it ■>'■*•* i\\xr^w* s^:. '.i.yn tsj.t'^'.? I'd'. Z9 f'tz c ■ - >--^ S 1^ 5-73 be ^ cS > << -J) u O QJ cS ^■^ a. <:'C S H o o t^O eu -t; -^ fu =« o g o §2 H ^^ M -(J iJ O! p5 s !-§ <H 83 33 34 DISEASES HAVING SPECIAL PROPHYLAXIS In countries like Germany. Sweden, Ireland, Scotland, the Philip- pine Islands, Porto Eico, and England, where vaccination is more or less compulsory, there is comparatively little smallpox. In countries, like Belgium, Russia, Austria, and Spain, which have no compulsory vaccination laws, smallpox yearly claims many victims. See the follow- incf table : TABLE 1. — DEATHS FROM SMALLPOX IN COUNTRIES WITH COMPULSORY VAC- CINATION AND THOSE WITHOUT COMPULSORY VACCINATION Population Sweden* 4,746.465 Ireland* 4,808,728 Scotland* 4.013,029 Germany* 47,923,735 England* 28,247,151 Switzerland 2,922,430 Belgium 5,940,365 Russia 92,822,470 Austria 23,000,000 Italy 29,717,982 Spain 11,864,000 Smallpox Deaths Average of Deaths Average per 1886 1887 1888 1889 Million of Pop. 1 5 9 2 4 1 2 14 3 0 5 1 24 17 0 6 12 3 197 168 112 200 i69 3.5 275 505 1,026 23 458 16 182 14 17 3 54 18.5 1,213 610 865 1,212 i 975 164 16,938 25,884 9 9 21,411 231 8,794 9,591 14,138 12,358 11,220 510 ■? 16.249 18,110 13,416 15,925 536 •> ■> 14,378 8,472 11,425 963 * Compulsory vaccination. April 8th, 1874, Germany passed a general compulsory vaccination and revaccination law. The law requires the vaccination of all infants before the expiration of the first year of life, and a second vaccination at the age of twelve. Since this law went into effect there have been no epidemics of smallpox in Germany, despite the fact that the disease has been frequently introduced from without. In 1897 there were but 8 deaths from smallpox in the entire German empire — population 54,- 000,000. Since then long periods have passed without a single death from smallpox. From 1901 to 1910 there were only 380 deaths from smallpox in Germany; during the same period there were 4,286 deaths from smallpox in England and Wales, with only about half the popula- tion of Germany; furthermore, many of the deaths in Germany were in foreigners. Thus in 1909, out of 26 deaths from smallpox, 13 were foreigners, 11 of whom were Russians. In 1911, there were 288 cases of smallpox in the German Empire. Of these, 119 were of foreigners. In 1912, there were 340 cases, of which 153 were foreigners. In 1913, there were only 90 cases, of which 39 were in foreigners. During the World War, the large number of Russian prisoners in Germany caused a marked increase of smallpox in the civil population. In the huge German army there were only two deaths from smallpox from 1874 to 1914. One of these was a reservist who had not been successfully vacci- nated. Germany has demonstrated how to utilize Jenner's great dis- covery. SMALLPOX AND VACCINATION 35 ISOLATION AND DISINFECTION Isolation and disinfection are only secondary measures in prevent- ing smallpox. They cannot be regarded as substitutes for vaccination. Isolation should be carried out vrith strictness for the reason that smallpox is one of the most contagious of the communicable infections. While the patient should be isolated, it is not necessary to isolate the hospital by banishing it to an inconvenient or undesirable location. There is, in fact, no good reason why a smallpox hospital should not be one of the units of the general hospital for communicable diseases. In any event, there is no danger from a smallpox hospital situated upon a highroad or near other habitations, provided always proper precautions are taken to prevent the spread of the disease. The smallpox hospital should not be a pesthouse, but should be as inviting and attractive as economic conditions Justify. Smallpox should not be treated in the home. From the standpoint of prophylaxis the hospital is the logical and best place to care for this and other communi- cable infections. If smallpox is treated in the home, this should only be permitted if skilled nursing and trained attendants can be provided. The room in which the smallpox patient is isolated should be simply furnished to facilitate cleanliness and to permit purification. It must be well screened and free from insects and vermin of all kinds. The room should be well ventilated. This may be accomplished by an open fireplace, in which case the contagium, if contained in the outgoing air, is burned in exit. The nurse attending a case of smallpox should also be segregated, and all visiting should be strictly interdicted. A separate kitchen should be provided and care should be taken that the dishes be scalded and remnants of food burned. Bedding, underwear, towels, and other objects should not leave the sick room unless they are first boiled, steamed, or immersed in a suitable germicidal solution, such. as bichlorid of mercury, 1-1,000, or formalin, 10 per cent. Carbolic acid should not be trusted. For terminal disinfection cleansing of surfaces with a germicidal solution is much surer than gaseous fumigation. Objects particularly contaminated or soon to be used by others should be given a separate and special disinfection. Finally, the room should be thoroughly cleansed, aired, and sunned. The patient must be regarded as the source and fountainhead of the infection, and measures should be used at the bedside to prevent the surroundings from becoming contaminated. 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""^ « ?: !^ X o 2.2 §:. 38 DISEASES HAVING' SPECIAL PEOPHYLAXIS be disinfected with chlorinated lime. The sputum and discharges from abscesses should be collected on cheap cloths and burned. As a rule, smallpox patients are not dismissed from quarantine until desquama- tion has ceased. This may be favored by the use of warm baths and a generous use of glycerin soap, also by anointing the skin with vaselin or a bland oil. Special attention should be given to the hair, which should be well shampooed; to the interdigital spaces, and the fingernails, as well as to all folds of the skin, before the patient is released. The management of a smallpox epidemic is discussed on page 495, EEFEBENCES Jenner^ Edward : "An Inquiry into the Causes and Effects of the Yariolae Vaccinae, a Disease Discovered in Some of the Western Counties of England, Particularly Gloucestershire, and Known by the ISTame of the Cowpox." London, 1798, Brit. Med. Jour., May 23, 1896 (Jenner Centenary Number). Brit. Med. Jour., July 5, 1902 (Special Vaccination Number). Report of the Royal Commission on Vaccination. 1897. AcLAND, T. D. : "Vaccinia in Man." Allbutt and Rolleston's "System of Medicine," Vol. IL Part I, p. 665. 1912. CoPEMAN, MoNCKTON : "Pathology of Vaccinia." Allbutt and Rolleston's "System of Medicine," Vol. II, Part 1, p. 746. Baron, John : "The Life of Edward Jenner, with Illustrations of His Doc- trines and Selections from His Correspondence." Vols. I and II, Henry Colburn, London, 1838. Vaccination Law of April 8, 1874. German Empire. Published in English. P. Paul, Berlin, 1904. ScHAMBERG, J. E. : "Vaccination and Its Relation to Animal Experimenta- tion." Defense of Research Pamphlet, No. 1. Am. Med. Ass'n. McVail, J. C: "Half a Century of Smallpox and Vaccination." Edin- burgh, 1919, RABIES Synonyms. — Hydrophobia; Wasserscheu, Wvt, Tollwut (Germ.an) ; Ijyssa (Greek) ; La Rage (French). Rabies is an acute, specific, rapidly fatal paralytic infection com- municated from a rabid animal to a susceptible animal, through a wound usually produced by biting. Man always contracts the disease from some lower animal, usually the dog. The infective agent must be in- oculated into the tissues; the virus is harmless when ingested, provided the mucosa is intact. The gastric juice has a pronounced deleterious ef- fect upon the virus. Rabies may be regarded as a wound infection. The specific principle is contained in the saliva of animals suffering with the disease. The infection, therefore, may be conveyed by licking, etc., EABTES 39 provided there are fissures or open wounds in the skin. It is also possible to introduce the virus through autopsy accidents and other unusual ways, but commonly it is introduced tlirough wounds produced by the teeth of a rabid animal. Every mammalian animal is susceptible. Even birds may contract the disease. It is most common in dogs, but it also occurs frequently in wolves, jackals, foxes, and hyenas, liabies in cats is comparatively rare. Cattle, sheep, and goats are infected relatively in about the same degree. It is less common in horses. Swine contract the disease less frequently than other domestic animals. Skunks may contract the dis- ease and sometimes transmit it to man. Althougli all mammals are susceptible to rabies, it is perpetuated in civilized communities almost exclusively by the domestic dog, only to a small extent by wild animals of the dog family, and occasionally by skunks, cats, etc. Eabies exists practically all over the world. It has never been in Australia, and has not been known in Denmark, Norway and Sweden for more than fifty years. Rabies had been eradicated from England, but was reintroduced during the World War by dogs carried in flying machines. It is most common in France, Belgium, and Russia, In France, rabies of a virulent type with a short incubation period has spread since the first of the World War. In the United States 111 hu- man deaths were reported in 1908. In the same year there wer« 535 localities in which rabid animals were reported; in 1911 there were 1,381 localities, and 98 deaths in man. In 1890 the United States census reported 143 deaths in 30 states, and in 1900 but 23 deaths. In 1916, 21 deaths were reported from 11 states. In 1919, 45 deaths were reported in the United States. Eabies is remarkable on account of its high mortality — practically 100" per cent. After symptoms are pronounced recovery rarely, if ever, takes place. Joseph Koch (1910), however, describes an abortive rabies. The disease is peculiar in several other particulars, especially the period of incubation, which is more variable and more prolonged than that of any other acute infection. Eabies is commonly supposed to prevail only during the hot months, but it is in fact more prevalent in cold weather. Exposure to cold seems to increase its virulence. More dog bites occur from April to September than from October to March in this climate, because dogs run abroad more freely at this season of the year. Period of Incubation. — From the standpoint of prevention it is for- tunate that the period of incubation of this disease is prolonged. This period varies from 14 days to a year or more. Such prolonged periods of incubation indicate latency. The average period is as follows: Man, 40 days (apt to be shorter in children) ; dogs, 21-40 days; horses, 28-56 40 DISEASES HAVIXG SPECIAL PEOPHYLAXIS days; cows, 28-56 days; pigs, 14-21 days; goats and sheep, 21-28 days; birds, 14-40 days. The period of incubation depends largely upon the site of the wound, the relation to the nerve, the amount and virulence of the virus. It requires about 15 days, counting from the last injection, to induce an active immunity to the disease by means of the Pasteur preventive treat- ment. There is, therefore, usually sufficient time, if the case is seen early, to prevent the development of symptoms. It is probable that the prolonged period of incubation is due in part to the fact that it takes time for the virus to travel along the nerves to the central nervous system, and also to the fact that after the virus reaches the central nervous system, it may remain dormant (latent) until favorable conditions permit multiplication and the production of toxic effects. Entrance and Exit of the Vims. — The active principle' of rabies occurs principally in the saliva and in the central nervous system. It may be in the saliva at least three days (possibly eight) before the ani- mal shows symptoms (Eoux and Xocard). It is, therefore, sufficient to watch a dog that has bitten a person or another animal for ten days. If no symptoms of rabies appear during this time there is no danger of convej'ing the disease, and the Pasteur prophylactic treatment is unneces- sary. The virus has been found in the adrenals, the tear glands, the pan- creas, the vitreous humor, the spermatic fluid, the urine, the lymph, the milk, as well as all parts of the central nervous system and the peripheral nerves. It is also found in the spinal and ventricular fluids. It has not been demonstrated in the liver, spleen, blood, or muscles. The virus enters the system through the broken skin and follows the nerve trunks from the seat of injury to the spinal cord, thence to the medulla and brain. The route corresponds to that of tetanus toxin. The mode of invasion of the virus may explc^in why pain, throbbing, tingling, numbness and other nervous disturbances are the first symp- toms to occur in parts of the body that have received the virus. It also partly explains the variable period of incubation, which is shorter in wounds of the face than wounds of the extremities. It also explains why the disease is more liable to occur when the wounds are in parts of the body with a rich nerve supply. I have experimental evidence (un- published) that indicates that the virus readily enters the nerve endings in the skin. iS^oguchi -^ announces that he has succeeded in growing the virus, which appears in cultures as granular and pleomorphic chromatcid bod- ies, some of which are surroimded with membranes. Williams -® and =^Xoguchi, Jour. Exp. Med.. 1913, XVII, 29. ^Williams, Anna Wessel; Jour. A. M. A., 1913, LXI, 17, p. 1509. RABIES 41 Moon ^^ believe they have evidence of growtli in Ijrain tissue, having pro- duced rabies in animals in the fiftli gont'ration or transfer of such ''cul- tures.*' The Relative Danger of Bites. — Wolf bites are most dangerous on account of the savage character of the wound, and the virulence of the virus. Cat bites come next, and then dog bites. The relative danger of bites of other animals is as follows: foxes, jackals, horses, asses, cattle, sheep, pig?. There is no authentic instance of the transmission of the disease by the bite of man, though this may be possible. The bites of horses and other herbivora are less dangerous because their blunt teeth usually cause contused wounds without breaking the skin. Bites on exposed surfaces are more dangerous than through the cloth- ing, because the saliva is wiped from the teeth and little or none enters the wound. Long-haired dogs and sheep often escape infection for the same reason. Bites upon the face are most apt to be followed by rabies. Not every person bitten by a mad animal develops rabies. Leblanc's figures are 16.6 per cent. The statistics are difficult to analyze, and it is almost impossible now to collect' sufficient data. According to the most reliable figures, it would seem that rabies develops in not less than one person in ten bitten by mad dogs, and not receiving the Pasteur treatment. Paltauf places the figures at 6 to 9 per cent. From 15 to 20 per cent, is a moderate estimate of the death rate for all persons bit- ten by rabid animals. 8ee also page 49. Viability. — The virus of rabies in the spinal cord of rabbits dies in about li days when dried at 20°-22° C. if protected from putrefaction and light. Spread in thin layers, it dies in -1 or 5 days, and exposed to the sunlight in 40 hours. It is quite resistant to putrefaction. In a decomposed carcass it may be recovered by placing some of the central nervous system in glycerin. The glycerin destroys most of the con- taminating bacteria, but preserves the virus. Rabic virus is completely destroyed at 50° C. in one hour, and at 60° C. in 30 minutes. It is not injured by extreme cold. Harris found the virus to be very resistant to dryness at low tem- peratures. Rabic virus in central nervous tissue is very resistant to ordinary germicides. Sawtschence ^° found that.it requires from five to seven days to destroy the fixed virus in 5 per cent, phenol, and that it is not destroyed by 0.5 per cent, phenol in 20 days. Other filterable viruses, notably variola and vaccinia, also show unusual resistance to phenols and cresols. Semple ^'^ found that the emulsion of fixed virus which resists the action of 1 per cent, phenol at room temperature for =»Moon, Jour. Infect. Dis., 1913. XIII. 232. »> Sawtschence, W., Ann. de VInst. Pasteur, 1911. XXI, p. 492. '^ Semple, "Sci. Mem. by OflBcers of Med. and San. Depts.," Gov. Ind., X. S., No. 44. 43 DISEASES HAVING SPECIAL PKOPHYLAXIS several da3^Sj succumbs at 24 hours at 37° C. x\ccording to Gumming ^^ 1 per cent, phenol does not destroy the virus in 6 hours, while 2 per cent. solution kills it in less than 24 hours. On the other hand, most of the aldehj'd compounds are very active in destroying the infectivity of the fixed virus. A 0.5 per cent, solution of salicylaldehyd, benzaldehyd, or furfurol destroys the virus in less than 3 hours. The specific disinfect- ing action of formaldehyd is shown by the fact that the virus is destroyed when exposed for two hours to 0.08 per cent, solution. This indicates that formalin may be a useful substance to treat dog bites, although experiments have shown that it is not as dependable as nitric acid. Bichlorid of mercury, 1-1,000, for 1 hour, or a . saturated solution of iodin in water, completely destroys the virulence, and Wyrsykowski has shown that gastric juice has a pronounced deleterious effect upon the virus. PROPHYLAXIS The prevention of rabies is considered under three heads: (1) Treatment of the wounds; (2) the Pasteur prophylactic treatment, and (3) the control of the disease in dogs by muzzling and quarantine. The cauterization of the wound and the Pasteur prophylactic treat- ment are efficient preventive measures for the individual, but they are not the true and best methods of controlling and preventing rabies. The disease may be avoided, even exterminated, by an intelligent system of muzzling and quarantining of dogs. A high tax on dogs and leashing are only restrictive measures. In England, when the dogs were muzzled, rabies diminished. The law was repealed, owing to misplaced sympathy for the dog, and rabies promptly increased. The law was again enforced, and in about two years the disease disappeared (see Fig. 10). A strict quarantine of six months was maintained against dogs en- tering England, but this was broken by the war and rabies reappeared in England in 1918.^^ Consistent muzzling of all dogs for two years will practically exterminate rabies. In Australia there are few carniv- orous animals, mostly marsupials; there rabies does not exist, for it has been kept out owing to early and effective quarantine measures. ]S[orway, Sweden, and Denmark also obtained good results and the same can be done in other peninsular regions. Prophylactic measures necessary to control the dog question are: the destruction of ownerless dogs ; license fee and tag for all dogs ; own- ers to be legally responsible for damage infiicted by their dogs; educa- tion of the dog-owning public concerning the spread of communicable diseases, especially rabies ; compulsory reporting of all cases or suspected cases of rabies. Further special measures advocated are: muzzling; ^^Jour. Infect. Dis., XIV, 1, January, 1914, p. 33. ^Br. Med. Jour., March 22. 1919, 350, 1. RABIES 43 restraint ^vitIl chains, leash, etc.; observation in quarantine, or killing of all animals hitton by dogs; disinfection, etc. ^* THE LOCAL TREATMENT OF THE WOUND Wounds produced by the bite of an animal in which there is any suspicion of rabies should at once be cauterized with "fuming" or strong nitric acid.^'^ The acid is best applied with a glass rod very thoroughly Fig. 10. — Chart Showing Relation of Enforcement of Muzzling Law to Prevalence of Rabies in Great Britain (the figures in the cross-hatching indicate the number of persons who died of rabies in England and Wales. The ordinates represent cases in dogs). (Straus and Frothingham. ) to all the parts of the wound, care being taken that pockets and recesses do not escape. Thorough cauterization at once reduces the danger of wound complications, and experience demonstrates that wounds so treated at once are pu'actically never followed by rabies. Marie obtained conflicting results with local treatment in experimental rabies ; Cabot ^^ obtained the best results with nitric acid, and was able to save the lives ** In addition to rabies, dogs are responsible for other infections in man, such as hydatids, tapeworms (especially in children), round worms, tongue worms, and also fleas and ticks which transfer from the dog to man and which may in this way transmit diseases and parasites. In animals, dogs are re- sponsible for gid in live stock and cysticerci in sheep, reindeer and live stock. ^' Sp. gr. over 1.48. ^' Medical News, March, 1899. 44 DISEASES HAVING SPECIAL PROPHYLAXIS of 91 per cent, of guinea-pigs by cauterization with nitric acid at the end of 34 hours; Poor ^^ saved 45 per cent., at the "end of 32 hours. In the absence of nitric acid, formalin or the actual cautery may be used, but they have inferior prophylactic value. Strong germicides, such as carbolic acid, are not reliable. Nitrate of silver is valueless. In any wound produced by the bite of an animal cauterize with nitric acid unless sure that the animal is not mad. Experiments made in my laboratory indicate that no substance takes the place of nitric acid, and further emphasizes the importance of, cauterizing all portions of the wound, especially the edges of the skin. It has been shown that the virus may remain alive and virulent in the scar for a long time, and it has become a question whether patients seen after the wound has healed should not have the scar excised and the wound cauterized with nitric acid ; this, however, is not the practice. THE PASTEUR PROPHYLACTIC TREATMENT This method of prophylaxis was announced December 6, 1883, by Pasteur, at the International Congress at Copenhagen, and on February 24, 1884, he laid before the French Academy the details of his experi- ments and results. The next year Pasteur, with the help of Eoux and Chamberland, worked out the details of the method now in general use. The principle of the treatment consists in producing an active im- munity by means of an attenuated virus. The virus is attenuated by drying. The fixed virus contained in the spinal cord of rabbits dead of hydrophobia is the material used, for subcutaneous injection. Street Virus and Fixed Virus. — The distinction between fixed and street virus is of fundamental importance in reference to the question of immunity. Street virus is obtained from mad dogs naturally in- fected. When this virus is inoculated into a rabbit, it reproduces the disease after a period of incubation of from 14 to 21 days or more. This street virus may then be conveyed from rabbit to rabbit through a number of transfers. In the passage from rabbit to rabbit the virus becomes more virulent for rabbits. The period of incubation is pro- gressively shortened, until finally the rabbits invariably sicken on the sixth or seventh day and die on the ninth or tenth. When the virus has reached this degree of virulence for rabbits, it is said to be "fixed," for the reason that its potency remains constant. In its passage through rabbits the modification from street virus to fixed virus is gradual. It is important to note that fixed virus, which has attained a high degree of virulence for rabbits, has lost much of its virulence for ^'Collected Studies, Research Lab., Dept. of Health, City of N. Y., VI, 1911, p. 25. T^ABTES 45 dogs, and seems to bo aviruli'iit fur man when introduced into the sub- cutaneous t issue. •''^^ Ferran in 1888 treated 85 persons for dog bites by injecting the fresh fixed virus subcutaneously, without ill effects. Wysokowiez in 1902 injected 70 persons intravenously without an accident. In in- stitutes using the method of Hoyges, many persons have received dilu- tions of an emulsion of the fresh pons and medulla. Xitsch. Proescher and others injected large amounts of fresh fixed virus subcutaneously without producing symptoms. Proescher, in fact, injected himself with the entire brain and medulla of a rabbit; and another entire brain into a volunteer. Xo ill eifects of any kind were noted. The virus used was shown to be virulent when a small amount of it was introduced under the dura of a rabbit. It is indeed quite difficult to give rabies to animals experimentally by subcutaneous injection. Marx tested the fresh fixed virus upon monkeys in large doses, with negative results. The evidence points clearly to the fact that the fixed virus of rabbits does not produce rabies in man when introduced into the subcutaneous tissue. Preparation of the Virus. — Eabbits are injected under the dura mater with a few drops of an emulsion of fresh fixed virus obtained from the pons or medulla of another rabbit dead of hydrophobia. Strict aseptic precautions are necessary in order to keep out other infections. The rabbit should begin to show symptoms on the six:th or seventh day, and die on the ninth or tenth. Usually the rabbit is not allowed to die, but is chloroformed on the last day in order to avoid terminal infections and unnecessary suffering. The spinal cord is removed and hung in a bottle containing potassium hydroxid. These bottles are kept in the dark at a temperature of 23° C. Under these conditions the cord grad- ually desiccates, and at the same time the virulence of the virus di- minishes, until the fourteenth day, when it is no longer infective. This is why Pasteur started the treatment with a cord fourteen days old. In fact, the virus dies long before the fourteenth day — five-day old cord usually fails to infect. About one-half a centimeter of the cord constitutes a dose. This is ground in about 2.5 c. c. of sterile salt solution so as to produce a uniform emulsion, which is injected into the subcutaneous tissue of the abdominal wall. In many institutes the small segments cut each day from the drying cord are placed in pure glycerin. The virulence of the cord in glycerin is not altered for at least 30 days, if kept in the dark and at 15° C. This method, introduced by Calmette^^ in 1891, based upon observation made by Roux in 1887,^° is very convenient, especially =^N. Y. Med. Jour., Oct. 9, 1909, also Arch, of Int. Med., Sept., 1911, VIII, 3, p. 353. ^Ann. de VInsi. Pasteur, Paris, 1801, Vol. V, p. 633. *^ Ann. de VInst. Pasteur, Paris, 1887, Vol. I, p. 87. 46 DISEASES HAVING SPECIAL PROPHYLAXIS where comparatively few patients are treated. Glycerin has the added advantage of destroying infections due to non-spore-hearing hacteria that may be present. As a further precaution, bacteriologic examinations are made of parts of the spinal cord in order to insure the absence of bacteria, and the rabbit is carefully autopsied as a guarantee that no other disease is present. The Scheme of Treatment. — The scheme of treatment advocated by Pasteur and still used at I'lnstitut Pasteur in Paris and many other places is shown in the following table: PASTEUR PROPHYLACTIC TREATMENT — RECOMMENDED BY PASTEUR Mild Treatment Intensive Treatment Amount of In- Amount of In- Day Age of jected Emulsion Day Age of jected Emulsion of the Dried 1-cm. of Cord to of the Dried 1 cm. of Cord to Treatment Cord 5 c. c. Salt Solu- tion Treatment Cord 5 c. c. Salt Solu- tion ri4 Days 3 c. c. 1 f 14 Days 113 3 c. c. 1 J 13 3 3 1 12 3 111 3 flO 3 2 ill 3 3 2 {f 3 3 3 3 {'I 3 3 3 f 6 \ 6 2 2 4 i' 3 3 4 5 2 5 it 2 2 5 5 2 6 5 2 6 4 2 7 5 2 7 3 1 8 4 2 8 4 2 9 3 1 9 3 1 10 5 2 10 5 2 11 5 2 11 5 2 12 4 2 12 4 2 13 4 2 13 4 2 14 3 2 14 3 2 15 3 2 15 3 2 16 5 2 16 5 2 17 4 2 17 4 2 18 3 2 18 3 2 19 5 2 20 4 2 21 3 2 Some Pasteur institutes now use a modified treatment, starting with an 8-day instead of a 14-day-old cord, which is exemplified in the scheme used at the Hygienic Laboratory, Public Health Service. See table on the following page. The tendency is to hasten the immunity by using only the intensive treatment for all cases, also to start with fresher cord, some using 4- day-old cord for the initial injection. Intensive treatment should al- ways be given for wounds of the face, head, hand and other exposed parts of the body ; for multiple wounds ; severe wounds ; or for wolf, fox, cat and skunk bites. RABIES PASTEUR PROPHYLACTIC TREATMENT— HYGIENIC LABORATORY WASHINGTON, D. C. 47 Amount of Emulsion 1 c. c. of Cord to 5 c. c. Salt Day Age of the Dried Cord Solution Adult 5 to 10 Years 1 to 5 Years 1 6—6* 2.5 c. c. 2.5 c. c. 2.5 c. c. 2 5 — 5* 2.5 2.5 2.5 3 4 — 4* 2.5 2.5 2.5 4 3 2.5 2.5 2.0 5 3 2.5 2.5 2.0 fi 2 2.5 2.0 1.5 7 2 2.5 2.5 2.0 8' 1 2.5 1.5 1.0 9 5 2.5 2.5 2.5 10 4 2.5 2.5 2.5 11 4 2.5 2.5 2.5 12 3 2.5 2.5 2.0 13 3 2.5 2.5 2.0 14 2 2.5 2.5 2.0 15 2 2.5 2.5 2.0 16 4 2.5 2.5 2.5 17 3 2.5 2.5 2.5 18 2 2.5 2.5 2.0 19 3 2.5 2.5 2.5 20 2 2.5 2.5 2.5 21 X 2.5 2.5 2.5 * Double dose. The scheme of Pasteur has been further modified in various ways, depending upon the method used to attenuate the virus. Thus Pasteur attenuated the virus by drying; Babes by heating; Frantzer by tlie use of bile; Tizzoni and Cattani attenuated the virus in gastric juice. Hog- yes used fresh material in a diluted suspension; Ferran fresh material and in increasing doses. Gumming altered the virus by dialysis. Har- ris dried the fresh virus at low temperature, which is used in diluted sus- pension. Other methods have been used to attenuate the virus, such as glycerin, carbolic acid, mechanical disintegration, and, lastly, antirabic serum. Ferran in Barcelona, Proescher in Pittsburgh, and others in- ject patients with the unaltered, fresh, fixed virus. The advantages of using the virus as fresh and strong as possible are that an active im- munity is produced more quickly, and this is of considerable importance in wounds of the face; also in wolf and cat bites, which frequently have a short period of incubation. Further, fewer injections of the fresh virus are necessary to produce an immunity, and this shortens and sim- plifies the treatment. Harris *^ has shown that rabic material may be completely desiccated without destruction of virulence, provided the dehydration takes place at a low temperature. The lower the temperature the greater will be the amount of virulence preserved. Virus so desiccated contains per weight as much infectivity as the fresh virus. The virus thus dried is so stable that it may be standardized, permitting an accuracy of dosage hitherto impossible. The unit is the smallest amount which, Avhen injected in- tracerebrally into a full-grown rabbit, will produce paresis on the *^Jour. of Infect. Dis., May, 1912, X, 3, pp. 369-377. 48 DISEASES HAVING SPECIAL PROPHYLAXIS seventh day. For slight wounds Harris gives seven injections, but for severe injuries he gives two injections a day for twelve to fourteen days. Treatment at a distance from a Pasteur institute is now practical by sending a piece of cord in glycerin; or the emulsion in glycerin, in a thermos bottle; or the dry material in accordance with Harris' method. Care During the Treatment. — During the treatment the patient may go about his usual business. It is not necessary to stay in bed. The patient should, however, avoid fatigue, cold, emotional stress, trauma, and alcohol. It has been shown that these are important pre- disposing factors to the disease. It was found that customs' officers re- turning to the Siberian borders after prophylactic treatment for wolf bites showed an unusual mortality, which seemed to de due to exposure to cold. The disease has been observed to be brought on after a cold bath, falling into the water, and similar depressing influences. Complications of the Treatment. — The Pasteur prophylactic treat- ment may be complicated, by (1) local reactions or (2). paralysis. Local reactions at the site of the wound are) usually trivial. Abscesses almost never occur. The local reactions consist of redness and indura- tion. It is not necessarily the last injection, but rather the site of some previous injection that flares up, but soon subsides without further trouble. This occurrence increases with the progress of the treatment; it is most frequent in the second week. As the treatment involves the introduction of a large quantity of foreign proteins into the body, it is probable that these reactions represent a phase of hypersusceptibility. See Anaphylaxis. Paralysis. — Paralysis occurs occasionally and may be fatal. This complication seems to be a mild or modified type of rabies, but there is doubt concerning its cause. There is evidence that it may be due to infection with the fixed virus or possibly to toxin — or both. Serious paralysis is a rare complication; it doubtless occurs in mild form more often than is known. It affects adults chiefly, young children almost never. Simon collected data up to and including 1911, showing the occurrences of 100 instances of paralysis among 317,774 persons treated. In this series there were 19 deaths. The incidence of paralysis seems to vary with different methods of antirabic treatment.*^ In a case treated at the Hygienic Laboratory the paralysis came on 18 days after treatment, and was transient. H. E. Hasseltine *^ reports two cases of paralysis following antirabic treatment, with one death. The New York Pasteur Institute reports a death from "ascending paralysis," which came on four days after the treatment. W. A. Jones ** reported two cases with recovery. In 1905 Eemlinger, head of the Constanti- **The subject is brought up to date in Fiedler's article in the Journal of the Amerioan Medical Assooiation, June 3, 1916, LXVI, p. 23. « Public Health Report, July 30, 1915, Vol. XXX, No. 31, p. 2227. '*Jour. A. M, A., Nov. 13, 1909, p. 1626. KABIES 49 nople Institute for Eabies, reported 40 cases of paralysis; Babes had 8 cases of paralysis (all mild) in (),5"i5 treatments; Miiller found 16 cases in the literature, and had two of his own ; Panpoukis, three cases ; Jones, 2. Mejio *'' reported 19,800 cases treated in the Pasteur institute, Buenos Aires, of whom 24 developed paralysis, with 4 deaths. One instance was a child of six, apparently healthy a month after the Pasteur treatment. He then had a fall from a hammock; the next day his legs were para- lyzed; the paralysis proved of the ascending type, fatal in two weeks. The Immunity. — Duration. — The immunity appears two weeks after the treatment and lasts a varying period of time, depending upon the individual — at least for several years. In this respect it does not differ from other instances of acquired immunity. The Pasteur prophylactic may be repeated in persons bitten a second time. The lower animals may also be protected. The fact that the immunity appears on the fifteenth day after the last treatment was discovered by Pasteur as a re- sult of animal experimentation. The statistics of the Pasteur Institute, giving the mortality from rabies in persons following the prophylactic treatment, exclude instances in which the disease develops within fifteen days after the last prophylactic injection. Nature. — The nature of the immunity is not clear. It certainly is not due to an antitoxin. Immune bodies are demonstrable in the blood twenty days after the last injection. The activity of the virus can be neutralized by mixing it in vitro with the blood serum of an im- munized animal. This neutralization is generally considered to be mi- crobicidal or lytic in nature. Degree. — The degree of the immunity also varies, as is evidenced by the fact that a certain small percentage of the persons treated die of rabies. The Results of the Treatment. — Statistics giving the results of the treatment are somewhat difficult to analyze, as many factors are unob- tainable. Patients should be kept under observation at least a year. Exceptional cases occur one year following exposure. Cases that occur within fifteen days after the treatment are excluded from the French statistics, for reasons that have already been stated. The figures on this basis show a mortality of less than 0.5 per cent. Better results are being obtained from year to year. The table on the following page gives the general results at ITnstitut Pasteur, Paris, since beginning the treatment. When we compare these figures with the fact that from 6 to 10 per cent, and sometimes 16.6 per cent, of all persons bitten by rabid dogs die of rabies, the prophylactic value of the Pasteur treatment is evident. Faber found 27 deaths out of 339 persons bitten by mad dogs; Kur- rimoto, 17 per cent, in Nagasaki; Babes, 15 per cent, of 995 in Hun- " Semana Medica, Buenos Aires^ XXIV, No. I, p. 10. 50 DISEASES HAVING SPECIAL PROPHYLAXIS RESULTS OF TREATMENT AT L'INSTITUT PASTEUR, PARIS Year Persons treated Deaths Mortality Year Persons treated Deaths Mortality 1886 2,671 25 0.94% 1903 628 2 0.32% 1887 1,770 14 0.79 1904 755 3 0.39 1888 1,622 9 0.55 1905 727 3 0.41 1889 1,830 7 0.38 1906 772 1 0.13 1890 1,540 5 0.32 1907 786 3 0.38. 1891 1,559 4 0.25 1908 524 1 0.19 1892 1,790 4 0.22 1909 467 1 0.21 1893 1,648 6 0.36 1910 401 0 0.00 1894 1,387 7 0.50 1911 341 1 0.29 1895 1,520 5 0.38 1912 395 0 0.00 1896 1,308 4 0.30 1913 330 0 0.00 1897 1,521 6 0.39 1914 373 0 0.00 1898 1,465 3 0.20 1915 654 1 0.15 1899 1,614 4 0.25 1916" 1,388 3 0.21 1900 1,420 4 0.28 1917 1.543 4 0.26 1901 1,321 5 0.38' 1918 1,803 3 0.16 1902 1,005 2 0.18 1919 1,813 " 0.16 gary; Horsley's figures are 15 per cent. Some series of cases give a much higher mortality. Thus, of 855 persons bitten by mad dogs, col- lected by Tardieu, Thamehayn, and Bouley, 399 ended in death, or 46.6 per cent. In another series of cases given by Bouley, out of 266 per- sons bitten by mad dogs, 152 died of hydrophobia. But of these 120 were bitten on the face and hands, the greater danger of which has been mentioned. The mortality resulting from bites of wolves is placed by Babes at from 60 to 80 per cent. Contraindications, — There are no known contraindications to the treatment. All ages and conditions should be treated if exposed. Ap- parently no harm is done pregnant women. I have injected patients having malaria without trouble following. The treatment may be con- tinued in patients having colds, fevers, and other ailments without no- ticeable harm. When to Give the Pasteur Prophylactic. — It is sometimes difficult to decide whether the Pasteur prophylactic treatment should or should not be given. Treatment causes sufficient personal inconvenience, not to speak of the danger (however slight) of paralysis, to avoid advising it if unnecessary. In many cases it is impossible to discover whether the dog that inflicted the bite is mad or not. The rule in cases of doubtful exposure is to advise the treatment. Persons who apply for treatment of dogbites fall into one of the five following categories with reference to the Pasteur prophylactic : ( 1 ) The dog is mad or shows suspicious symptoms : In this case, begin treatment at once. (2) The dog is not mad: Observe it carefully for ten days, and if no symptoms develop, there is no danger of rabies in the person bitten. The treatment is therefore unnecessary. (The dog may nevertheless develop rabies after ten days and if it has been bitten by another dog should be kept in quarantine for six months.) EABIES 51 (3) The dog is not identified: This is a common occurrence, es- pecially with children. The rule in such cases is to advise the Pasteur prophylactic treatment, except in places known to be free of rabies. (4) Exposure to saliva: Persons not infrequently apply for ad- vice giving the following history : They have not been bitten, but they have been licked on the hands and face by a dog that subsequently was discovered to have the disease. Persons are sometimes similarly exposed by washing the mouth of a rabid horse. In tliese cases the important question is whether there were fissures or abrasions in the skin at the time. There may be little wounds in the skin not evident to the naked eye. It is possible to infect animals by rubbing the virus on the shaved skin. The rule is therefore to advise the protection which the treat- ment affords in persons thus exposed. (5) In psychoneurotic patients with a distressing phobia of rabies, it may atford comfort to give a mild course of treatment as much for its psychotherapeutic effect as for specific immunity. The Dog. — In all cases it is important to know whether the dog is mad or not. If the dog can be found and kept under observation for 10 days and no symptoms appear, the Pasteur treatment is not necessary. Animals killed early in the course of rahies may fail to show the mi- croscopic evidence of the disease, thus causing an indefinite delay in diagnosis awaiting inoculation tests. Dogs that have bitten persons should not be summarily killed, but should be apprehended and turned over to the proper authority; if killed, the head should be sent to the nearest diagnostic laboratory. Should the dog develop symptoms, the question of diagnosis is all-important. Diagnosis of Rabies in Dogs. — The diagnosis of rabies in dogs may be made in four ways: (1) from the symptoms; (2) from the presence of Negri bodies in the central nervous system; (3) from the lesions in the- peripheral ganglia, and (4) by animal inoculations. 1. The symptoms may be very suggestive, but a diagnosis must al- ways rest upon the pathological lesions and the inoculation tests. The course of the disease may be divided into three stages: (a) a premoni- tory stage, (b) a stage of excitement, and (c) a paralytic stage. The first two stages may be absent or transient. All rabid animals invariably become paralyzed before they die. In dogs the first symptom consists solely in a change in the disposition of the animal. He is easily excited, but does not show a tendency to bite. Soon the restlessness becomes more marked, and the animal may become furious and even show signs of delirium. The dog does not fear water, as is commonly supposed, but rushes about attacking every object in his way. Dogs suffering from furious rabies have a tendency to run long distances (25 miles or more), often biting and inoculating large numbers- of other animals and persons en route. Very soon paralysis sets in, commencing in the hind legs, and 52 DISEASES HAVING SPECIAL PROPHYLAXIS finally becomes general. The course of the disease is always rapid, averaging from 4 to 5 days, rarely exceeding 10 days. When the stage of excitement is brief or absent, the disease is known as dumb rabies. 2. There is a difiEerence of opinion concerning the significance of the Negri bodies {Neurorrhydes hydrophobiae) , which, however, are very constant in rabies and peculiar to it. If Negri bodies are found in the dog, the Pasteur treatment should be started at once. The absence of Negri bodies, however, does not necessarily mean the absence of rabies. These bodies are sometimes difficult to find, or may not be present in the parts of the central nervous system which are examined. Negri bodies are found especially in the horn of Ammon and the cerebellum; they are 1 to 23 micra in diameter; usually round or oval; strongly eosino- philic; occur within and without the nerve cells; and sometimes con- tain a nucleus (?). Owing to their resemblance to red blood cells, the finding of Negri bodies iHthin the cells is the safest criterion. The diagnosis may thus be established in about 90 per cent, of cases. Negri bodies for diagnostic purposes are best demonstrated by im- pression preparations of Amnion's horn and cerebellum, stained accord- ing to Van Giesen as recommended by Frothingham or stained by Bond's modification of the Mann stain. Impression preparations are made by gently pressing a microscopic slide upon the cut surface of Ammon's horn and the cerebellum and lifting with a quick movement. Care should be taken to obtain thin uniform impressions because thick impressions do not show differential staining for Negri bodies. Pieces of the Ammon's horn and the cerebellum selected for impressions should be from four to six millimeters thick. Three or four impressions to a single slide should be made from each piece of the Ammon's horn and ccreljellum. Four or five pieces of each Ammon's horn and the same number from the cerebellum are sufficient. The impression preparations obtained in this way show the characteristic arrangement of the cells of the hippocampus and of the cerebellum and rarely fail to contain the Negri bodies in infected material. When the brain is badly mutilated or decomposed, impressions taken from any of the available material containing gray matter will frequently show the Negri bodies if infected. To stain impression preparations as recommended by Frothingham the following slightly modified procedure is given: (1) Fix before the impression dries in methyl alcohol for five minutes; (2) stain at room temperature with Van Giesen, while still moist with alcohol, for eight to ten minutes; (3) wash thirty seconds with running tap water; (4) blot with filter paper. The Van Giesen stain is made as follows: Tap water 20 c. c. to 50 c. c; saturated alcoholic fuchsin (f. Bac. Grubler) 1 drop; saturated aqueous solution methylene blue (f. Bac. Koch Grubler) one to ten drops. The amount of tap water and the RABIES 53 amount of methylene bine required for irood differentiation vary with different stock solutions of the stains. This stain changes little in three to four days. To stain by Bond's mudilication of the Mann stain proceed as fol- lows: (1) Fix before the impression dries in methyl alcohol five to six minutes; (2) wash thirty seconds with running tap water; (3) stain for four to five minutes Avith a mixture consisting of 1.0 c. c. of 1 per cent, aqueous eosin (Eosin W. gelbl. Grubler), 0.7 c. c. to 1.0 e. c. of 1 per cent, aqueous methyl blue (Grubler) and 6.0 c. c. of distilled water; (4) wash with running tap water for thirty seconds; (5) blot with filter paper; (6) dehydrate with absolute alcohol; (7) clear with a mixture consisting of one part of xylol and two parts of aniline oil; (8) Avash with xylol: (9) mount in balsam. The ^lann stain should be freshly prepared each time it is used. In practice it is better to stain by both methods because each has its advantages and disadvantages. The Mann's stain gives definite Xegri bodies but the differential staining be- tween the red blood corpuscles and ]Sregri bodies is not always clear. "With the Frothingham method Xegri bodies can hardly be mistaken for anything else but the stain itself may be capricious in action and shows relatively fewer Xegri bodies. 3. The lesions of Van Gehuchten and Xelis, described in 1900, are the most characteristic anatomical changes. These lesions are found late in the disease in the peripheral ganglia of the cerebrospinal and SA'mpathetic systems, especially in the plexiform ganglia of the pneumo- gastric nerve, and the Gasserian ganglia. The normal nerve cells of these ganglia lie in a capsule lined with a single layer of endothelial cells. In rabies these endothelial cells proliferate and the nerve cells may be partly or entirely destroyed and replaced by diverse cells as- sociated with chronic inflammatory processes. In addition, lymphatic infiltration also occurs about the sheaths surrounding the individual nerve cells. Either the proliferative or infiltrative changes may pre- dominate. In order to find these lesions, it is necessary to fix the ganglia in Zenker's fluid and to stain the sections by the eosin-methylene blue method. This method of diagnosis is available in only a small per- centage of cases. 4. The final diagnosis of rabies rests upon animal experimentation. A small quantity of an emulsion of the medulla or pons of the suspected animal is placed under the dura mater of a rabbit or guinea-pig. The diagnosis by this method, however, requires so much time (on account of the long period of incubation of the disease) that it is of no practical value in deciding whether or not the Pasteur prophylactic treatment should be given, but in any critical case the positive evidence furnished by animal experimentation is incontrovertible. If the inoculated rabbit shows no symptoms in one month, and Xegri 54 DISEASES HAVING SPECIAL PEOPHYLAXIS bodies were not seen in the specimen, then a negative diagnosis may be given, although it is customary to observe the animal for six months. REFERHNCES Pasteur, Chamberland, Koux and Thuillier: "Sur la Rage," Compi. rend, de I'Acad. de Sci., 1881, 92, p. 1555. Pasteur, Chamberland and Roux: "iSTouvelle Communication sur la Rage," Compt rend, de VAcad. de Sci., 1884, 98, p. 457; "Sur la Rage," Compt. rend, de VAcad. de Sci., 1884, 98, p. 1229. Pasteur: "Methode pour Prevenir la Rage apres Morsure," Compt. rend, de I'Acad. de Sci., 1885, 101, p. 765; "Resultats de TApplication de la Methode pour Prevenir la Rage apres Morsure," Compt. rend, de I'Acad. de Sci., 1886, 102, p. 459; "Note Complementaire sur les Resultats de I'Application de la Methode de Prophylaxie de la Rage apres Morsure," Compt. rend, de I'Acad. de Sci., 1886, 102, p. 835; "Xouvelle Communi- cation sur la Rage," Compt. rend, de I'Acad. de Sci., 1886, 103, p. 777; "Lettre sur la Rage," Ann. de I'Inst. Pasteur, 1887, 1, p. 1; "Sur la Methode de Prophylaxie de la Rage apres Morsure," Compt. rend, de I'Acad. de Sci., 1889, 108, p. 1228. Babes, Victor: "Traite de la Rage." Paris, Bailliere et Fils, 1912. A comprehensive monograph. Contains a good historical account of the story of Pasteur's discovery, with original references. Stimsox, a. M. : "Facts and Problems of Rabies." Hygienic Laboratory Bulletin No. 65, June, 1910. Contains a selected bibliography. More comprehensive bibliographies will be found in : Heller: Schutzimpfung gegen Lyssa, 1906. Hogyes: "Lyssa" in Nothnagels Spez. Path. u. Therap., Wien, 1897. Marie : L' etude experimentale de la rage. Encyclop. scient., 1909. Marx, E. : Kolle u. Wassermanns Handh. d. path. Mikroorg., 1904, 4, Bd., 2. TL, 1264. VENEREAL DISEASES*^ As a danger to the public health, as a peril to the family, and as a menace to the vitality, health, and physical progress of the race, the venereal diseases are justly regarded as the greatest of modern plagues, and their prophylaxis the most pressing problem of preventive medicine that confronts us at the present day. Xo serious attempt was made by the sanitary authorities of any of our great cities to deal with this problem until Xew York City in *' Objection has been made to the stigma implied in the term venereal dis- eases, for these infections are not always transmitted in venery and are often contracted innocently. Syphilis and gonorrhea, however, are unlike other com- municable diseases in that they do involve a moral principle. Gonorrhea or syphilis contracted innocently is usually only one remove from promiscuity. Only one venereal disease among the lower animals is known, — dourine, a syphilis of horses caused by a trypanosome. VENEREAL DISEASES 55 1012 *'' determined to treat the venereal diseases as any other higlily communieablo and prevcntabU^ infection, dealin<i purely with tiie sani- tary features of the problem from a public health standpoint, ignoring the social and moral phases. The opposition to such activity is slowly being broken down. Progress against the venereal diseases is a repeti- tion of the warfare along other lines of sanitation and hygiene. It is the history of a continuous struggle carried on in the name of law, religion, personal rights, or expediency. Although the dilliculties in this case are much greater thrn in any other group of diseases, an intelligent and persistent campaign must end in a long-delayed success. Biggs states that in 1912 at least 800,000 people, or more than one- fifth of the adult population of New York City, have, or have had, some venereal disease, and that in a large percentage of these persons the disease is still active. The number of new infections occurring each year probably exceeds that of all other notifiable diseases combined. In view of such figures the magnitude and the importance of the problem of administrative control, as applied to these diseases, become clearly apparent. The venereal diseases are a constant menace to the clean living public as well as to the licentious. The history of preventive medicine can present no greater tragedy than the home invaded by syphilis or gonorrhea. There are three venereal diseases : syphilis, gonorrhea, and chancroid. In order to have a clear understanding of the problems of venereal prophylaxis it is necessary to have a knowledge of the essential features of these preventable infections. Two of them, syphilis and gonorrhea, are of great importance, because they are very prevalent and because they are very serious infections with grave consequences. Gonorrhea is the great preventer, syphilis the great destroyer of life. SYPHILIS Syphilis is a specific infection caused by the Spirochcefa pallida.^ It is acquired by direct contact with infected persons, by inoculation with infected things, and by congenital transmission. Syphilis runs a chronic course with lesions and symptoms of extraordinary diversity. The initial lesion or chancre forms on the skin or mucous membrane at the site of entrance of the spirochetes. The period of incubation is never less than 10 days, with a maximum of 90 days. In the majority of cases, the chancre appears between the 14th and 40th days. There are many striking things about syphilis, but nothing so strik- ing as its persistence in spite of knowledge complete enough to stamp " Resolutions adopted by the Board of Health. February 20th. "°.4itn known as Treponema pallidum. 56 DISEASES HAVING SPECIAL PEOPHYLAXIS it out and in view of the popular dread in which the disease is held. It is preventable, even curable — yet scarcely another disease equals it in the extent and intensity of its ravages. It is the great canker of humanity. Syphilis is a good illustration of the fact that it is much more diffi- cult to control a disease transmitted directly from man to man than a disease transmitted by an intermediate host, or one in which the virus is transferred through our environment. We have a certain amount of control over our surroundings, and we have dominion over the lower animals, but the control of man requires the consent of the governed. Civilization and syphilization have been close companions, but syph- ilis is now less prevalent among civilized than uncivilized peoples — this is promising. Civilization, however, should not be content until it has controlled syphilis as effectively as it has some other preventable infec- tions. The effort to do so, at least, must be persistent and sincere. From the economic side syphilis is not a serious disease in its pri- mary and secondary stages; that is, persons with syphilis during the early stages are usually not ill enough to cease work.*^ Acutely fatal cases, such as frequently occurred in the sixteenth century, are now rare; in other words, the disease has lost much of its early virulence. It is the late manifestations, or the so-called parasyphilitic lesions, as well as the inherited consequences of the disease, that play havoc. About one-fifth of all the insane in our asylums are cases of general paresis; 90 per cent, of these give the Wassermann reaction. Syphilis, alcohol, and heredity fill our insane asylums, jails and almshouses. The consequences of syphilis are often more severe upon the off- spring than upon the syphilitic parent. The infection itself, or various defects, especially of the nervous system, resulting from the conse- quences of syphilis, may be transmitted from parent to child, often with fatal results. When death does not ensue the results may be still more tragic. The health officer should regard syphilis just as he does the acute febrile exanthematous diseases. Because syphilis runs a slow and often chronic course with mild constitutional symptoms during its early stages, it is often placed in a class by itself. This is a mistake. Syphilis has its period of incubation, eruption, and decline, just as measles and smallpox have. Historical. — There is an accurate historical record of the startling spread of syphilis over the known world in a few years after 1495, and from that time it has everywhere been endemic. No similar record exists of the sudden establishment of any other great disease among the larger part of the earth's inhabitants. Evidence, however, points to the severe character of the disease during this early epidemic, the cases often run- *9 But it is most communicable during this time. VENEREAL DISEASES 57 ning an acute, febrile course, accompanied by symptoms of such severitv as are now seen only occasionally. Syphilis was unknown before the year 1493. It is said to have been brought by the crew of Columbus, on his first voyage from Espanola, or Hayti.'^" Some of the returning (Tcw acconiitanied Charles YIII of France in the autumn of 1 }!>1 with the army, 35,000 strong, which invaded Italy for the conquest of Xaples. The epidemic began in Italy at this time, and the disease spread quickly over Europe with the scattering of the troops. At first the French called it the Xcajjolitan disease, and the Italians called it the French pox, or Morbus Gallicus. The name of the disease was taken from a popular poem written by Fracastor in 1530 entitled, "Syphilis sive Morbus Gal- licus," in Avhich the symptoms are clearly described in the principal pastoral character — Syphilis. In 1903, Metclmikoff and Eoux ^^ transmitted the disease to lower animals and demonstrated the prophylactic value of calomel inunctions, and also opened up a rich field of animal experimentation. In 1905, Schaudinn ^- discovered the cause and thus made diagnosis certain. In 190G, Wassermann, Xeisser and Bruck ^^ introduced the indirect method of diagnosis by serum reaction. In 1910, Ehrlich,^* after many years of experiment, gave to the world salvarsan, a specific, synthetic spirocheti- cide. In 1911, Xoguchi °^ cultivated Spirochceia pallida outside of the body and prepared luetin. In 1913, Xoguchi ^^ demonstrated the spirochetes in the brain of paretics and in the cord of a tabetic. This un- paralleled group of achievements, all the result of scientific work in laboratories, in 10 short years threw light upon the cause, mode of trans- mission, patholog}% treatment and prevention of the disease. Prevalence. — The percentage of syphilitics in the population at large is difficult to determine. It is commonly estimated at about 8 per cent. The amount of infection in certain groups is given by Tedder as follows : Prostitutes, 50 to 100 per cent. ; tuberculous in institutions, 20 to 30 per cent. ; ^^ sick children in hospitals, 2 to 10 per cent. ; men- tally backward and idiots, 20 to 40 per cent.; criminals, 20 to 40 per cent.; presumabh' healthy men of the class that enlist in the regular army, 20 per cent. : this group represents unskilled labor and a certain percentage of the tradesmen. Among men of better families the per- »/. A. M. A., June 12, 1915, LXVI. 24. p. 1962. ^^Ann. de VInst. Pasteur, 1903, p. 809. ".Ir6. a. d. k. iJsndhtsamte, 1905, XXII. p. 527. "Deutsch. med. ^ychnschr., 1906, XXXII, p. 745. ^ Dw experimentelle Chemotherapie der ,^pirillosen, 1910, Julius Springer, Berlin. ''''Jour. Exp. Med., 1911, 99, p. 557. "Jour. Exp. Med., 1913, XVII, p. 232. " The prevalence of syphilis among the tuberculous in this country has been variously placed by different investigators on the basis of a clinical examination or a positive Wassermann, or both. Some of these are as follows: Vedder, 23.2 per cent.; Snow and Cooper, 20 per cent.; Petroff, 21. S per cent.; Lyons, 9.2 per cent.j Jones, 29 per cent. 58 DISEASES HAVING SPECIAL PROPHYLAXIS centage varies from 2 to 10 per cent., depending upon age, marital con- dition and other factors. Among young women in the community, the percentage of syphilitic infections fluctuates between 3 and 20 per cent., depending upon age, marital condition, education and social status. As among men, the proportion of infections increases as we descend in the social scale. It is estimated that the rates for the colored race are at least double those for the white race. See also page 73. Stages of the Disease. — Syphilis is divided into four stages which are not always well defined in time or sequence. The chancre. — The primary stage consists of the chancre which forms at the site of the initial infection. The regional lymph node becomes enlarged and hard. The typical Hunterian chancre is an indurated and undulated ulcer in the skin or mucous membrane, and ap- pears about three weeks (not less than ten days) after the receipt of the infection. It is usually single and painless, but frequently is atypical, and may be but a trifling lesion. In the absence of a careful daily in- spection, it may exist many days before it is detected, or even escape notice altogether. The chancre contains many spirochetes which may readily be seen with the dark field illumination. This is the best method of early diagnosis.. The Wassermann reaction usually does not become positive until from two to six weeks after the appearance of the chancre. It is important to examine every sore on the genitalia for spirochetes, for the initial lesion of syphilis often resembles a chancroid, sometimes only a gimple abrasion. Mixed infections are frequent. The secondary stage is determined by a general invasion of spirochetes throughout the system, and is characterized by involvement of the lymph nodes, eruptions upon the skin and mucous membranes, fever, anemia, and other indications of a generalized infection. The third stage is characterized by a localized granulomatous growth known as a gumma. Gummata may appear in almost any tissue or organ of the body. A fourth stage, consisting of inflammatory and degenerative lesions of the heart, blood vessels and central nervous system, is often added to the picture, and occurs long years after the primary sore. This stage, formerly regarded as sequelae or parasyphilitic phenomena, is now known to be associated with spirochetes, and should be classed as a stage of the disease. This is the most serious and disabling stage of the disease and is a frequent cause of insanity or premature death. Examples of the chief manifestations of the late stage of syphilis are locomotor ataxia and dementia paralytica, also arteriosclerosis, aneurism, cere- brospinal syphilis, etc. The prevention of these serious conditions de- pends upon early recognition of the chancre, followed by prompt and thorough treatment. VENEBEAL DISEASES 69 Fatality. — Syphilis is the chief cause of dcatli in early ailult life in persons otlicrwise hale and hearty. If it be remembered that syphilis is the real cause of dealli in all cases of general paresis, locomotor ataxia, and aortic aneurysm, in many cases of apoplexy, and is a contributory cause of death in a host of other conditions, including many cases of pulmonary tuberculosis, the real influence of syphilis on the mortality rate begins to be suspected. Osier some time ago made the statement that "of the killing diseases, syphilis comes third or fourth." But recently from an analysis of the TJegistrar General's statistics for 1915, he estimates the actual deaths from syphilis in England and Wales at about 60,000, thus moving syphilis to the top of the list. Leredde estimates that s}'philis probably kills 25,000 persons each year in France. According to Lenz,^'^ in the large cities, 25 per cent, of syphilitics die as the result of endarteritis (angina pectoris, aortic insufficiency, aneurysm), while 3 or 4 per cent, of syphilitics die from general paraly- sis, 1 or 2 per cent, from tabes and at least 10 per cent, more as the result of syphilitic lesions of the brain, liver and kidneys. Almost half of all syphilitics eventually succumb as the result of their infection. Syphilis is therefore the greatest cause of premature death of men in large cities. Mattanschek and Pilcz ^^ found that of 413-i officers of the Austrian Army who contracted syphilis between the years 1800-1900, on January 1, 1912: 198 had general paralysis; 113 had locomotor ataxia; 132 had cerebrospinal syphilis; 80 suffered from different psychoses; 17 died of aneurj'sm; 147 died of tuberculosis; 20 died with syphilis designated as the cause; 101 developed myocarditis and arteriosclerosis, 86 of whom died from this condition. Diag'nosis. — Early diagnosis and prompt treatment are the most practical and promising measures to control syphilis (page 85). The clinical symptoms are often atypical and elusive; reliance on laboratory tests is therefore imperative. Darlc field illumination should be applied as a routine to every genital sore, by an expert. A single negative finding is not conclusive, and. should be repeated daily for several days. No local antiseptic should be applied until the diagnosis is established. One application of a spiroche- ticide, such as silver nitrate, mercury, copper sulphate, iodin or iodoform, is often sufficient to cause the disappearance of the spirochetes from the surface of the sore. The Wassermann reaction becomes positive only after a general in- vasion of the spirochetes takes place. At the time of the first appear- " Ueher die Haufigkeit der syphilitischen Sklerose der Aorta relatw zur geicehnlichen Athero-sklerose und zur Syphilis iiberhaupt, Med. Klinik, 1013, IX, 955. ''Med. Klinik, 1913, IX, 1544; also Berl. Klin. Wchnschr.. 1908, XLV, 1213. 60 DISEASES HAVING SPECIAL PEOPHYLAXIS ance of the chancre this reaction is invariably negative. It appears by the tenth day in about 30 per cent, of cases, and is positive in 96 per cent, of all cases by the 40th day. The Wassermann reaction therefore cannot be depended upon for early diagnosis^ but soon becomes the most reliable laboratory test. It (see also p. 65) should be remembered, how- ever, that in a small percentage of syphilitics, the Wassermann reaction remains negative, while on the other hand it may become positive in other infections, such as yaws, and sometimes in tuberculosis, malaria, pneumonia, scarlet fever, and especially in diseases associated with de- ranged metabolism of the liver. We must be cautious in drawing con- clusions from positive Wassermanns in other diseases, for it is often difficult to rule out syphilis. The hietin test is an anaphylactic reaction depending upon sensitiza- tion of the skin. It does not always appear, and then late in the disease. It is more useful in prognosis and as a guide to treatment than in diagnosis. Methods of Transmission. — Syphilis is transmitted directly, in- directly, and congenitally. In a large majority of all cases of syphilis, the infection is trans- mitted during sexual approach and usually as a consequence of adulter- ous relations. It is, therefore, spoken of as a venereal disease; many cases, however, are contracted out of venery. These innocent infections are more common than is ordinarily supposed. The spirochete is an animated corkscrew and can probably penetrate the unbroken mucous membrane and perhaps the skin, although a fissure or slight abrasion is the site of most chancres. Marital Syphilis. — The subject is of great interest and importance because marital syphilis is so frequent, and because the individual so infected is an innocent victim of the disease, and usually remains ignorant of the infection, and therefore receives little or no treatment. The transmission of syphilis from wife to husband is comparatively rare. On the other hand, the transmission of disease from husband to wife is comparatively common. M. Dechambre says, "Syphilis is divided among husband and wife like the daily bread." Extragenital Chancres. — Extragenital chancres constitute from 5 to 10 per cent, of the total infections with syphilis. Metchnikoff reports that a great number of cases of non-venereal syphilis occurs among chil- dren in Eussia, where peasants live huddled together and in ignorance. Genital syphilis is not necessarily due to immorality, since it frequently results from marital relations, and has occasionally followed the rite of circumcision. Extragenital chancres are usually acquired innocently but may be the result of improper practices. It is particularly desirable to make this distinction from the public health standpoint, as the measures taken to prevent syphilis resulting from immorality and syphilis VENEREAL DISEASES 61 acquired accidentally are naturally quite different. Innocent syphilis, however, is generally the result i)y one or two removes of syphilis ac- quired by promiscuity. Buikley,*"'" Munchheimer, and Eournicr "^^ have coHocteil from the literature 20,000 cases of extragenital chancre ; Scheuer ^- has analyzed 14,590 of these in regard to location : 3880 occurred on the lips, con- tracted mainly by kissing; ::^14-i on the arm, caused by the old- fashioned arm-to-arm vaccination; 1569 occurred on the breast, mainly of healthy wet nurses from syphilitic infants; 1104 on the tonsils; 897 on fingers and hands, chiefly of physicians, nurses and midwives; 753 were caused by circumcision, 181 by cupping, and 109 by tattooing. Kissing. — It is difficult to treat this subject seriously, and yet it must be considered as the most important single method by which accidental syphilitic infection is transmitted. When the public understands that not only syphilis, but also pneumonia, influenza, common colds, sore throats, measles, scarlet fever, whooping cough, diphtheria, and many other infections may be transmitted through kissing, the practice will become automatically reduced to normal and proper limits. The danger from kissing is great when there are mucous patches or other open, lesions upon the mucous membrane of the mouth. The kissing party reported by Schamberg ®^ has become classic : Eight individuals acquired chancres of the lip from kissing a young man who also had a chancre of the lip. The percentage of infection was very high — eight were infected, only five or six escaped. Indirect Transmission. — The list of articles that have conveyed the contagium by indirect transmission is comprehensive and includes towels, clothing, razors, handkerchiefs, surgical and dental instruments, pipes, et cetera ; a considerable number of infections have been traced to barber shops, drinking glasses, and minor operations. ' Congenital and hereditary transmission of syphilis, see p. 645. Infectiousness of Lesions and Tissues. — The chancre is highly in- fectious from its first appearance until it is completely healed. Hence the importance of early diagnosis and prompt treatment. All secondary lesions are potentially infectious because spirochetes have been demonstrated in all of them. The mucous patch is the sec- ondary lesion most commonly responsible for the transmission of the disease. Like the chancre, it fairly teems with spirochetes, it is com- paratively painless, and occurring on the mouth or genitalia it occupies the two regions of the body most commonly brought into close and intimate contact with persons of the opposite sex. The vast majority of ^Syphilis in the Innocent. Bailey and Fairchild, Xew York, 1894, p. 197. '^ Les Chancres Extragenitaux. Paris, 1897. ^ Die i<yphilis der Unschuldigen, Berlin, 1910, Urban and Schwarzen- berg. '^J. A. M. A., 1911, LVII, p. 783. 62 DISEASES HAYING SPECIAL PROPHYLAXIS infections are acquired from syphilitics in the primary or early secondary stages of the disease. Nevertheless, we must regard any uncured syphilitic as a possible source of infection. The secondary stage with its endless lesions may last for 29 years. Tertiary lesions are infectious, although it was thought for many years that they were not. Practically, cases of infection from tertiary lesions are comparatively rare and only occur from late eruptions of the skin and superficial gummatous ulcerations. The infectiousness of the hlood has been demonstrated in all stages of syphilis, but the danger from this source is slight. An exception to this statement is to be noted in the case of surgeons, physicians, nurses, dentists and midwives, among whom syphilis is the great occupational disease. The milh of a syphilitic woman must be regarded as infectious, since it is well known that a syphilitic wet nurse without lesions will almost surely infect a healthy child ; the spirochetes therefore appear to be trans- mitted in the milk. Spermatic fluid. — Warthin's findings *^* demonstrate that the seminal fluid from many secondary cases is infectious, and we may assume that the seminal fluid from tertiary cases may be infectious in the presence of a suitable lesion in the testicles, and this is confirmed by clinical experience, which indicates that some cases of syphilis appear to be transmitted in this way. Spinal fluid is infectious in many cases in which the central nervous system is involved. The sputum, sweat and urine are generally believed not to be infectious, except in the presence of discharging lesions. For public health purposes, a person suffering from syphilis is con- sidered to be in an infective stage so long as he shows any symptom or lesion of primary or secondary syphilis, or any discharging lesion of the tertiary stage. „,,,. v, ,' Viability. — The spirochete of syphilis is a frail organism, yet it may live long enough on towels, glasses, razors, dental instruments, pipes, and other objects to command hygienic respect. Thus, Zinsser and Hopkins ^^ found that pure cultures lived IIV2 hours on a moist towel. Dried on covered slips, the spirochete failed to grow after one hour. Bronfenbrenner and Noguchi ^" found that the viability of the spirochete is markedly diminished by lack of nutritive substances, pres- ence of oxygen, effect of light, and the toxic effect of sodium chlorid. Gastou and Comandon ^'' recovered living and active spirochetes from drinking glasses up to half an hour after they were deposited on the glass. «Aw. Journ. Med. Bci., 1916, CLII, p. 508. ^J. A. M. A., LXII, 23, June 6, 1914. "'Jour. Phar. and Exp. Therap., March, IV, 4, pp. 251-362. "'Bull, de la 80c. Franc, de Dermat. et Syph., 1908, XIX, 292. VENEREAL DISEASES 63 Hertmanni *** found that the si)iro('hete lost its motility as soon as (l^^•ing occurred. Ncisscr '''■' also dctcrniiiuMl tliat Ihc virus Troni syphilit- ics that produced syi)hilis when inoculated iido monkeys al)solutely lost its power to transmit infection as soon as the fluid which contained the organism was dried. We may therefore regard it as demonstrated that any material that has dried has lost its power to transmit the infection. These facts are in accordance with clinical experience, which indicates that infection by indirect contact is tli rough a hricf jx-riod of time or a short interval of space. Any object recently soiled or still moist with infectious secretions from a syphilitic must be regarded as a possible source of infection. The Spiroeha'ta jKiUida may retain its life and infectious properties for long periods in tissues that are excised from the body and in various bodily fluids when kept in the laboratory under suitable conditions or in cultures. Immunity. — There is no natural immunity to syphilis and probably no true cure wdthout specific treatment. The disease is much milder now than it w^as in the 16th century. This indicates that either the spirochete has lost some of its earlier malignancy, or the human race has become more resistant through syphilization. A similar phenomenon is seen in malaria and some other infections caused by animal parasites. Syphilis confers no definite immunity. Second infections may take place after cure. Chancres are not auto-inoculable, but it is now known that a second chancre can be produced if the inoculation from the first chancre is made soon after its appearance. In other words, super-infec- tion cannot take place when the disease is once established. This in- dicates a kind of "immunity" while the living spirochetes are in the body. The same sort of resistance is found in leishmaniasis and other parasites belonging to the animal kingdom. Inability to produce super- infections is also seen in active tuberculosis and some other diseases. The Wassermann reaction is not an index of immunity. If the luetin test becomes negative after having been positive, it is an indication that resistance has disappeared and such persons are susceptible to reinfection. The hereditary and congenital transmission of syphilis is discussed on page 645 Syphilis and Life Insurance. — Syphilis lowers the standard of health and paves the way for other diseases. Whatever the etiological relation- ship may be, it is definitely known that syphilitics are prone to die early from affections of the heart and vessels, general paresis, diseases of the central nervous system (locomotor ataxia), chronic nephritis, arterio- sclerosis, aneurysm, apoplexy, etc. The actuaries of all life insurance '^Ztschr., 1909, XVI, 633. "Ar6. a. d. k. Gsndhtsamte, 1911, XXXVII. 64 DISEASES HAVING SPECIAL PEOPHYLAXIS companies know that the morbidity and mortality rates among syphi- litics are very much higher than those of any other class of individuals of the community who enjoy apparent good health at the time of examination. The actuaries of a German life insurance company estimate that the mortality of luetics is 130 to 100 for normal in- dividuals, and in the 36- to 50-year period the average mortality in syphilitics is doubled. Most insurance companies refuse to accept syphilitics at all. Some companies require extra premiums to compensate for the extra risks. A few companies will accept exceptionally favorable cases who have had a thorough course of treatment and who have shown no symptoms for from 3 to 5 years, but under these circumstances only special policies are issued which do not keep the applicant on the companies' books after 55 years of age. Marriage and Syphilis. — Fournier thought that, with fe^^ exceptions, syphilis constitutes only a temporary bar to marriage. As a result of his experience, he concluded, in 1880, that marriage should be pro- hibited to every man having syphilis which was transmissible, and that it ought to be permitted in men in whom the disease was in such a condition as not to be transmissible. It is impossible, however, to in- sure any guarantee of safety whatever except in the presence of a definitely established cure. Finger's rules as modified by Vedder ""^ are as follows : 1. A mild normal course of the disease. 2. An efficient course of treatment with both salvarsan and mercury in accordance with the best practice in the treatment of syphilis. 3. An interval of at least four full years between infection and marriage. 4. An interval of three years from the last syphilitic manifestation to marriage with careful observation to determine the existence of symptoms. 5. A negative Wassermann reaction just before marriage, best con- firmed by a test at a second laboratory to insure accuracy. Osier states that the family physician should insist upon the necessity of two full years elapsing between the date of infection and the con- tracHng of marriage. This, it should be borne in mind, is the earliest possible limit, and marriage should be allowed only if the treatment has been thorough and if at least a year has passed without any mani- festation of the disease. It is clear that the great burden of responsibility must be borne by the family physician. It is his duty to warn the patient that mar- riage may not be absolutely safe, that he must watch for small erosions on the genitalia or in the mouth, that may affect his wife. The '"Vedder's "Syphilis and Public Health," p. 209. VENEREAL DISEASES 65 family physician should know tho facts so that he can watch huth wife and children, and alford })roni))t treatment shuuhl it Ijecunie necessary. It is not practical to prevent the marriage of many syphilities by law, although legislation making syphilis a bar to marriage has been enacted by several states.'^ Such laws in practice enable the state to step in after the fact, and while of interest in divorce proceedings, must be regarded as of limited public healtli usefulness. The family, is the sanitary unit, and it is of fundamental importance to public and private health to protect the sanctity of the home. There is also truth in Hutchinson's "'- contention "that counsels of perfection are often not trustworthy in practice." The Wassermann Reaction and Marriage. — Assent to matrimony should be withheld from individuals with a positive "Wassermann test. On the other hand Keyes '^^ concludes that a negative Wassermann is not sufficient evidence of the cure or absence of syphilis. Again, a positive Wassermann, unsupported by clinical evidence, may not be sufficient evidence of the presence of syphilis, and therefore in itself does not prohibit matrimony. A fixed, positive Wassermann in the later years of the disease does not inevitably point to the prospect of grave lesions. A negative Wassermann after salvarsan, in the first year of the disease, does not mean that the patient is cured, or that lesions will not reappear, because the reaction may again become positive. The return of chancre, glands, eruption and positive Wassermann reaction, a few months after control of the disease by salvarsan in its first few weeks, does not prove reinfection. Standard of Cure. — A person is not cured until all syphilitic spirochetes disappear from the body. This disinfection may be accom- plished easiest during the early stage of the chancre. Hence, the im- portance of early diagnosis by dark field illumination, and the prompt and intensive use of salvarsan, followed by mercury. The standard of cure may be set as follows: One year without treatment, without any suspicious clinical signs, with several negative Wassermann • reactions and no positive ones, and with a spinal fluid examination negative for syphilis. Calomel Ointment as a Prophylactic. — Syphilis was regarded as an infection peculiar to man until MetchnikofE and Eoux in 1903 trans- mitted the disease to the higher apes. Later it was found that monkeys and rabbits are susceptible. As a result of these experiments, certain important facts in reference to prophylaxis were discovered. Of all the " Thirteen states, namely, Alabama. Indiana, Michigan, Xew Jersey, Xew York, North Dakota, Oregon, Pennsylvania. Utah, Vermont, Virginia, Washing- ton and Wisconsin, have laws enforced relating to venereal disease in connection with marriage. The laws vary in wording, but the purport of all is to prevent the marriage of all infected with acute syphilis or gonorrhea. " Syphilis, 1909, Cassell & Co., p. 553. "JoMr. A. M. A., March 6, 1915, LXIV, 10, p. 804. 66 DISEASES HAVING SPECIAL PROPHYLAXIS various germicidal substances tried, Metchnikoff and Eoux found that mercurial inunctions are most successful in preventing the development of the chancre. Calomel ointment has proved itself best. In a communication published in 1906, Metchnikoff and Eoux ^* state that having tried 12 experiments on monkeys with uniformly satis- factory results, they next performed the experiment on a man. A stu- dent of medicine offered himself, and they assured themselves that he had never had syphilis^ either acquired or hereditary. The man did not develop syphilis, although watched for more than three months. Seven- teen days after the inoculation the two control monkeys that were not treated with the ointment developed primary lesions, while the monkey, treated after a twenty-hour interval, developed a chancre after thirty- nine days' incubation. It is interesting to note that the subject of this experiment was Maisonneuve,^^ who published this experiment on him- self as part of his thesis for the doctorate. Calomel ointment- to be effective must contain 33 per cent, of calomel, should be incorporated in lanolin ^*' as a base, and great care should be taken in its preparation to ensure thorough mixing. No doubt many failures in actual practice and even in some experiments may be at- tributed to ignorance or negligence on the part of the pharmacist in not following these directions. With rare exceptions, those who have watched the use of the prophy- lactic among troops or other large bodies of men are enthusiastic in regard to the results obtained, but the figures and statements they present would hardly serve to convince the critical. In practice it cannot be expected that the use of the prophylactic will be invariably successful, but it seems reasonable 'to believe that if properly applied during the first hour after exposure it will prevent the great majority of syphilitic infections. The efficacy of the prophylactic diminishes rapidly as the time between its use and the exposure increases. In addition to this time factor, there will be variations in efficacy in practice, depending upon the care with which the calomel ointment is compounded and upon the intelligence and thoroughness with which the prophylactic is applied. Colonel Edwin P. Wolfe,'^^ who conducted work at Fort McKinley, P. I., found that only two cases of primary syphilis occurred among 19,465 men who were given prophylactic treatment, whereas 99 cases developed among men who did not receive the treatment. Acevodo ''^ in 1908 reported 1435 prophylactic treatments in the Chilean Navy following exposures in ports all over the world: only 3 cases developed syphilis. See also page 81. ■'*Bull de I'Aoad. de Med., 1906, LV, 554. " These de Paris, 1906, Steinheill. " Adeps lanse hydrosus, containing not more than 30 per cent, water. "Vedder's "Syphilis and Public Health," p. 190. " Mai Cutan. et SyphiUtiques, 1908, XIX, 868. VENEREAL DISEASES 67 Excision, or destruction of the chancre with the actual cautery or with corrosive antiseptics does not iniiuence tlie development of the disease. Further measures for the prevention of syphilis are considered with Venereal Prophylaxis and Hygiene of Sex, pages 73 to 86. Summary. — Syphilis affects about 8 per cent, of the total population, occurs at all ai^es and in all class^vs of society, is the cause of from U) to 35 per cent, of all insanity, and is one of the causes of mentally and physically deficient children. It is the cause of locomotor ataxia, paresis, and the chief cause of apoplectic strokes in early life, and is responsible for a large proportion of diseases of the heart and blood vessels; is the cause of nearly half of abortion and miscarriages. Syphilis decreases the length of life about one-third; it also lowers the standard of health and paves the way for other diseases; it greatly decreases earning capacity ; is the most serious cause of disruption of home and happiness, and causes untold suffering and misery. Withal, it is preventable and curable. The public health control of syphilis depends upon early diagnosis and facilities for prompt treatment. GONORRHEA Gonorrhea is much more prevalent than syphilis, and common opin- ion regards it as a mild and not very shameful disease, that is, "no worse than an ordinary cold." As a matter of fact, gonorrhea is one of the serious infectious diseases, and the gonococcus occupies a position of high rank among the virulent pathogenic microorganisms. From an economic and public health standpoint, gonorrhea does not fall very far short of syphilis in importance. The gonococcus occurs characteristically in the polymorphonuclear leukocytes as small, biscuit-shaped. Gram negative diplococci. The or- ganism is aerobic and can be cultivated only on special media and then with difficulty. It is killed in a few minutes at 55° C. It soon dies when dried or when exposed to the air. It is very frail, outside the body, weak germicides being sufficient to kill the coccus. Cultures soon lose their virulence. Infantile types appear to be much less pathogenic than adult types. The complications of gonorrhea are: periurethral abscess, prostatitis and epididymitis in the male; vaginitis, endocervicitis and inflamma- tion of the glands of Bartholini in the female. Perhaps the mose serious of all the sequelae of gonorrhea are those which result from the spread by direct continuity of tissues, such as inflammation of the uterus, often extending into the fallopian tubes to the ovary, and even the peritoneum. The gonococcus has been found in pure culture in cases of acute general peritonitis. Other inflammations caused by the spread of the infection 68 DISEASES HAVING SPECIAL PROPHYLAXIS are cystitis, which sometimes extends upward through the ureters to the kidneys. The gonococcus sometimes invades the blood and produces a general septicemia; death may occur from acute endocarditis. Gonorrheal arthritis is, in many respects, the most damaging, disabling, and serious of all the complications of gonorrhea. It may even follow ophthalmia neonatorum. It is more frequent in males than in females, but a gonorrheal arthritis of great intensity may occur in a newly married woman infected by an old gleet in her husband. The serious nature of gonorrheal complications in the eye will be considered separately under Ophthalmia Neonatorum. Gynecologists tell us that the greater part of their practice is made up of the consequences of gonorrhea. Morrow ^^ assures us that 80 per cent, of deaths from infections peculiar to women are due to gonorrhea. From 75 to 80 per cent, of all operations of the female genital tract are said to be due to > gonorrheal infections alone. Sterility is one of the serious consequences of gonorrhea. This may be caused in the male through epididymitis or orchitis, which is a very common complication, and in the female by salpingitis, which closes or obstructs the fallopian tubes. Gonorrhea is said to be the cause of about one-half of all cases of sterility. Stricture of the urethra in the male is a frequent sequel. Gonorrhea is usually transmitted by sexual congress; however, acci- dental or innocent infections are not infrequent, especially in children. Standards of Cure. — It is difficult to determine when a case is cured. The following tentative rules are laid down by the U. S. Public Health Service: Males: (1) Freedom from discharge. (2) Clear urine; no shreds. (3) The pus expressed from the urethra by prostatic massage must be negative for gonococci on four successive examinations at intervals of one week. (4) After dilation of the urethra by passage of a full-sized sound, the resulting inflammatory discharge must be negative for gonococci. Females: (1) No urethral or vaginal discharge. (2) Two suc- cessive negative examinations for gonococci of secretions of the urethra, vagina, and the cervix, with an interval of 48 hours and repeated on 4 successive weeks. The diagnosis of gonorrhea is usually made from stained smears of the secretions. Unless the preparation is well made, properly stained, and examined by a competent microscopist, the results may not be de- pendable. Positive results are indicated by the presence of Gram- negative diplococci in the leukocytes. Negative findings do not rule out the disease, especially in the female. The specificity of the complement ''^Boston Med. d Surg. Journ., 1911, CLXV, p. 520. VENEREAL DISEASES 69 fixation test depends upon the tethnii.' and the operator : When positive, it indicates gonorrhea. A negative test does not exclude tlie disease. This test has not yet heen standardized. Prevention. — Inject, as soon after exposure as practicable, 2 per cent, protargol or lU per cent, argyrol. See page 82 Vulvovaginitis in Children,. — Vulvovaginitis (epidemic vaginitis) is common in children and is frequently due to the gonococcus. Out- breaks are common in schools, tenements, playgrounds, asylums, hos- pitals or Avherever children congregate in considerable numbers and where the same lavatories, towels, nurses, etc., are provided in common. Paul Bendig ^^ reports the following instance : Of 40 girls sent for con- valescence to a brine bath, 15 showed signs of gonorrhea after the re- turn. The infection came from an eight year old girl, who apparently had been suffering from gonorrhea for several years, and was spread through indiscriminate bathing in one bath tub and the use of the same bath towel. Infants may contract the infection from the hands of the nurse. Syringes, bed pans, catheters, thermometers, towels, diapers, wash cloths, and bed linen may account for the transmission of the gonococcus in hospitals and asylums, although the rapidity with Avhich the gonococcus dies when dried diminishes the danger somewhat from this source. Diapers should always be disinfected by boiling or steaming before they are again used, especially in institutions; this, not only on account of gonorrhea, but of infectious diarrheas. In the public bath, children who use the same towel, tub, soap, etc., run a great risk. Taussig ^^ believes the seat of the water-closet favors the infection in little girls. These seats are usually too high and thus readily become smeared with the discharges from the vagina, and thus infect others. In schools and tenements the water-closets are often used by a stream of children one after another. Hence, such seats should be low and U-shaped. The frequency of gonorrhea in children may be judged from the observations of Pollack, who reports 187 cases treated in the Women's Venereal Department of Johns Hopkins Hospital during the year 1919.^- Pollack estimates that 800 to 1000 children are infected each year in Baltimore, and that the same proportion probably holds good for other cities. Seippel estimates that 500 cases occur annually in Chicago. One cause of the infection among children is the horrible superstition that a person infected with gonorrhea may get rid of it by infecting another — especially a virgin. Gonorrhea in children due to rape is rare. When gonorrhea enters a children's hospital or an infant's home it is prone to become epidemic and is very difficult to eradicate. The *" Miinchener med. Wochenschr., 1909, p. 1846. ^^Amer. Journ. Med. Sciences, CXLVIII. 4, Oct., 1914, p. 480. '^ Johns Hopkins Hospital Bull., May, 1909, p. 142. 70 DISEASES HAVING SPECIAL PEOPHYLAXIS story of the infection in the Babies' Hospital, New York, for eleven years, as told by Holt,^^ illustrates the singular obstinacy of the in- fection. In spite of the greatest care and precaution, there were, in 1903, 65 cases of vaginitis with 2 of ophthalmia and 12 of arthritis. In 1904 there were 52 cases of vaginitis, only 16 of which would have been recognized without the bacteriological examination. In all, in the eleven years, there were 273 cases of vaginitis; 6 with ophthalmia, and 26 with arthritis. Holt urges isolation and prolonged quarantine as the only measures to combat successfully the disease. It is impossible to control such epidemics without bacteriological diagnosis, aided by complement fixation tests. Hess believes that the greatest obstacle to controlling the disease is the difficulty of recognizing latent cases. It is possible to convert the concealed carrier into an open case by means of provocative inoculations of gonococcus vaccines. The complement fixation test gives 'a very high percentage of positive results when gonococci are present, except in the very acute stage. Epidemic vaginitis is intractable in children and tends to a spon- taneous cure at puberty. Many cases continue for years despite careful treatment, and disappear spontaneously at puberty. Complications and sequelae of vulvovaginitis in children are much less common than gonococcus complications and sequelae in the adult. Louise Pearce ®* has shown that the infant types of gonococci differ from the adult types when tested by agglutination and complement fixation. The infantile types are also much less virulent, and cause fewer complications. The social and public health problems which this disease presents are very great, and our knowledge of the disease from the standpoint of diagnosis, quarantine, and treatment, is not sufficient to enable us to handle this question in a satisfactory manner. A diagnosis resting solely upon the morphological and staining characteristics of the or- ganisms found in smears is not sufficient to brand a child with the diagnosis of gonorrhea. Vulvovaginitis in children is not a venereal dis- ease. If the term gonorrheal or gonococcus vaginitis were dropped from the literature, and the term epidemic vaginitis substituted, it would be much easier to handle these cases from a public health standpoint. For the prevention of vulvovaginitis in children, the good advice of the American Pediatric Society should be followed : ^^ (a) That cities be required to provide adequate hospital and dis- pensary facilities for the care and treatment of children having vaginitis. "2V. y. Med. Journ., March, 1905. ^*Journ. Exper. Med., XXI, 4, April, 1915, p. 289. »' Arch, of Ped., XXXII, 1916, p. 361. VENEREAL DISEASES 71 (b) That matrons be placed in charge of the girls' toilet rooms in public schools. (c) That toilet seats embodying the principle of the U-shape be used in all schools and that the toilets bo of proper height for different ages. (d) That city and state laboratories be empowered and equipped to make bacteriological examinations for physicians when patients can- not afford to pay a private laboratory fee. (e) That educational literature on the subject of vaginitis be pre- pared and distributed to mothers through the medium of physicians, hospitals, dispensaries, health centers, municipal and visiting nurses. (f) That asylums for children and day nurseries be licensed and that the license be not granted unless : first, the institution has adequate facilities for the recognition of gonococcus vaginitis; and second, the institution excludes children having this disease if they cannot be prop- erly isolated. That the American Pediatric Society address a special letter to hospitals which care for children, containing the following recom- mendations : (a) That separate wards be maintained for the treatment of chil- dren with vaginitis who are also suffering from other diseases. (b) That microscopic examinations of smears be made before ad- mission to the general wards of the hospital. In securing material for the smears extreme care should be taken to observe rigid aseptic pre- cautions, (c) That observation wards be provided. (d) That individual syringes, bed pans, catheters, clinical ther- mometers, thermometer lubricant, wash basin, soap, powder, wash cloths and towels be provided. . (e) That single service diapers be used (at least for girls) ; or, that diapers be sterilized in an autoclave at 15 pounds pressure for five minutes. (f) That nurses be required to make daily inspection of the vulva of each girl at the time of bathing and to report immediately the pres- ence of the slightest suggestion of a vaginal discharge. (g) That low toilets be provided and equipped with seats embody- ing the principle of the U-shape. (h) That for routine purposes, the spray be used in place of tub baths for the bathing of young girls, and that older girls be sponged in beds. (i) That nurses receive special instruction as to the nature of vaginitis, the ease with which it is transmitted, the methods of prevent- ing its spread and the necessity for rigid aseptic surgical technic in its handling and treatment. 72 DISEASES HAVING SPECIAL PEOPHYLAXIS (j) That a dispensary with special facilities for the treatment of gonococcus vaginitis be provided. (k) That nursing care and supervision be given in the home. (1) That mothers be instructed as to the dangers of vaginitis, the manner in which it is transmitted, the "best method of protecting other children, and the necessity of prolonged observation. (m) That all cases of vaginitis under observation be voluntarily reported to the local health officer in states or cities where no legal requirements are in force. Summary. — Gonorrhea is the most constantly prevalent of all serious infectious diseases, except measles; affects all ages and all classes of society; is responsible for from 6,000 to 10,000 cases of blindness in the United States ; is the cause of 60 per cent, of blindness of the new born ; is the cause of more than 10 per cent, of all blindness; is the cause of from 60 to 75 per cent, of surgical operations on the female generative organs; of 50 per cent, of sterility; of many chronic diseases of the joints, bladder and generative organs ; greatly decreases earning capacity ; is the underlying cause of untold suffering and misery; and affects prac- tically all prostitutes, public and clandestine. Xotwithstanding, gon- orrhea is a preventable disease. Further measures for the prevention of gonorrhea are considered with Venereal Prophylaxis and Hygiene of Sex, pages 73 to 86. CHANCROID Chancroid is a specific, local, auto-inoculable, and contagious venereal ulcer, caused by the streptobacillus of Ducrey (1889). The ulcers are often multiple and confer no immunity. Chancroids are local ulcers and cause no sequelae or general systemic effects, such as follow chancres. Chancroids, or soft chancres, are peculiarly liable to mixed infections, and are apt to become phagedenic. As many as 50 per cent, of soft chancres are mixed infections with the Spirochceta pallida. Every venereal lesion should be examined by dark- field illumination for spirochetes. This is of great importance from a public health standpoint as well as for individual prophylaxis. A little soap and water at the time of exposure is almost an absolute preventive against chancroid. If the ulcer has developed it may be aborted by cauterization, provided the chancroid is not more than three days old. Even when seven days old the ulcers may often thus be cured, but when more than a week old, cauterization should not be em- ployed, for, if it fails, it leaves the sore larger than ever. The method of cauterization advised by Keyes consists in washing the ulcers with peroxid of hydrogen, drying, applying pure carbolic acid, then pure nitric acid, washing again with peroxid of hydrogen, and dusting with VENEREAL PROPHYLAXIS AND HYGIENE OF SEX 73 calomel. Spiroi'lietofiiU's should nut be used locally until syphilis has been delhiitely excluded by dark held illumination. Chancroids are usually contracted in venery. The disease should not be regarded as a slight or negligible malady, for, on account of the mixed infections to wliich they are prone, serious consequences, and sometimes death, may result. The complications of the ulcers are various forms of phimosis, resulting from inflammation and swelling; destruction of the frenum; gangrene and phagedena; lymphangitis, with inguinal adenitis. Tiie inguinal buboes arc painful and frequently suppurate. Chancroid is usually given subordinate consideration because syphilis and gonorrhea are much more prevalent and much more serious. VENEREAL PROPHYLAXIS AND HYGIENE OF SEX The same principles apply to the prevention of the venereal diseases as apply to the prevention of other communicable diseases. The fight against venereal diseases, however, is especially complicated and ditficult because of the close association with prostitution, the problems of sex, morality, and alcoholism — in fact, the question pervades the woof and warp of society. There are three primitive ai^petites of man — hunger, thirst, and the sexual appetite. . The first two persist throughout life; the last comes on at puberty, grows stronger during adolescence, and wanes with age. Any program for the control of the venereal diseases or the hygiene of sex must take into account the fact that we are deal- ing with, a primal, impulsive, and natural passion which is the greatest force for social good, when nsed in accordance with the laws of nature, but may result in dire consequences when these laws are transgressed. The venereal diseases are among the most widespread and universal of all human ills, and enter more largely into the marring of domestic happiness than any other disease known to man. The difficulties of the situation should not deter the health officer and all those who labor for social uplift, for there is no more pressing problem in preventive medicine. Prevalence. — The prevalence of the venereal diseases among the popu- lation at large can only be approximated. Definite figures, however, are at hand for selected groups. The reports from the armies of the various nations give the following figures : ^^ VENEREAL. INFECTIONS PER THOUSAND MEN Years Per Thousand Germany 1905-6 19.8 France 1906 28.6 Austria 1907 54.2 Russia 1906 62.7 United States United Kingdom 1907 ;. . .1907 167.8 68.4 Wliite and Melville, Lancet, London, 1911, II, 1615. 74 DISEASES HAVING SPECIAL PROPHYLAXIS Kober ^"^ gives a somewhat more recent and more detailed table. DIFFERENTIATED INFECTION PER THOUSAND MEN Year U. S. Army 1909 \ V. S. Navy 1909 Japanese Navy 1907 British Navy 1908 British Army 1908 Japanese Army 1907 Prussian Army 1907 Syphilis Chancroid Gonorrhea Total 30.45 30.77 135.77 196.99 26.49 28.23 105.11 159.83 139.75 37.46 17.87 67.16 122.49 35.1 28.23 40.7 75.8 10.1 10.4 17.1 37.6 4.4 2.1 12.2 18.7 Both these tables indicate that the English-speaking people are, in their navy and military organizations at least, greater sufferers from venereal infections than the other nations. The figures however are not strictly comparable, because of different methods used of recording these diseases. The venereal disease incidence, expressed as annual rates per 1,000 of mean strength for United States Continental (excluding Alaska) enlisted men, ])y years 190G to 1917, follows: 1906 — 143.63 1907 — 149.21 1908 — 155.17 1909 — 151.35 1910 — 137.98 1911 — 145.29 1912 — 115.74 1913 — 85.83 1914 — 89.84 1915 — 83.60 1916 — 91.23 1917 — 113.82 Of the first 990,592 physical records received by the Surgeon Gen- eral, Y. S. Army, under the Selective Service Act, a total of 28,411 men had venereal disease — 2.86 per cent. Of these, 23,049 had gonorrhea, 4,412 had syphilis, and 941 chancroid. Camp medical examiners found a higher percentage — 5.4. These figures indicate the minimal amount of venereal disease coming from civilian life among the first million drafted. After enlistment, venereal cases expressed as annual rates per 1,000 of mean strength, averaged 15 during the year 1919. In slightly over a year and a half after the first drafted men were mobilized, 225,000 cases of venereal disease were reported to the Surgeon General, .TJ. S. Army, among all troops in the United States. Approximately 200,000 of these were contracted in civilian life.*^ In civil life accurate figures are not obtainable. Cunningham ^^ says . that 60 per cent, of men acquire venereal infection some time. Twenty per cent, of these are incurred before the 20th year, 50 per cent, before "Kober, Tr. Assn. Am. Phys.. Phila., 1011, XXVI, 155. '' The venereal disease rate in American troops in France was about 45 cases per 1,000 men per annum. This rate was never before closely approached in the U. S. Army. The corresponding incidence rate in the United States averaged above 60. • *° Cunningham, Boston Med. and Surg. Jour., 1913, LXVIII, 77. VENEREAL PROPHYLAXIS AND IIVCIK.M-: OF SKX 75 the •v^")tll year, and 80 per cent, before the 30th yt'ar. (Jerrisli ^° estimates that 10 per cent, of the popuhition of New York has syphilis. Fischer "^ guesses that' 18 per cent. re])reseuts the syphilitic cases in the United States, and further, that there, are 250,000 deaths each year due to venereal infections. Biggs °- judges that there were about 200,000 cases of venereal diseases in the city of New Y'^ork in 1912. Morrow °^ states that 75 per cent, of adult males acquire gonorrhea at some time, and that from 5 to 10 per cent, acquire syphilis; these figures are based, not alone on his own observations, but on tlie opinion of such men as Xeisser and Fournier. Zinsser "'' estimates that 10 per cent, of the men registered for draft under the selective service act were actively infected. There were 2-4,234,021 men between 18 and 45 registered. It is conservatively esti- mated that of this number 2,600,000 were diseased, of whom 500,000 were syphilitic. The pathologists of Melbourne, Australia,^^ found syphilitic lesions in 30 per cent, of 200 necropsies ; furthermore, 5 per cent, of the popula- tion within a ten-mile radius from the Melbourne postoffice were positive to the Wassermanu test. Banks ^'^ states that we have nearly two and one-half million cases of venereal diseases occurring yearly in the United States — about one person in every forty. These findings are ample to indicate the extent of the scourge. See also page 58. Attitude. — Our attitude toward the venereal diseases is very incon- sistent. There is a natural aversion toward these aiflictions. The sani- tarian should make no distinction between the venereal diseases and other epidemic diseases; he should regard the greatpox in the same light that he regards the smallpox. The principles for the control of syphilis and gonorrhea differ in no wise from those used to control smallpox, leprosy, tuberculosis, measles^ diphtheria, etc. The health officer must not regard venereal disease as a punishment for sin — the victim or culprit needs help, even sympathy. The immediate problem is the prevention of further spread of the infection. A person afflicted with a venereal disease should be treated in the same humane spirit that actuates us in other diseases. Furthermore, the interests of the com- munity require that the patient be accorded the best possible care and treatment. The usual attitude toward the venereal diseases may well startle us when we consider that in most of our large cities no hospital will take a case of s}^hilis or gonorrhea during the acute stages, when these diseases are especially communicable. Morrow holds that the notoriously inadequate provision made for the reception and treatment *°Gerrish, "Social Diseases," New York. 1911. II. ]. »> Fischer, Public Health, Lansincr. Mich.. 1913. VIII, .51. *' Biggs, .Y. Y. Med. Jour., 191.3, XCVIII, 1009.' ^'Morrow, Boston, Med. and Surg. Jour.. 1911, CLXV, 520. ^♦Letter, .June 21, 1919, Am. 8oc. Hi/g. Assn. "Barrett, West Canada Med. Journ.. 1913, YII, 164. ^Public Health Rep., Feb. 26, 1915, XXX, 9, p. 618. 76 ■ DISEASES HAYING SPECIAL PROPHYLAXIS of venereal patients is a disgrace to our civilization. Formerly lepers were segregated in vile lazarettos and cases of smallpox isolated in hor- rible pesthouses ; now we have comfortable and congenial isolation wards or special sanatoria for these diseases. From the standpoint of pre- vention suitable hospital accommodations must be provided for venereal cases. Education, — Ed^ication in sex hygiene and the venereal peril ac- complishes a certain amount of good. A knowledge of the consequences will not control passion. Efforts to instill a wholesome fear of venereal diseases are futile. Even one attack of a venereal disease does not act as a deterrent to future immorality, and medical students who are pre- sumably informed are no more moral than other members of the student body. The only education that will effect a reduction in immorality is the education that forms character and, as Huxley says, "Molds the desire to live in accordance with the laws of nature." However, the old-style innocence must be regarded as present-day ignorance. Every boy and girl, before reaching the age of puberty, should have a knowledge of sex, and every man and woman before the marriageable age should be informed on the subject of reproduction and the dangers of venereal diseases. Superficial information is not true education. On the other hand, it is a mistake to dwell unduly upon the subject, for in many instances the imagination and passion of youth are inflamed by simply calling attention to the subject. One of the objects of education is to avoid the dangers of sex impurities, and all agree that this may often best be accomplished by keeping the mind clean, that is, away from the subject. The education must, therefore, be clear, pointed, brief, and direct. The object of educa- tion is not alone to help the individual to help himself, but to influence necessary legislation and concerted public action; also to lessen the influence of quacks. A simple knowledge of the facts is a sufficient deterrent for some; others may be influenced through fear of the con- sequences. Boys, as a rule, cannot be controlled through fear. The spirit of adventure is rife in healthy lads; they love to take a chance. Boys may be reached by an appeal to their better natures and by allu- sions to sister or mother. ISTormal boys are heedless of self, but are re- gardful of others : hence, a knowledge of the peril to future wife and offspring is the most impressive fact to keep boys straight. Instruction in sex hygiene should emphasize the rewards of strength and virtue, rather than the penalties of weakness and vice. The only foundation for a healthy sex life is an individual and social morality, combined with a knowledge and full understanding of sexual realities. The teaching of sex from a biological standpoint alone is inadequate, for there is little basis for character forming or ethical instruction in the physiological analogies of animal and plant life. Instruction should be VENEREAL PROPHYLAXIS AND HYGIENE OF SEX 77 positive rather than negative, constructive rather than destructive, Tlie fear of disease or fear of anything else is not a sufficient motive for goodness. In contrast to the usual procedures, the empliasis should he placed on the beauty of goodness rather than on the ugliness of vice. In general, it may be said that the best plan of education in mat- ters sexual is to answer the questions of young children upon the subject of maternity frankly and truthfully, but to offer them no information on the subject. The growing child at the age of puberty should be offered a certain amount of information concerning unnatural habits and should study physiolog}', biology, especially botany, and the facts of fertiliza- tion. At about the age of sixteen or eighteen girls as well as boys should be instructed as to the venereal peril. Emphasis should be placed upon the future hazard to wife and offspring. The person to impart the information may be parent, doctor, minister, friend, or teacher — in any event, two qualifications are essential: (1) Knowledge of the facts; (2) an impressive personality. As a rule the school- teacher is not naturally endowed nor is the class-room the best place to attain the reverent attitude essential to teach lessons in sex hy- giene. Unless education in sex hygiene to the young is properly given, which is most difficult, it may do more harm than good. Some of it excites morbid curiosity, and there is a peculiar twist to human nature that drives many to do anything specifically charged not to do. The general reluctance of parents and teachers to discuss sex matters with the young is ascribed by many to prudery, but it is often a safe instinct to follow. The problem of sex should be approached in the spirit of personal re- serve that we associate with the better sort of home life rather than in the spirit of eager curiosity and practical experimentation that we associate with the school. The ideal method of instruction in these matters is therefore individual. See also pages -139-441, 447, 448. Admirable pamphlets are distributed by the United States Public Health Service, Washington, D. C, by the American Social Hygiene Association, 105 West 40th Street, New York City, and by some state and city boards of health. Some of the facts all young men should know are : that the true purpose of the sex function is reproduction and not sensual pleasure; that the testicles have a twofold function, (a) reproduction and (b) to supply force and energy to other organs of the body; that occasional seminal emissions at night are evidences of normal physiological activity ; that sexual intercourse is not essential to the preservation of virility; that chastit}' is compatible with health ; and that the sex instinct in man may be controlled. The primary function of the testicles is to build the boy into the man. Castration in early life, as in the case of eunuchs, results in 78 DISEASES HAVING SPECIAL PROPHYLAXIS a loss of the internal secretion ^^ of the testicles and a failure in develop- ment of the secondary sexual characters which distinguish the male. There are an alteration in physical conformation and in the voice, lack of beard, development of the mammae, etc. — in other words, an approach to the feminine type. Healthy sexuality, stimulates the imagination, sentiment, the esthetic sense, and the higher creative functions. Excesses or any influence which weakens the sexual system impair the will power, influence self-respect, and diminish mental force. Experience shows that arduous physical and mental labor, even after maturity is attained, is best performed when the sex organs are not exercised ; that is, sexual excess distinctly impairs muscular strength and mental efficiency. It is unwise to frighten boys by exaggerating the results of self -abuse, which is rather the effect and not the cause of idiocy, insanity, degen- eracy, and other defects of the central nervous organization. Self- abuse is no worse in its effects than natural coitus, except for its in- fluence upon character. Both are alike harmful when indulged in to excess. Eesults through education will be slow, for the aggressive conscience of the world in these matters has awakened too recently to have achieved as yet a great deal. Good results are already apparent upon the youth of the growing generation. Notification. — It is not possible to control any communicable dis- ease, especially one that is pandemic, such as syphilis or gonorrhea, with- out a knowledge of the cases and deaths. It is perhaps even more impor- tant to collect morbidity and mortality statistics of the greatpox than it is of the smallpox. But the public registration of private disease at once defeats its own object. Compulsory methods are only partly successful, and little may be expected from voluntary registration. When we consider that in our country we have no means of knowing the amount and distribution of smallpox, except to a limited degree in the registra- tion area, what can we expect from the registration of the closely guarded secrets of the underworld? The public registration of ophthalmia neonatorum is successful because this form of gonorrhea is so apparent and the consequences so immediate and serious. Notification by serial number became effective in Massachusetts in February, 1918, and is meeting with increasing success. In the 11 months of 1918, 7,681 cases of gonorrhea and 3,281 cases of syphilis were reported to the State Department of Public Health; in 1919, 9,435 cases of gonorrhea and 4,127 cases of syphilis. To be effective, compulsory notification must, in the judgment of the National Council for Combating Venereal Diseases, include as the first and most necessary measures: (1) The provision in every area of adequate facilities for prompt diagnosis and efficient treatment, free of *' Both the testes and ovaries produce hormones. VENEREAL PROPHYLAXIS AND HVOIFAK OF SEX 79 charge. (2) The pruliibitioii of <juack trcatnicnt. (;5) (iraiitin",^ of privilege to any communication nunlc in j;tio<l faith by a medical man in order to ]irevent the spread of infection. False reporting hy number docs not, after all, give the information necessary to deal Avith the con- ditions. Tlic Australian hiw requires notification hy physicians and requires that the patient go to a qualified practitioner for treatment upon penalty of (hie and imprisonment. Any system of notification without adequate facilities for treatment will fail of its ])urposo. The difficulties, however, need not deter us, and registration should he at- tempted even though the returns are incomplete. A start should l)e made, and, though the returns will he only partial at first, a gradual im- provement may be expected. Every case known and properly cared for is a focus of infection neutralized. Continence. — One of tlie important facts to teach boys is that con- tinence is compatible with health. It is also the best preventive against venereal infection. The testicles are like the tear gland and the sweat glands, in that they do not atrophy with disuse. Benjamin Franklin taught, as many another man of influence believes to-day, that the exer- cise of the sexual functions is necessary for health. This is a mistake and has done much harm. The physiologic normal for frequency of nocturnal emissions in sexually abstinent males is commonly given as one to four per month. The sex principle is universal in nature. It is the force behind the constructive and progressive processes of all life, from the color adaptations of birds and flowers to the highest leadership in men. Re- production is only one of its many functions; and the man who assumes that the so-called physical desire that at times thrills him indicates a need of sexual intercourse is in danger of depleting and wasting from his life a chief source of physical and mental power. - The single standard for men and women must be insisted upon, and the parent or guardian is justified in demanding a clean bill of health of the young man who proposes marriage. The young man, in turn, is entitled to the same from his prospective father-in-law. One of the defects of our artificial civilization which leads to harm is the post- ponement of the marriage age. To denounce youth as vicious when youth has merely followed the impulse of adolescence is futile, because youth will not believe this; other and juster reasons must be given, if youth is to listen and be controlled. Any young man, properly warned and properly informed will not be merely w^illing hut anxious to learn from his doctor before marriage if he is fit to be a husband and a father. Carnal lust may be cooled and quelled by hard w^ork of the body, as well as attention to personal hygiene — hence, one of the great ad- vantages of athletic sports for growing young men. 80 DISEASES HAVING SPECIAL PEOPHYLAXIS Personal Hygiene. — Idleness, stimulating food, overeating, impure thoughts, evil associates, and alcohol excite the passions and are the bed- fellows of the venereal diseases. Purity of mind and cleanliness of body are helpful prophylactics. Physical exercise and an out-of-door life divert the mind and help the body ; it is a good safety valve for the excess animalism of youth. A full diet raises basal metabolism and stimulates sexual desire, whereas a low diet diminishes procreative interest and power.^® The public should be taught the necessity for thorough daily cleans- ing of the external genitals in both sexes, even in children. The large number of secreting glands and the decomposition of their secretions are liable to induce irritation and even minute lesions which open portals to infection of all kinds. Circumcision is recommended as an aid to genital cleanliness; as a prophylactic against syphilis and chancroid, venereal warts, herpes, and epithelioma, balanitis and phimosis; and also as a deterrent to mastur- bation. In order to prevent innocent infections it is necessary to educate the public to place chief dependence upon personal prophylaxis. The hazard of kissing, the common drinking cup, unsanitary barbers, and the un- hygienic practice of mouthing pipes and other things must become better known. Alcohol. — The strongest indictment against alcohol is that it excites the passions and at the same time diminishes the will power. The fact that alcohol blunts moral tone does much more harm than all the cirrhotic livers, hardened arteries, shrunken kidneys, inflamed stomachs, and other lesions believed to be caused by its excessive use. Alcohol is not a stimulant, but depresses the higher functions of the brain from the beginning. See Index for references to Alcohol. Prostitution. — Any sanitary measures taken for the prevention of venereal diseases which do not include some method for treating the problem of prostitution are doomed in advance to failure, since they will ignore the main source and root of these diseases. Fournier ^^ states that among the class of men seeking treatment in the hospitals of Paris, 72 per cent, of all syphilitic infections were derived from regis- tered prostitutes, 25.1 per cent, were derived from clandestine prosti- tutes and general immorality, and only 2.7 per cent, of these infections from adulterous relations. The Chicago Vice Commission states that: "So long as there is lust in the hearts of men it will seek out some method of expression. Until the hearts of men are changed, we can hope for no absolute annihilation of the social evil." While waiting for the slow evolution that aims at bettering the moral fiber of mankind, «* Miles, Jour, of Neur. and Mental Dis., Vol. 49, No. 3, March, 1919. ^ Les Chancres Extragenitaux, Paris, 1897. VENEREAL PROPHYLAXIS AND HYGIENE OF SEX 81 the I'ollowiiii;- four ways of dealing with prostitution have been at- tempted: (1) laissez-faire, (2) suppression, (3) regulation, and (4) the systematic treatment of all infected. A policy of non-interference satisfies no one. Despite the didiculties and complexities of the situa- tion, we must insist that prostitution be met with determined but humane action to lessen its extent and diminish its dangers. Prostitution must at least be made difficult and distant, for the extent of the patronage is in direct ratio to its accessibility. The elimination of prostitution is beyond the dream of even the theoretical reformer. Any program must take into account the facts that a great nuijority of jirostitutes are feeble-minded. Suppression does not suppress. Virtue cannot be secured by legisla- tion. Repressive measures drive the traffic into obscurity and reduce it materially. Vice is not flaunted in public, but is driven into corners Avhere the vicious will find it, but where it will not entice the innocent and unwary. Between the flagrant evil of segregation and the im- perfections of suppression, the choice is with the latter. Regulation of prostitution by means of medical inspection and li- censure has proven a failure wherever tried. Regulation implies the absence of any expectation of male self-restraint; it is society's tacit assent to laxity. Regulation fails because it makes vice easy, gives a false sense of security, and does not reach clandestine prostitution. The systematic treatment of all infected persons, especially of prostitutes, would go far towards diminishing the prevalence of venereal disease. To accomplish this, we must have adequate facilities for treatment. See page 85. Segregation. — Theoretically, every case of syphilis or gonorrhea should be isolated until the danger of infection is passed. Practically, however, segregation is impracticable except with a limited number of cases. With better and more attractive hospital facilities and free beds a certain amount of segregation may be accomplished voluntarily and humanely. An alert health officer can trace the source of infection in certain cases, aiid induce the women responsible to take the salvarsan treattoent in the case of syphilis, or to submit to hospital care in the case of gonorrhea or chancroid. Sanitary isolation through self restraint and care necessary to pre- vent the infection of innocent persons must be taught and impressed upon all infected individuals. Medical Prophylaxis. — In accordance with the researches of Metch- nikoff and Roux a reasonably efficient prophylaxis against syphilis is now possible. Calomel ointment (331/3 per cent.) applied within an hour of inter- course is generally effective in preventing syphilitic infection. There are several more or less efficient irrigations or ointments destructive to the gonococcus if used soon enough — the silver salts being the best 82 DISEASES HAVING SPECIAL PROPHYLAXIS (2 per cent, protargol or 10 per cent, argyrol). Prophylaxis is there- fore possible, but it takes a great deal of care and vigilance, and the double method must be promptly and skillfully applied in order to be effective. It has been used with success in armies and navies, but in civil life, where strict routine and control of men are impossible, it is im- practicable except in individual instances; even then it requires time, in- telligence, and sobriety. For this reason, it has been found inadvisable to furnish soldiers and sailors with prophylactic packages.^"" Better re- sults are obtained by shortening leaves of absence and applying the pro- phylactic by competent attendants. To be effective it should be applied within six hours of beginning of exposure ; the best results are obtained when used within one hour. Method of Using Prophylactic. — Before intercourse use a liberal amount of vaselin or other lubricant. This aids in preventing abrasions and forms a coating through which infectious organisms penetrate with difficulty. As soon as possible after intercourse: 1. Wash the genitalia thoroughly with soap and water, using plenty of soap. Soap solution is a spirocheticide, and there is good evidence that chancroid infection may also thus be avoided. 2. When the prophylaxis is performed under medical instruction or by a man of sufficient intelligence this may be followed by a wash of 1-1000 mercuric chlorid. The efficacy of this solution is undoubted, but it should not be used by ignorant persons, nor should bichlorid of mercury tablets be issued as a routine. 3. Dry, and apply about 1 dram of 33 per cent, calomel ointment in lanolin. Anhydrous lanolin ^°^ should not be used, and the ointment should be most thoroughly mixed. This should be well rubbed in for at least ten minutes, paying particular attention to the glans, corona and prepuce, but neglecting no part of the penis and the anterior portion of the scrotum. This should be rubbed in for at least ten minutes, and should not be removed but should be allowed to remain for 12 hours, meanwhile protecting the clothes by the application of an impervious paper napkin. This favors absorption and ensures prolonged action of the mercury on any organisms that may remain. 4. For the prevention of gonorrhea, a solution of argyrol 10 per cent, or protargol 2 per cent, should be injected into the urethra. In the United States Navy the following method is employed: The entire penis is scrubbed with liquid soaj) and water for several minutes and then washed well with a solution of mercuric bichlorid, 1 to 2,000 in strength. If there are any abrasions present, they are sprayed with hydrogen peroxid from a hand atomizer. The man is then placed in ^""Package K of the Army; and Sanitube of the Navy containing 33% per cent, calomel and 2 per cent, tricresol. "^Adeps lanae hydrosus, see page 66. VENEREAL PROPPIYLAXIS AND HYOTENE OF SEX 83 a sitting position, well forward in a cliair in front of a convenient re- ceptacle, and given two injections of a 10 per cent, solution of argyrol. He is required to retain each injection in the urethra for five minutes. After taking tlio injections, the entire penis is thoroughly anointed with a 33 per cent, calomel ointment. He is told not to urinate for at least two hours, and to allow the ointment to remain on tlie penis for some hours. A temporary dressing is placed on the parts to protect his clothes. Medical prophylaxis has been in general use in the United States Army and Navy since about 1908, and since 1912 the use of prophylac- tics has been compulsory in the army. Many officers have published their opinions, for the most part favorable, and a few have furnished some statistics. The best figures on this subject are given by Riggs,^°- who records 5,103 prophylactic treatments with only 81 infections, as shown by the following table: Hours Subsequent to Exposure Number of Treatments Number of Infections (Syphilis, Gonorrhea, Chancroid) Per cent. of Infections 1 1,180 1 0.08 2 1,172 7 0.59 3 521 4 0.77 4 330 2 0.61 5 199 3 1.57 6 321 5 1.58 7 277 6 2.27 8 390 16 4.22 9 283 10 3.62 10 214 11 5.14 More than 10 216 16 7.40 Total.. 5, 103 81 1.58 . There were 1,180 treatments during the first hour which were fol- lowed by a single infection. This infection was carefully investigated and there is considerable doubt as to whether it was genuine or not. The disea-se was diagnosed as chancroid, and w^as cured in two days. These figures emphasize the importance of time — the efficiency of the prophylactic diminishes as the time increases. Riggs states that out of 3,556 prophylactic treatments there were only 67 infections, and of these only 8 were cases of syphilis. Ledbetter ^°^ reports that at Cavite, before medical prophylaxis was instituted, the percentage of venereal diseases of all classes among the men averaged from 25 to 30 per cent, annually, and at times even higher. The percentage of gonorrhea was reduced to 8 per cent, an- nually, and this percentage included about 30 patients w-ho did not re- ^"^ Social Hygiene, 1917, III, 299. ^"'Ledbetter, Robert E., "Venereal Prophylaxis in the U. S. Xavy," Jour. A. M. A., April 15, 1911, Vol. LVI, No. 15, p. 1098. 84 DISEASES HAVING SPECIAL TROPHYLAXIS port for treatment. Chancroid was reduced from 5 to 2 per cent., which, included 2 patients not reporting for treatment. Syphilis has been reduced from about 20 cases annually to one case for the entire year 1910, and this patient did not report for prophylactic treatment. The results speak for themselves and show the efficiency of the prophy- lactic measures if properly and thoroughly carried out. Holcomb and Cather ^°* report the following as a result of treatment used by them in 3,268 persons in the TJ. S. ISTavy between May 1, 1910, and August 31, 1911. Treatment taken within eight hours after ex- posure in 1,385 cases shows 19 infections, or but 1.37 per cent. In the interval of from eight to twelve hours after exposure in 741 cases shows 25 infections, or 3.31 per cent. Between twelve and twenty-four hours in 920 cases shows 46 infections, or 5 per cent. Of the 56 cases of gonorrhea occurring in the first twenty-four-hour interval, ^6 were re- current cases; the remaining 30 were primary infections. Eiggs states that the normal expectancy for venereal disease re- sulting from illicit sexual intercourse not followed by prophylaxis is about 1 in 20 or 1 in 30. The expectancy for venereal disease when prophylaxis is used depends almost entirely upon the factor of time. The absence of the time factor in a set of prophylactic statistics invali- dates any conclusion that may be drawn concerning probable efficiency of prophylaxis. In actual practise the number of infections appears to be reduced by nearly one-half. The questionnaire method of investiga- tion, in which the identity of the individual is concealed, has proved unreliable and the results obtained cannot be accepted with any con- fidence as to their accuracy. Furthermore, many of the reported results are difficult to analyze on account of lack of accurate data, and especially lack of control figures. ^°^ The use of salvarsan early in syphilis will prevent the further spread of the infection. Mechanical Methods. — The condom was introduced late in the 17th or early in the 18th century in England. It was described by Turner in 1717, who attributed its invention to a Dr. Condom, from whom the device was named. Le Pileur, who has made a study of this literature, questions the existence of Dr. Condom, and thinks it more probable that the name is derived from the Latin verb condere, meaning to hide or to protect. Most authorities agree that the use of a condom is an al- most certain protection against venereal infection, being even more re- liable than prophylactic ointments. In regard to the protection afforded, we may conclude that the condom if properly tested and made of good rubber will afford practically complete protection to anyone who can ^»^ Holcomb, E. C, and Cather, D. C, U. S. N., "Study of 3,268 Venereal Prophylactic Treatments," Jotir. A. M. A., Vol. LVIII, No. 5, February 3, 1912, p. 368. "=U. S. Naval Med. Bull., 1921, Vol. XV, No. 1. VENEREAL PKOPHYLAXIS AND HYGIENE OF SEX 85 obtain and will use it, and it may therefore be recommended to those in- dividuals who persist in immorality in spite of advice to the contrary. Specific Treatment. — From the standpoint of preventing syphilis, the treatment of the infected is perhaps the most efficacious single method that can be applied. It is obvious that if all infected individuals are rendered incapable of transmitting their infection, the disease will dis- appear. Notification, early recognition, and prompt treatment, there- fore, become our most important prophj'lactic measures against syphilis. Salvarsan (arsphenamine and related arsenical compounds) promptly kills the spirochetes in the chancre, mucous patches and other exposed lesions, and thereby destroys the focus of infection. Salvarsan promptly used is a specific and a preventive, even though some of the parasites hidden in the cells of the inner organs escape destruction. Unfor- tunately, salvarsan has always been a drug of the proprietary class, made in an atmosphere of mystery, under a patent giving an imperfect account of its preparation, produced at small cost and sold at a very high price. Eecent efi'orts in this country to make and distribute this chemical free of charge in the same way that antitoxins and vaccine virus are distributed by boards of health is a commendable public health measure. The danger of syphilis to the community or individual is increased in proportion to the inadequacy of the treatment received by those suf- fering with the disease. The possibility of controlling the amount of syphilis acquired, whether by prostitution or general immorality, by means of enforced systematic treatment, has not yet been given the se- rious consideration that the subject merits. When proper facilities are afforded the poor for the treatment of this class of diseases, one of the main props of the quack will have been removed. The Massachusetts State Department of Public Health has made and distributed arsphena- mine free of charge since December, 1917. Hospitals and Clinics. — Pontoppidan, on the basis of his large expe- rience with the Danish system, estimates that 1 bed to 2,000 of the pop ulation is insufficient to care for sexual diseases. Stokes,^"® says that in 1914 it was estimated that the city of London, with 7,000,000 inhabi- tants, had only 163 beds available for the treatment of venereal disease, and the same condition obtained throughout Great Britain. Of 30 gen- eral hospitals in New York City, a recent investigation showed that only 10 received recognized cases of s}T)hilis; 13 of 30 will not receive medi- cal cases with complications of s}'philis or gonorrhea. Chicago has 200 beds in the Cook Coimty Hospital for 2,000,000 people. All the con- temporary comment clearly indicates that the attitude of the general hospital toward syphilis and other venereal diseases is slowly changing. Special hospitals for the treatment of venereal diseases will not serve the ^"Wour. A. M. A., 1916, LXVII, 1960. 86 DISEASES HAYING SPECIAL PEOPHYLAXIS purpose, for while a patient might go to a general hospital for the treatment of these conditions, very few would seek assistance in a hos- pital openly devoted to the treatment of venereal diseases because of the stigma necessarily attached. Every general hospital should have wards assigned for the treatment of syphilis and gonorrhea. Beds are neces- sary in order that salvarsan or similar drugs may be administered un- der proper safeguards, No patient would occupy a bed long, since salvarsan usually causes a prompt disappearance of external lesions. It will be generally admitted that present facilities are sadly deficient, and that the extension of those facilities should be among the first steps to be taken to control this disease. Summary. — Finally, in considering venereal prophylaxis, it should be remembered that these diseases are of great antiquity and seem likely to continue indefinitely; that they already affect a large number of the population, and are spreading; that the existing means for the treat- ment of them among the poor is insufficient ; that the common mode of propagation is irregular and illicit intercourse; that prostitution arose in response to the strongest instincts and passions in the human breast ; and that prostitutes themselves need protection and have claims on the humanity of the law. Furthermore, Lecky thinks that "The prostitute is ultimately the efficient guardian of virtue." To diminish the amount of venereal infection requires education and publicity, notification, laboratory facilities for diagnosis, dispensary and hospital facilities, public health nurses and social service, and good laws actively administered. Medical schools should give more time to the diagnosis and handling of early syphilis, since at this time the best results in treatment and prevention can be offered. A stricter super- vision of barber shops, restaurants, hotels, soda water fountains, in- fant asylums and schools should be maintained; prostitution should be made difficult and distant and early treatment of all cases instituted. Medical prophylaxis should be better understood and the importance of personal hygiene impressed. Insistence should be stressed upon con- tinence and efforts made to improve the moral and physical fiber of man- kind. REFERENCES The American Social Hygiene Association, 105 West 40th Street, New York City. Popular prints. Also the publications of the IJ. S. Public Health Service. Social Hygiene. Pub. by the Am. Soc. Hyg. Assn., New York City. PREVENTABLE BLINDNESS PREVENTABLE BLINDNESS Preventable blindness is considered in this place because the largest single factor causing needless loss of eyesight is gonorrhea. Among the infectious eye troubles llie most destructive is ophthalinia neona- torum. There were 04,000 registered blind persons in the United States, ac- cording to the census of 1910.^"' Ten per cent, (between six and seven thousand) arc blind as the result of ophthalmia neonatorum. From 25 to 30 per cent, of all the blind children in all the blind schools of this country owe tlieir infliction to gonorrhea. It has been estimated that probably one-half of the blindness in the world is preventable. Emphasis upon the great harm done by ophthalmia neonatorum should not blind us to the fact that there are other causes of blindness and eye deterioration which are preventable; thus we have to consider the later pus infections, also syphilis, tuberculosis, smallpox, trachoma, sympathetic inflammations, industrial accidents, accidents at play, pro- gressive near-sightedness caused by violation of ocular hygiene, and a variety of inflammatory conditions. Functional disturbances of vision (toxic amblyopia) followed in severe cases by atrophy of the optic nerve and permanent blindness may be brought about by poisoning with lead, wood alcohol, tobacco, and other poisons. This form of dimness of vision, or even loss of sight, occurs rather frequently, and in most in- stances is preventable. One of the common causes of impaired sight is phlyctemdar heraiitis which leaves scars on the cornea. This condition is often associated with tubercular glands of the neck and is probably a form of bovine tuberculosis, hence preventable. OPHTHALMIA NEONATORUM Ophthalmia neonatorum or inflammation of the eyes of the new- born includes all the inflammatory conditions of the conjunctiva that occur shortly after birth — usually before the end of the first month. The conjunctivae of the newborn are peculiarly liable to infections. The gonococcus is usually the cause of severe conjunctivitis occurring in a baby a few days old. The gonococcus causes about 60 per cent, of all cases, mild and severe. ^'" These figures we now believe are altogether too low. Green states that in Massachusetts only about 53 per cent, of the actual cases had been recorded, and estimates the total blindness in the United States to be not less than 118,999. The figures vary greatly, because there is no accepted rule as to what constitutes blindness. A watchmaker would be practically blind with vision ample for a masoa. 88 DISEASES HAVING SPECIAL PEOPHYLAXIS Ophthalmia neonatorum is not always gonorrheal, but may be pro- duced by other virulent microorganisms or by irritating substances. The microorganisms other than the gonococcus that sometimes cause conjunc- tivitis during the early days of life: pneumococci, streptococci, men- ingococci, the Koch-Week's bacillus, the diphtheria bacillus, and even staphylococci. These are relatively so rare or benign that we may dis- regard their etiological signiiicance for our present purpose. The diag- nosis of gonorrheal ophthalmia may readily be made by simply examin- ing a stained smear of the secretion for Gram-negative, biscuit-shaped diplococci, although in rare cases infection with the micrococcus catar- rhalis may cause confusion. The infection commonly occurs during the passage of the child through the genital tract of the mother and usually just before delivery. It is caused by the entrance of the vaginal secretion containing gonococci into the conjunctival sac. It may also occur after delivery by infected hands, towels, sponges, or other objects. The disease varies in severity; sometimes it is very mild, with slow onset and spontaneous recovery. Usually, however, it is severe and serious. The inflammation may extend from the conjunctiva to the cornea leading to corneal ulcers and partial or complete loss of vision. In a typical case both the ocular and palpebral conjunctivae are red and very much swollen; the eyelids and surrounding tissues are infil- trated and there is a thick, creamy, abundant secretion. There are many grades of mild inflammatory conditions, which must not be mistaken for gonorrhea. At birth the eyelids are almost always glued together with a normal sticky secretion. It is common, too, for the lids to remain red and sticky for a day or so. The diagnosis may be made in a few minutes by a microscopic examination. Prevalence. — Kerr calls attention to the fact that there are no com- plete statistics showing the prevalence of ophthalmia neonatorum, and only an approximate idea can be had of the number of cases by study- ing the admissions to schools for the blind. A committee of the Brit- ish Medical Association found that more than one-third of those in blind schools of Great Britain owed their affliction to this disease.^"® In the United States and Canada, in 1907, out of 224 admissions to 10 schools for the blind, 59, or 24.38 per cent., were blind as a result of ophthalmia neonatorum ;^°^ and out of 351 admissions to certain schools in the United States and Canada in 1910, 84, or 23.9 per cent., were blind from this cause.^^*' As a result of studies made of ophthalmia neonatorum in 10 man- ufacturing cities of Massachusetts, Greene has presented figures which ^"^ British Medical Journal, Mav 8, 1909. , ^"Wour. A. M. A., May 23, 1909, p. 1745. ^"Jour. A. M. A., July ], 1911, p. 72. PREVENTABLE BLINDNESS 89 show that the minimum morbidity rate for this disease was 6.4 per 1,000 births. A more compk^te oonsus made l)y him from the practice of 173 physicians in 9 cities revealed an average morbidity rate of 10.8 per 1,000 births."' It is estimated that tlie total annual loss from gonorrheal ophthalmia in the United States is seven million dollars, and that more than one million dollars annually is spent in partially caring for its victims. A blind child costs the community an excess of about $4,500 for its school- ing. Prevention. — Crede's Method. — Crcde in 1881 introduced an effi- cient method of preventing ophthalmia neonatorum at the Lying-in Hospital at Leipzig, thereby connecting forever his name with the pre- vention of the disease and the subsequent saving of the sight of many persons. Crede's original method consisted simply in placing one or two drops of a 2 per cent, solution of silver nitrate in each conjunctival sac, as soon as practicable after the birth of the head. In order to prevent gonococcic as well as other infections of babies' eyes, the following procedure is recommended: During pregnancy women should be instructed to practice daily external cleansing with soap and water and a clean wash-cloth. In case of any irritating dis- charge or even profuse white discharge, a physician should at once be consulted. Immediately after labor the eyelids should be carefully cleaned with sterile absorbent cotton or gauze and a saturated solution of boric acid. A separate pledget should be used for each eye and the lids washed from the nose outward until quite free of all mucus, blood, or meconium without opening the lids. Next the lids should be separated and one or two drops of a 1 per cent, silver nitrate solution should be dropped into each eye, between the outer ends of the lids. The lids should be sep- arated and elevated away from the eyeball so that a lake of silver nitrate solution may lie for one-half minute or longer between, them, coming in contact with every portion of the conjunctival sac. One application only of the silver nitrate should be made, and ordinarily no further at- tention need be given to the eyes for several hours. Each time the child is bathed the eyes should first be wiped and cleaned with pledgets of sterile absorbent cotton wet with a saturated solution of horacic acid. Crede used a 2 per cent, solution of silver nitrate, but, as this is sometimes irritating, a 1 per cent, solution is now commonly employed, and seems to afford equally efficient protection. The silver nitrate solu- tion should be instilled into each conjunctival sac but once. Eepeated applications may cause serious inflammations. In fact, a single treat- ment sometimes causes a conjunctivitis, known as "silver catarrh." ^^ Monograph Series of Hie American Association for Conservation of Vision, Vol. I, Xo. 1. 90 DISEASES HAVING SPECIAL PROPHYLAXIS Other prophylactic substances have been proposed. The best substitutes are the newer silver compounds, as argyrol, which is a collodial silver (25 per cent.), or protargol (3 per cent.). The following have also been recommended: Bichlorid of mercury, 1-3,000 or 1-5,000, silver acetate, 0.23 per cent., recommended by Zweifel, who used it in 5,222 cases. Schmidt and Eimpler recommend aqua chlorini. Carbolic acid (1 per cent.) or other antiseptics have also been tried. ISTo substance, how- ever, is known to be as reliable as silver nitrate, which should be used in all cases where there is any reason for believing that the mother is infected with the gonococcus. There is no specific treatment for this disease. While silver nitrate and the various silver preparations are undoubtedly effective as pro- phylactics, when once the organisms have penetrated the tissues these agents can no longer reach them in effective concentration and hence are useless in treatment. They are, however, still generally used for this purpose. The disease is practically self limited, but the frequency of corneal complications can be greatly reduced by frequent irrigations with non-irritating solutions, such as boric acid or normal saline solution. Great care should be taken not to abrade the cornea. As a general rule, it is advisable to use a prophylactic as a matter of routine in hospital and private practice. To use Crede's method upon every case necessitates the unpleasant suspicion that every woman is a possible source of gonococcus infection. If statements of the father about his previous life can be relied upon, an eye prophylactic may be omitted. In his private work Williams uses a boric acid solution ex- cept where there is special reason for believing that the mother has gonorrhea. The responsibility for risking the baby's eyes rests upon the medical attendant. There can only be one safe rule in case of doubt. It should be remembered that gonococcic infections of the conjunctiva occur in about one to every two hundred births (Edgar). The good results of Crede's method are sufficiently convincing to justify criminal proceedings upon those who fail to apply this simple prophylactic. Crede reduced ophthalmia neonatorum in the Leipzig Lying-in Hospital from 10.8 per cent, to 0.1 per cent. Haab reduced the frequency of ophthalmia neonatorum in hospital practice from 9 to 1 per cent., while the statistics of many hospitals show only a very small fraction of 1 per cent. At the Sloane Maternity Hospital in New York, there were 4,660 births during a period of 6 years, in which Crede's method was carried out without a single case of ophthalmia. Stephen- son's results are typical. In 2,265 births, ophthalmia neonatorum de- veloped in 10 per cent, of the cases preceding the use of Crede's method. In 1,160 births after this method only 0.17 developed any trouble. The technic of applying the nitrate of silver is very important, for, in the opinion of Edgar, when ophthalmia neonatorum develops after PREVENTABLE BLINDNESS 91 the use of nitrate of silver, it is due either to a secondary infection or to the fact that the solution does not really bathe the mucous membranes, but remains upon the lashes. The lids must be everted and the silver solution placed in the conjunctival sac either from a glass rod or a pipette. Care must be taken not to touch or injure the delicate mem- brane. Crede's method does; not strike at the root of the evil. It would, of course, be much better to eradicate gonorrhea from men and women than to be compelled to drop silver nitrate into babies' eyes. Wrapped up with the question of ophthalmia neonatorum is the question of mid- wives, for to prevent blindness we must have intelligent and conscien- tious obstetrical atendants, especially for the poor and i.cfnorant cla.<ses. Midwifery practice needs regulation, supervision, and elevation. Educa- tion is one of the bulwarks of prevention in this as well as other pre- ventable infections. Legislation. — Ophthalmia neonatorum is an instance in which ''the protection of the citizen from the assaults of ignorance, indifference, or neglect, when they threaten his well-being and even his economic ef- ficiency, is a duty which the state cannot evade and which he has a right to exact." Laws for the prevention of the blindness of newborn infants are mak- ing progress slowly. Many states have now made prophylaxis com- pulsory. In some states the nurse, midwife, or parent is required to re- port the disease, in other states the attending physician. Maine was the first state to take legal steps in 1891 to control ophthalmia neonatorum. In 1892 Xew York followed, with an amend- ment to the law relative to midwives and nurses. Subsequently most of the other states took legislative action.^^^ The provisions of the several "^Kerr, J. W., '"Ophthalmia Neonatorum: An Analysis of the Laws and Regnilations Relating Thereto in Force in the United States," Public Health Bull. Xo. Jf9, U. S. P. H. & M. H. S., October, 1911. The Massachusetts law reads as follows: Section 49. . . . Should one or both eyes of an infant become inflamed, swollen and red, and show an unnatural discharge at any time within two weeks after its birth, it shall be the duty of the nurse, relative, or other attendant having charge of such an infant to report in writing within six hours thereafter, to the board of health of a city or toAvn in which the parents of the infant reside, the fact that such inflammation, swelling, and redness of the eyes and unnatural discharge exist. On receipt of such report, or of notice of the same spnptoms given by a physician as provided by the following section, the board of health shall take such immediate action as it may deem neoec- sary in order that blindness may be prevented. Whoever violates the pro- VI.SIOXS OF THIS SECTION SHALL BE PUNISHED BY A FIXE OF XOT MORE THAN OXE HUXDRED DOLLARS. Section 50. ... If a physician knows that ... if one or both eyes of an infant whom or whose mother he is called to visit become inflamed, swollen, and red. and show an unnatural discharge within two weeks after birth of such infant, he shall inmiediately give notice thereof in writing over his own signa- ture to the selectmen or board of health of the to^vn ; axd if he refl'SES or xeg- LECTS TO GIVE SUCH XOTICE. HE SHALL FORFEIT XOT LESS THAX FIFTY XOR irORE THAX TWO HUXDRED DOLLARS FOR EACH OFFEXCE. (Revised Laws. Chapter 75.) 92 DISEASES HAVING SPECIAL PROPHYLAXIS laws are quite varied. In all of them, however, the object is to insure early treatment, and to this end compulsory notification is generally re- quired. The health authorities of many states furnish prophylactic out- fits to physicians. The outfit ordinarily consists of a small vial, protected from the light, containing a 1 per cent, solution of nitrate of silver, a sterilized dropper and bulb, and a circular of instructions. In 3 years following the enforcement of the law of 1911, Massa- chusetts reduced the number of cases of blindness from this cause 50 per cent.; and in 1919 and 1920 no new cases of blindness from gonor- rheal ophthalmia occurred. Good results are also evident in New York and wherever intelligent measures are vigorously carried out. In order to make material progress against ophthalmia neonatorum, as well as against infant mortality, it is essential that laws require prompt report of all births ; it is the duty of the health authorities to see to it that such laws are effectively carried out. TRACHOMA Trachoma is a menace to the intregrity of sight. It is a specific, communicable, destructive inflammation of the conjunctiva, charac- terized by the formation of the so-called trachoma granulations, which may be either papillary or follicular; the ultimate formation of scar tissue; marked chronicity and intractability to all forms of local treat- ment. The disease has been transmitted experimentally in human be- ings and possibly also in apes, but neither the degree nor the nature of its contagiousness is understood. The virus of trachoma is probably frail. Important factors in communicability are poor hygienic surround- ings and lowered resistance from any cause, Avhich accounts for the slow and uncertain manner in which the disease spreads in families. The disease may occasionally be confined to one eye. The filtrability of the virus of trachoma remains undetermined. Experimental evidence permits no more than the suspicion that the virus may be filtrable under some circumstances. In 1907 Prowaczek ^^^ described the so-called inclusion or trachoma bodies. The nature of these bodies and their possible etiologic relation to trachoma still re- main undetermined. Noguchi and Cohen ^^* have reported the suc- cessful cultivation of these inclusion bodies, but since the cultivated bodies proved non-pathogenic the question still remains an open one. Trachoma flourishes best where sanitary conditions are worst; it oc- curs chiefly among the overcrowded, underfed and overworked. The "^ Halberstadter and Prowaczek. Deut. med. Wochnschr., 1907, XXXIII, 1285, Arb. a. d. Tc. Oesundheitsamte, 1907, XXVI, 44. "* "Experiments on Cultivation of So-Called Trachoma Bodies," Jour. Exp. Med., 1913, XVIII, No. 5. TRACHOMA 93 diagnosis rests upon the history and ilu> appearance of the lesions, es- pecially scar tissue, papillary <j:ranu hit ions, trachoma follicles and pan- nus of the cornea. Trachoma presents varying- rliniial aspects, and as there is no cri- terion of the disease, errors in diagnosis arc frequent. It should be differentiated from other infiannnatory conditions of the conjunctiva, especially from follicular cvnjunclirilis. wiiich is benign; from vernal catarrh. Avhich is accompanied by a poiuliar })avement-like appearance and ])ron()uneed subjective symptoms during the first M-arm davs o[ spring; from Parinaud's conjunctivitis, which is an acute febrile disease, with glandular enlargements, and conjunctivitis usually limited to one eye. Impairment of vision can be prevented and often greatly improved by surgery — grattage. Adults who for years have been burdens to them- selves and often charges on the community, and children who have been compelled to remain out of school have been "cured" by surgical methods. Free trachoma hospitals have been established in Kentuck}^ Virginia, "West Virginia, Tennessee, and Xorth Dakota. ^^^ A case cannot be said to be cured until all the conjunctiva of the upper lids has become replaced by smooth, white, avascular, fibrous scar tissue, and the lower lids are free from any evidence of disease. The control of trachoma consists in eliminating the foci of the disease, im- proving personal hygiene, and community sanitation. The disease is slow and insidious in its development; acute or fulminating cases are rare. Impairment of sight is due to involvement of the cornea, especially to scars resulting from recurring corneal ulcers. The infection is rubbed into the eye by roller towels, handkerchiefs, fingers, and other ways. "When once established, the disease is chronic, and permanent cures are doubtful. - Trachoma is much more prevalent in the "United States than is ordi- narily supposed. It is not an exotic disease, but a public health problem of some magnitude in many states. The public eye clinics of Chicago are filled with patients showing the resulting deformities. Wilder located a center in southern Illinois, and it has also been found in the moun- tains of Kentucky and Tennessee, while in Oklahoma this disease has become a public menace. It is more or less prevalent in the poorer sec- tions of all the larger centers. Trachoma is of such a serious nature that all immigrants arriving at our shores have their eyelids everted and conjunctivae examined for evidence of this infection. An alien immigrant arriving with trachoma is deported, and the steamship is liable to a fine of one hundred dollars for bringing every case of trachoma where it can be shown that the disease might have been recognized at the port of departure. ,- i«J. A. M. A., October 23, 1920, p. 1109. 94 DISEASES HAVING SPECIAL PROPHYLAXIS TOXIC AMBLYOPIA Toxic amblyopia^ may be caused by wood alcohol, tobacco, lead, quinin, salicylic acid, male fern, santonin, iodoform, atoxyl (arsenilic acid and derivatives), and also digitalis. Wood alcohol, Columbian spirits, methyl alcohol (CH3OH), causes blindness through atrophy of the optic nerves. As small a quan- tity as a teaspoonful has caused loss of vision. Blindness may even be caused by inhaling the vapor. Quantities as small as 0,2 per cent, in the inspired air may accumulate in the body and cause toxic effects. Wood alcohol is used as an adulterant, especially in liquors and lotions, and also in industry as a solvent. It should be prohibited in any form of material used for internal or external use on the human body. Ample ventilation should be provided in all works where wood alcohol is made or used, as in brewery vats. Containers in which wood alcohol is mar- keted should have suitable display of labels of warning. The very selective effect of wood alcohol is shown by the way it poisons specifically only those fibres of the optic nerve which are con- nected with the macula, lutea in the retina, the seat of direct and most acute vision, other portions of the retina and optic nerve escaping. In severe cases, total atrophy of the fibres occurs. Tobacco. — When tobacco impairs sight, it is always the result of a combination of several circumstances : (1) adult life; (2) absorption of a large quantity of nicotin, either by smoking, chewing or taking snuff to excess, or by prolonged handling of tobacco by workers in the weed ; (3) disturbed digestion which may be an indirect consequence of to- bacco abuse; and (4) too free use of alcohol. Individuals vary greatly in susceptibility. The symptoms are dimness of sight and a loss of color sense in central vision. This is the cause of some marine and railroad accidents. The use of tobacco becomes largely a habit. Few gain the pleasure and solace from it which they crave and expect; on the other hand, to- bacco is in no way a help to health. Under ordinary circumstances, smoking three or four moderately strong cigars a day should suffice as a maximum; at least, this amount is not likely to cause trouble with vision. ACCIDENTS Accidents. — In New York State about 200 industrial accidents resulting in total blindness occur annually. Besides this, there are a large number of accidents occurring on railroads, in construction work, and in the field and forest. Many of the accidents to the eyes occurring in factories are pre- TETANUS 95 venlable through the use of nifchanical guards or goggles. As a rule, the majority of such accidents are due to small flying particles. A material proportion of blindness is caused by accidents to children at play; sometimes the eyeball is torn by a buttonhook, or pierced by a knife or awl; or a scissors blade, used to untie a knot, slips. Some eyes have been injured by the crack of a whip, by a shot from an air-gun or toy pistol. Accidents also occur to the eyes from fireworks, curling tongs, a child's finger scratching the parent's cornea, or a doll's china head broken into the eyes of its tumbling "mother." Many cases of blindness were caused by the gases used in the World War. Ocular Hygiene, see page 91G. COLLATERAL READING National Com. for the Prevention of Blindness, 130 E. 22nd St., N. Y. C. Popular prints. TETANUS (Locl-jaiv) Compared with the major plagues of man, lockjaw has always been a rare disease. It is on account of the characteristic and fatal spasms that it early attracted attention. The student will be well repaid by a study of the historical development of the theories that have been ad- vanced since the time of Hippocrates to explain the cause of tetanus. These theories mirror the prevailing thought upon the nature of dis- ease as it developed from that of evil spirits, through the humoral theory, the realm of miasms and noxious effluvia, to the germ theory. Tetanus could not escape the rheumatism theory which has been such an alluring catchall for symptoms and diseases difficult of explanation. "Taking cold" was assigned its usual role here as elsewhere. When no assignable cause seemed at hand, the disease was given the learned title — idiopathic tetanus. Etiology. — Carle and Eattini,^^^ in 1884, first clearly demonstrated the infectious nature of tetanus by inoculating rabbits subcutaneously with pus from a human case of the disease. In the same year, Xico- laier ^^^ inoculated laboratory animals subcutaneously and saw the tetanus bacillus at the site of injection. In 1889, Kitasato "* for the first time grew the organism in pure culture, and by successful inoculation ex- periments proved that this bacillus was the real cause of tetanus. Kita- sato further showed that the tetanus bacillus is not found in the heart's "° Giornale della T. acad. di Med. di Torino. ^" Deutsch. med. Wchnschr., 1884, No. 52: Inaug. Diss., Gottingen, 1885. ^''Deutsch. med. Wchnschr., 1889, No. 31: Zt.schr. f. Hyg., 1889, VII, 225. 96 DISEASES HAVING SPECIAL PROPHYLAXIS blood of mice dead of tetanus, and therefore concluded that we are deal- ing with an intoxication, and not bacteremia. We now regard tetanus as a type of the true toxemias; that is, the virus remains localized in the wound, and the soluble toxin does the damage. This work of Kita- sato's was one of great importance, and led to the epochmaking dis- covery of Behring and Kitasato ^^^ in the following year (1890) upon tetanus and diphtheria toxins and antitoxins, laying the foundation of serum therapy. Tetanus may be regarded almost solely as a wound complication. All wounds are not equally liable to this complication, even though tetanus spores are present. Punctured, lacerated, and contused wounds are much more susceptible to tetanus than clean-cut or open wounds. The size of the wound is of much less consequence than its character and content. Fatal tetanus may develop from trivial wounds, such as pin scratches, small splinters, insect bites, vaccinations, etc. Necrotic tissue, foreign bodies and other irritants favor the development of tetanus. Symbiosis is an important factor in tetanus. Wounds infected with the gas bacillus, vihrion. septique, pyogenic organisms and other bacteria favor anaerobic conditions and permit the tetanus spores to germinate, and seem to encourage the growth of the bacillus and the development of toxin. ^-° Tetanus spores washed free of toxin and placed in healthy tissues do no harm, but add a trace of gas gangrene toxin, or a chemical irritant as saponin, or a physical irritant such as a foreign body, and tetanus develops. Weinberg ^^^ has shown the multiplicity of anaerobic wound infec- tions, and has also shown how they influence each other. The gas bacil- lus {B. perfringens, also known as B. Welcliii) plays an auxiliary part in the causation of tetanus. The bacillus of malignant edema {vi- brion septique) is also an ally of tetanus. Antitoxins against both these spore-bearing anaerobes have been produced. These antitoxic sera, as in the case of tetanus, have prophylactic value, but feeble curative prop- erties. The experience in the war soon taught the usefulness of em- ploying, for the prevention of tetanus, a serum containing three anti- bodies: (1) against tetanus, (2) against the gas bacillus, and (3) against vibrion septique. These are the commonest but not the only in- fective agents that play a part in stimulating the growth of the tetanus bacillus in wounds. Tulloch ^^^ on the basis of agglutination tests has separated tetanus cultures into four types. Fortunately, any one of the four antitoxins will neutralize any or all of the four toxins. ^' Deutsch. med. Wchnschr., XVI, No. 40, p. 1113. ^^ In the laboratory some of the strongest tetanus toxins have been prepared from mixed or contaminated cultures. '''Ann. de I'lnst. Pasteur, Sept., 1917, XXXI, No. 9, p. 442. '^^ Proc Royal Soc, Series B, April, 1918. TETANUS 97 The normal habitat of tetanus is in the intestinal tract of herbiv- orous animals. Sanchez, Toledo, and Veillon ^-^ found tetanus in the feces of 4 out of (i horses and in the feces of 1 of 3 cows. Turk found tetanus bacilli in the intestines of about 15 per cent, of horses and calves living in the vicinity of Xew York City. They are present to a variable e.xtent in the intestines of man; from 5 per cent, up to 20 per cent, in ostlers and dairymen. It is rather a curious paradox that the horse, which is the most sus- ceptible of all animals to tetanus toxin, is one of the principal hosts of the tetanus bacillus. The intestinal canals of certain animals are per- fect anaerobic incubators for the growth of tetanus bacilli ; such animals may be regarded as "tetanus carriers." Occurrence. — The spores taken in the food are not affected by gastric digestion, and in the intestines find ideal anaerobic conditions, food supply and temperature for growth and development. Here they multi- ply and pass in the dejecta to pollute the soil. The soil, therefore, in all regions inhabited by man and domestic animals is more or less con- taminated with tetanus. The bacilli, however, do not multiply in the soil. While the soil acts only as a vehicle, it is the immediate source of the large proportion of tetanus in man. The presence of tetanus spores in soil, street dust, fresh vegetables and on clothing and the skin may be traced to fecal contamination. On account of the great resistance of the spores, they are blown about in dust and are spread everywhere by dirt and manure. Tetanus has been found in hay dust, on horses' hair, in the dust of houses, barracks, and hospitals, in the mortar of old masonry, in street dust, on food, in gelatin, on the skin, and in the greatest variety of places. One of the agencies in the distribution of tetanus spores over limited areas is undoubtedly the common house fly. The poisoned arrowheads of certain savages in the Xew Hebrides contain tetanus spores obtained by smearing the arrowheads with dirt from crab holes in the swamps (Le Dantic). Tetanus bacilli are not equally numerous in all localities. The in- fection is much more prevalent in warm than in cold countries. It is especially severe in the tropics, yet Iceland at one time suffered severely from tetanus neonatorum. In the United States, tetanus occurs es- pecially in the Atlantic States, and in some parts of Long Island, New Jersey, and the Hudson Valley, which have become noticeable for the number of cases of tetanus complicating small wounds. The soil of Flanders and France has through long cultivation become saturated with the spores of tetanus and other anaerobes. One grain of it from the trenches injected into a laboratory animal invariably produced tetanus. Tetanus spores are widely disseminated in India. Goodrich states that "^La Semaine Med., 1890, X, p. 45. 98 DISEASES HAVING SPECIAL PEOPHYLAXIS in Boiiibay alone there were 1,955 cases of tetanus in five years. These do not include the puerperal cases. Tetanus occurs either sporadically or in epidemic form. Formerly epidemics in hospitals (especially in lying-in hospitals), and in wars were rather common. The conditions of trench warfare in the World War favored wound complications, and included a frightful amount of tetanus until antitoxin was used as a routine prophylactic in all wounds. Before the days of asepsis the infection was often spread through sur- gical instruments, fingers, bandages, etc. The wounds produced by blank cartridges are especially liable to develop tetanus. The source of the tetanus spore in these cases is not entirely clear. Wells examined 200 cartridges from five firms without finding the tetanus bacillus. It is probable that the spore is upon the skin and is carried along with the paper and powder from the blank cartridge. The peculiar character of the wound favors the development of tetanus. The great decrease in the number of cases of tetanus following Fourth of July wounds is due to the vigorous campaign carried on by the American Medical Association. In 1903 there were 406 deaths from tetanus; in 1904, 91; 1905, 87; 1906, 75; 1907, 73; 1908, 76; in 1911 only 18 cases and 10 deaths and so on until 1916 when no deaths occurred from this cause. Eighty per cent, of these followed blank cartridge wounds. The good results are attributed to the more thorough and careful treatment of the wounds and especially the use of tetanus antitoxin as a prophylactic — and more recently to safer and saner methods of celebration. Tetanus spores or toxin may contaminate bacterial vaccines, anti- toxic sera, vaccine virus, and other biologic products used in human therapy. The possible association of tetanus with bacterial vaccines was demonstrated in the unfortunate outbreak at Mulkowal, India, in 1902.^^* One hundred and seven persons were inoculated with Haii- kine's plague prophylactic. Of these 19 were affected with symptoms of tetanus and died. In this case the tetanus probably grew as a con- tamination in the plague culture, for it is now well known that the anaerobic conditions produced in B. diphtheriae, B. pestis, B. suhtilis, and other organisms in liquid culture media favor the growth of tetanus and the development of its toxin. In St. Louis (1901) diphtheria antitoxin was taken from a horse during the period of inculcation of tetanus and used in amounts from 5 to 10 c. c. upon 7 children, all of whom died of tetanus. Bolton, Fisch, and Walden ^-■' found that the serum was sterile, but contained tetanus ^^*Jour. Trop. Med. <md Hyg., 1907, X, p. .3.3. "= Bolton, Fisch, and Walden in .S'f. Louis Medical Review, Vol. XLIV, No. 21, Nov. 23, 1910, p. 361. TETANUS 99 toxin iu considerable amount. If the serum had first been tested upon animals, its poisonous properties would have been discovered. This test is now required by the United States law of July 1, 1902, for all serums and vaccines sold in interstate traffic. As a further precaution against this complication horses undergoing treatment for the production of im- mune sera are given prophylactic doses of tetanus antitoxin from time to time. Tetanus sometimes occurs as a complication of vaccination. See page 22. It is, of course, not the rust on a nail that is dangerous, so far as tetanus is concerned, but the spore-bearing dirt it carries into the deep, contused wound that causes the trouble. Gelatin may contain tetanus spores, and the subcutaneous injection of imperfectly sterilized gelatin as a hemostatic has sometimes resulted in accidents. Tetanus is harmless when taken by the mouth. Susceptible animals •mav be given enormous doses of tetanus toxin by the mouth without producing the disease. The bacillus and its spore may be regarded as a saprophyte in the intestinal tract. There is. however, a suspicion that tetanus spores sometimes invade the organism through small wounds in the digestive or respiratory tract. Perhaps some of the cases following surgical operations may be accounted for in this way rather than by in- fection of the catgut used for ligatures. Tetanus sometimes occurs where no wound can be found. This is the so-called "idiopathic tetanus." One explanation of these cases is to be found in the fact that the spores are numerous in street dust and may enter the respiratory tract. They cannot do harm so long as the mucous membrane is healthy, but may enter through inflamed mem- branes or through small wounds in the nose. Tetanus bacilli have been found in the bronchial mucus of idiopathic cases. Tetanus spores have occasionally been found in the lymph glands, liver, and other parts of the body, upsetting our previous view that they are always strictly confined to the site of the wound. The spores may remain latent or dormant in scar tissue or the sequestrum of bone and may be released and start an attack months or years afterwards, thus giving another plausible explanation of some cases of idiopathic tet- anus. Puerperal tetanus was formerly a frequent and serious complication following childbirth, but has been conquered by asepsis. Trismus Neonatorum, or tetanus of the newborn, is still a common and very fatal infection, especially in the tropics. Before the days of asepsis the infection was permitted to enter through the umbilical wound. In certain of the West Indian islands more than one-half of the mortality among the negro children has been due to this cause. In Venezuela, trismus neonatorum is one of the chief causes of deaths, and goes by the name of mocezuelo. 100 DISEASES HAVING SPECIAL PROPHYLAXIS The following figures are taken from official reports :^-^ Total Deaths Population Total Deaths Deaths from from Tetanus, all Year of in Infantile Forms Except Venezuela Venezuela Tetanus Puerperal Variety 1905 2,598,063 58,100* 3,316 1906 52,949 3,485 1907 52,140 3,713 1908 56,903 4,360 1909 53,364 2,782 3,942 1910 2,685,440 55,436 3,574 4,721 1911 55,428 3,474 4,505 1912 65,729 2824 3,794 1913 52,847 2,743 3,662 1914 51,697 2,816 3,691 1915 2,818.220 63,133 2,804 3,699 Total 617,736 18,201 28,015 * Infantile 1908, inclusive. tetanus not separated from total of tetanus deaths in years 1905- Incubation. — The period of incubation in man is usually from 6 to 14 days. The period is directly proportional to the amount of toxin and the severity of the disease. This can readily be demonstrated upon susceptible animals. In a study of 600 serial tests, Bosenau and Ander- son found this direct relation between the period of incubation and the severity of symptoms by the subcutaneous injection of varying amounts of toxin into guinea pigs. Thus guinea pigs receiving fairly large doses showed symptoms on the third day and usually died; when the dose is smaller, the period of incubation is longer, the disease milder, and the chances of recovery greater. In man, with a short period of incubation, 6 days or less, the disease is almost invariably fatal. With longer periods the disease is usually milder and recovery frequently takes place without the use of antitoxin or other measures. Tetanus toxin is ab- sorbed by the terminal nerve endings, and travels up the axis cylinders of the nerves to the cord and brain. It is also distributed in the blood. The period of incubation, therefore, depends somewhat upon the point of entrance of the poison and its proximity to abundant motor nerve endings. ^^'^ Resistance. — The tetanus hacillus is readily destroyed by the or- dinary agencies that kill vegetative bacteria. It is killed almost at once in contact with the free oxygen of the air. On the other hand, few, if any, forms of life have a greater resistance than the tetanus spore. Hours of exposure to 60° or 70° C. do not affect them. They usually survive an exposure of one hour to 80° C, but, as a rule, are killed in ^^^ Furnished by Surgeon W. J. Stewart, U. S. Public Health Service. '^^ For discussion of tetanus toxin and tetanus antitoxin, see pages 103, 553 and 568. TETANUS 101 streaming steam or boiling water in 60 minutes. Tetanus spores, how- ever, vary greatly in the power to resist the boiling temperature. Kita- sato ^^* found them to resist 80° C. for one hour, but to be killed in streaming steam in 5 minutes. Vaillard and Vincent ^^^ found that the spores heated in the presence of moisture in a closed vessel would re- sist destruction at 80° C. for G hours, at 90° C. for 2 hours, and 100° C. 3 to 4 minutes, that they were not always destroyed in 5 minutes, but never resisted more than 8 minutes at 100° C. Levy and Bruns ^^° found that destruction begins at 8I/2 minutes at 100° C. ; after 15 minutes few survive, after 30 minutes none. Falcioni ^^^ studied the subject in view of the dangers of the subcutaneous injection of gelatin. He impregnated gelatin with spores of tetanus bacilli grown in agar or broth for 10 to 12 days, and used Koch's steam sterilizer. He found the spores to resist destruction for 2^4;- but not for 3, hours in stream- ing steam. The experimental results are, therefore, sufficiently varied and con- flicting to suggest that races of tetanus bacilli exist, the spores of which vary widely in their resistance to moist heat at 100° C. Theobald Smith ^^^ found that under certain conditions of cultivation some tet- anus spores survive a single boiling or streaming steam regularly for 20 minutes, usually for 40 minutes, and occasionally for 60 minutes; in one case 70 minutes' exposure did not destroy the spores. He also showed the possibility of tetanus spores surviving in culture fluids sterilized by discontinuous boiling or steaming in routine laboratory work for fully 20 minutes on three successive days. In general, dry spores are more resistant than moist spores; and young spores are often harder to kill than old spores. Tetanus spores resist the action of 5 per cent, carbolic acid for 10 hours, but are killed in 15 hours. A 5 per cent, solution of carbolic acid, however, to which 0.5 per cent, of hydrochloric acid has been added, destroys them in 2 hours. Bichlorid of mercury, 1-1,000 kills the spores in 3 hours, and in 30 minutes when 0.5 per cent, of hydrochloric acid is added to the solution. According to Park, silver nitrate solution de- stroys the spores of average resistance in 1 minute in 1 per cent, solu- tion, and in about 5 minutes in a 1 to 1,000 solution. Tetanus spores are destroyed u'xtli certainty when exposed to dry heat at or above 160° C. for one hour, or to steam at 120° C. for 20 minutes. Entire con- fidence may he placed upon either of these tiro methods. The temperature recorded on the thermometer of the sterilizer may be higher than the actual temperature within the apparatus. Good ^^Zeiiselir. f. Hijg., VII, p. 225. ^^Ann. de Vlnst. ^Pasteur. 1891. V. p. 1. "^ Grenzgeb. d. Med. u. Chir.. 1902. X. p. 235. ^^ Annali d'igiene sperimentale, 1904. N. S.. XIV, p. 319. ^'Wour. A. il. A., March 21, 1908, Vol. L, pp. 929-934. 10? DISEASES HAVIXCt SPECIAL PROPHYLAXIS sterilizing technic is essential and a factor of safety desirable. The time necessary for penetration must be taken into account. Thus, the gov- ernment regulations ^^^ require an exposure of 170° C. for two hours for dry sterilization of glassware intended to contain biologic products. These same regulations require 121° C. (15 pounds) for 30 minutes for steam sterilization of glassware and rubber tubing. Glassware and rub- ber tubing must be moistened immediately before steam sterilization and each flask or hollow apparatus should contain one-eighth of its volume of water when put in the autoclave. This is for the purpose of insuring that steam will be in contact with all surfaces. In some cases, rubber goods may be sterilized by boiling for 30 minutes in 3 to 5 per cent, phenol or some similar disinfectant. Direct sunlight does not kill the spores, but seems to diminish their virulence. Under certain circumstances they may live a very long time; Henrijean reports that, by means of a splinter of wood 'which once caused tetanus, he was able after 11 years again to cause the disease by inoculating an animal with the infective material. Prophylaxis. — Local Treatment of Wounds. — Thorough surgical treatment of the wound as soon as possible is the first important meas- ure in the prevention of tetanus. Wounds, however insignificant, should be thoroughly cleansed. Punctured or lacerated wounds, in which there is special danger of tetanus, should be freely opened, and every particle of foreign matter carefully removed. Promptness in cleansing the wound surgically is almost as important as thoroughness. Gunshot wounds and wounds containing garden earth, street dust, or other ma- terial liable to contain tetanus spores should receive special considera- tion. All necrotic tissue, or tissue likely to die^ must be removed. The experience of the war demonstrated that thorough excision of the wound (debridement) is good practice. Germicides are useless — the surgeon's knife is the best antiseptic. The division of the umbilical cord and the treatment of the navel in the newborn must be done under the strictest asepsis. Wounds in which there is suspicion of tetanus should be kept open and freely drained, and otherwise treated so as to discourage anaerobic conditions. Tetanus spores gain entrance into wounds not only from manure, garden soil, street dust, and similar sources, but also from the hands, instruments, bandages, suture material, or other objects. It is impor- tant to remember that the tetanus spore is exceedingly resistant to heat and chemical agents, and that in surgical and obstetrical practice con- fidence should not be placed simply upon brief boiling to destroy the spores. A^ery particular care must be exercised in the disinfection of substances injected into the body, such as gelatin and other organic materials. 133 Regulations of the U. S. Public Health Service, Oct. 1, 1919. TETANUS 103 Specific Propliylaxis. — Tetanus antitoxin is a specific and trust- worthy preventive. The great experience of the war adds confirmation to the protective power of this specific and sovereign serum. Its use, however, must he understood to achieve satisfactory results. The anti- toxin must he administered before the advent of symptoms, for after the tetanus toxin has combined with the motor nerve cells in the central nervous system it can neither be displaced nor neutralized with anti- toxin. In such cases the most that the antitoxin can do is to combine with and neutralize the free toxin and thus prevent further damage. From 500 to 1500 units of tetanus antitoxin are used as a prophy- lactic dose.^^* The amount varies with the severity of the wound and the hazard of tetanus. In wounds liable to infection, the injection should be repeated every seven days until the wound is clean, or the danger passed. It is important to remember that the tetanus antitoxin is eliminated or otherwise disposed of in the body in the course of 10 days or 2 weeks. Therefore, in cases in which the wound does not heal Well, as a result of mixed infection, or for other reasons, it is desirable to repeat the injection. This may be done at intervals of 7 or 8 days as long as the danger persists. Occasionally tetanus bacilli persist in the pus-infected tissues, and, when the injected antitoxin has been exhausted, there may occur a late development of tetanus. Instances in which 1,500 units of tetanus antitoxin, repeated if necessary, have failed to prevent the development of tetanus are rare. During the latter part of the war, a triple antitoxin, made from the tetanus bacillus, the gas bacillus ^^^ {B. perfringens) , and the bacillus of malignant edema {vibrion septique), was used as a routine prophylactic, and resulted in preventing much suffering and saving many lives. Gunshot wounds and wounds produced by blank cartridges should always be regarded as suspicious, and should be given careful local treatment, supplemented with a prophylactic injection of antitoxin. Tetanus was a frequent complication of trench foot, and therefore a prophylactic injection of antitoxic serum should be given and repeated at intervals of seven days until the wounds are healed. The prevention of tetanus complication of vaccine wounds con- sists in: (1) The use of a reliable vaccine which has been biologically tested in accordance with the federal act. (2) Proper methods of vac- ^'■'^ As soon as symptoms appear 20.000 units or more of tetanus antitoxin should be introduced directly into the circulation by intravenous injection; some antitoxin may also be injected into the nerves leading from the wound. Xicolle has obtained favorable results with antitoxin, even after symptoms liave devel- oped, by injecting 3 to 5.000 units into the spinal canal, 10.000 units intra- venously, and 10,000 units subcutaneously. {Jour. A. M. A., LXTV. 24. .Tune 12, 191.5, p. 19S2.) In tetanus, as in diphtheria, time is the important element. A few units introduced early are worth more than thousands late. "^ Bull, C. G.. and Pritcliett. I. W. : "''Toxin and Antitoxin of and Protective Inoculation against Bacillus Welchii." Jour. Exp. Med., XXVI, Xo. 1, Julv, 1917, p. 119. 104 DISEASES HAVING SPECIAL PEOPHYLAXIS cination to avoid unnecessary scabs and anaerobic wound conditions. (3) Surgical asepsis of the operation and after-treatment. Tetanus and other wound infections may be avoided, in those ex- posed to accidents, by cleanliness of body and clothing. A bath before a battle is a reasonable protection said to be adopted in the Japanese Army and jSTavy, The common experience of mankind teaches that most wounds heal without tetanus, and that tetanus is, in fact, a relatively rare infection. The physician, however, is in no case Justified in taking chances, and it is one of the duties of the medical profession to teach the public that it pays to thoroughly cleanse and care for wounds, how- ever trivial, at once, and in accordance with modem methods. CHAPTER IT DISEASES SPREAD LARGELY THROUGH THE ALYINE DISCHARGES ' TYPHOID FEVER {Typlius Ahdominalis) Typhoid fever is a sanitan' problem of first magnitude, especially in this country, where it is still unduly prevalent. In the United States typhoid fever for a long time stood fourth on the list of mortality tables : tuberculosis coming first, then pneumonia and cancer; typhoid fever has now been reduced to about ninth place. The average case fatalit}' from typhoid fever being nearly 10 per cent., it would, therefore, take higher rank on the morbidity tables. In 1910 there were 25,000 deaths from typhoid fever in the United States, representing at least 250,000 cases — one person in every 400. Marked improvement began to occur about 1910, and from that time on nearly every year has witnessed a fall in the t}T)hoid death rate. For about 27,000,000 people in 60 cities of the United States, in 1919 it reached the exceedingly low point of 4.2. Our general attitude toward typhoid fever is inconsistent; familiar- ity has bred a remarkable indifference to the disease. Every case of typhoid fever means a short circuit between the alvine discharges of one person and the mouth of another. The physician has a dual duty in the care of a case of t^'phoid fever : one is to assist the patient, the other is to protect the community. On the other hand, the people should learn the lesson that a case of typhoid fever must be regarded as se- riously as a case of cholera. These two diseases present many features in. common. Both are intestinal infections of bacterial nature ; in both diseases the alvine discharges contain the microorganisms which rein- fect another person when taken by the mouth. Both diseases prevail es- pecially in hot weather, and both diseases are peculiar to man, so that the patient is the fountainhead of each infection. Water, food, fingers, flies, contacts and carriers play a similar role in both instances. In the case of cholera the dread of the disease is an important factor in keep- ' The control of this group of infections is one of the most notable achieve- ments in preventive medicine. The cause, mode of transmission, and prevention are well understood in theory and readily attainable in practice. Sanitation here finds its first fruitful field, hygiene its useful lessons, and immunology its special application. 105 106 DISEASES SPREAD BY THE ALVINE DISCHARGES ing it out of the country or in preventing its spread when once intro- duced. By strange contrast, there is a remarkable indifference to ty- phoid fever. A wholesome fear of typhoid fever would materially as- sist the health authorities in combating what may be considered one of the major sanitary problems of the age. From the standpoint of pre- ventive medicine, it is proper to regard an outbreak of typhoid fever as a reproach to the sanitation and civilization of the community in which it occurs. When the matter is better understood health authorities will be held responsible for this and other preventable infections, just as some one is now held responsible for preventable accidents. ^^ Much harm has been done by insisting that typhoid fever is in- fectious, but not contagious; it is both — that is, communicable.^ Typhoid fever occurs both in endemic and epidemic forms. It may truly be regarded as pandemic. iSTormally, typhoid fever is a warm weather disease. It recurs as an annual crop from July to October.^ Epidemics caused by infected water occur especially in cold weather. Milk outbreaks may occur at any time of the year. Autumnal typhoid is due partly to infection contracted at "health" resorts, and has, there- fore, been called a vacation disease. Typhoid fever is more prevalent in rural districts than in cities. In the United States there is more typhoid fever in the southern states than in the northern zone. The only explanation to account for this is the influence of temperature, rural conditions, and association with the negro. Typhoid fever is no respecter of ric4i or poor; it attacks those in robust health, all ages, both sexes. The period of incubation is usually 7 to 23 days, commonly about 10 to 14 days. Typhoid fever is a disease which ordinarily attacks the individual during the period of greatest economic value to the community. The economic loss, therefore, is appalling, and has been estimated to reach the sum of no less than $100,000,000 annually in the United States. Again, typhoid fever is an infection against which the individual alone cannot protect himself wholly without the aid of the community. The control of typhoid fever in modern armies and the marked re- duction in its prevalence in the civilian population in the United States in recent years is one of the great triumphs of preventive medicine. Historical Landmarks. — Typhoid fever was confused for centuries with other continued fevers, such as recurrent fever, septic infections, and typhus fever. The first full description of what was probably typhoid fever was written by Thomas Willis, an English physician, who, in 1643, described an epidemic that occurred in Parliamentary troops. Breton- la See Vennen vs. New Dells Lumber Co., page 1291. ^ For distinction between these terms see page 463. ^In the southern hemisphere the typhoid season is during our winter. TYPHOID FEVET? 107 neau in 1826 further described tho clinical characteristics and called it "dothienentcritis," or abscess of the small intestine, a name it fre- quently bears in French literature. Ix)uis, the distinguished French clinician, in 1820 gave the name typhoid fever to the malady to dis- tinguish it from typhus fever. William Gerard, of Philadelphia, a pupil of Louis, showed the difference in the lesions between these two fevers, which established typhoid fever as a distinct disease. William Budd in 1856 pointed out that the disease is transmitted by the patient's excreta. He stated that: "The living human body, therefore, is the soil in which this specific poison breeds and multiplies; and that most specific of processes which constitutes the fever itself is the process by which the multiplication is effected." The first water- borne outbreak carefully studied and described was at Lausanne, Swit- ^^erland, in 1872 ; the first water-borne outbreak to attract attention in the United States occurred in Plymouth, Pennsylvania, in 1885. In 1873, Murchinson traced an epidemic to a contaminated milk supply. Eberth in 1880 saw the Bacillus typhosus in the tissues, and four years later Gaffky grew it in pure culture. Metchnikoff and Besredka, in 1900, finally established the etiological relation by producing the disease in an- thropoid apes with pure cultures. In 1894, Pfeiffer and Kolle first gave small subcutaneous inoculations of dead typhoid bacilli. x\bout the same time, and independently, A. E. Wright began similar inoculations in British soldiers, but it took something over 10 years to establish the prophylactic value of typhoid vaccines. Prevalence. — Typhoid fever prevails more or less in all countries — the amount of the disease, however, varies greatly. It appears to be a disease of defective civilization, for those communities paying least attention to sanitation, as a rule, suffer most. In the United States there are comparatively few communities of 1,000 inhabitants or more wh-ich, during any period of twelve consecutive months within the last decade, have been entirely free from typhoid fever. According to the United States census report fox 1900, the average typhoid death-rate in the United States was 46.5 per 100,000 inhabitants. In 1917, this was reduced to 13.4. The improvement in the situation within recent years is shown by the following rates per 100,000 of population for the registration areas: 1910 23.5 1911 21.0 1912 16.5 1913 17.9 1914 15.4 1915 12.4 1916 13.3 1917 13.4 108 DISEASES SPREAD BY THE ALVINE DISCHARGES A still greater lowering of the typhoid rates in our large cities is shown in table, page 109. In 1908 the death toll from typhoid fever was no less than 35,000 in the United States. In other words, one person in about 300 in the United States contracted typhoid fever that year. It is estimated that in 1910-11 the number of deaths was reduced to about 25,000. The significance of these figures may be judged by estimating the probable number of cases of typhoid fever among persons handling the milk supply. Take, for instance, a city, as Washington, receiving its milk from a thousand dairy farms. On the average there will be about four persons on each farm who in one way or another come in contact with the milk. That makes 4,000 persons among whom about 20 cases of typhoid may be expected to occur annually. Add to this the carriers, and it is no wonder that milk-borne outbreaks of typhoid fever are fre- quent occurrences. The rate of prevalence of typhoid fever in the United States in com- parison with the rates of many other countries was very high. Thus, the annual death-rate from typhoid fever per 100,000 population for the period 1901-1905 was: in Scotland, 6.2; in Germany, 7.6; in Eng- land and Wales, 11.2; in Belgium, 16.8; in Austria (1901-1904), 19.9; in Hungary, 28.3 ; in Italy, 35.2 ; while the rate in the United States during the same period was about 46.5. A great improvement in the typhoid situation is now taking place in this country — and many states and cities are reporting figures approaching and even bettering the Eu- ropean rates. In 1917, the rate in the registration area of the United States was 13.4, a reduction of 63 per cent, since 1900. In northern Europe the 33 principal cities, with an aggregate pop- ulation of 31,500,000, had an average typhoid death-rate per 100,000 population of 6.5 in 1909 and 1910. This includes such a notorious ty- phoid center as Petrograd, which had a rate of 33.7 in 1910. The high rate in Petrograd was due to the water supply, which is partly filtered and partly raw JSTeva water. A comparison of these rates with typhoid fever in America is given in Table 2, page 109. The typhoid rates in our larger cities are coming down, owing to safer water supplies, better sanitary conditions and the increasing use of typhoid vaccines. In fact the improvement in our typhoid situa- tion is one of the great sanitary reforms now going on. This improve- ment is shown in the table on the following page, which gives the death rates in the large cities of the United States. Eesidual or "Normal" Typhoid. — When a city, such as Albany, Chicago, Lawrence, Lowell, or Pittsburgh, which had been using grossly polluted water, is furnished with a water supply of good sanitary qual- itv, there at once results a marked reduction in the amount of typhoid TYPITOTD FEVER 109 Annual Death Rates from Typhoid Fever per 100.000 Population in 50 Cities of THE United States Having Mque than 100,000 Inhaiutants City 1909 1910 19H 1912 1913 1914 1915 1916 1917 1918 Birmingham, Ala.. Los Angeles. Cal.. . Oakland, Cal San Francisco, Cal . Denver. Colo Bridgeport, Conn.. New Haven. Conn.. Washington, D. C. . Atlanta, Ga Chicago, 111 Indianapolis, Ind.. Louisville. Ky New Orleans. La . . Baltimore. Md Boston. Mass Cambridge. Mass. . Fall River, Mass.. . Lowell. Mass Worcester. Mass . . . Detroit, Mich Grand Rapids. Mich Minneapolis, Minn . St. Paul, Minn.. . . Kansas City, Mo.. . St. Louis, Mo Omaha, Nebr Jersey City. N. J . . Newark. N. J Paterson, N. J. . . . Albany, N. Y Buffalo, N. Y New York. N. Y . . . Rochester, N. Y. . . Syracuse. N. Y . . . . Cincinnati, Ohio .. . Cleveland, Ohio.. . . Columbus. Ohio. .. . Dayton, Ohio Toledo, Ohio Portland. Oregon. . Philadelphia. Penn. Pittsburgh, Penn.. Scranton. Penn. .. . Providence. R. I.. . Memphis, Tenn.. .. Nashville. Tenn. . . . Richmond. Va Seattle. Wash Spokane, Wash .... Milwaukee, Wis. . . . 59.7 16.1 11.2 13.9 24.1 9.0 20.5 34.3 50.0 12.6 22.3 45.0 28.4 24.9 13.8 7.7 21.3 10.5 8.4 20.5 17.2 21.t» 18.9 29.3 16.2 36.8 8.8 11.9 9.7 19.0 23.8 12.1 9.4 11.2 13.3 13.3 19.6 26.9 41.7 22.0 22.3 24.6 16.4 11.4 48.8 52.0 24.1 23.8 43.2 21.4 49.5 14.2 16.5 15.5 27.5 4.9 17.9 23.2 50.1 13.7 28.5 31.7 31.5 42.0 11.3 9.5 15.0 19.7 15.7 23.0 28.3 58.7 19.5 54.4 14.9 86.7 11.5 13.1 7.1 14.0 20.4 11.6 13.7 28.2 8.8 17.9 18.1 21.4 37.2 22.4 17.5 27.8 16.9 17.7 27.4 48.9 21.9 14.2 45.4 45.7 45.5 11.6 14.0 15.3 18.0 3.8 24.9 22.2 66.1 10.9 25.8 23.7 31.0 27.6 8.7 2.8 14.7 7.3 6.0 15.8 26.7 11.9 10.5 29.9 16.1 18.1 7.2 10.5 7.0 18'.8 25.0 10.9 10.6 16.2 11.4 14.2 13.9 18.6 23.1 19.1 14.6 25.6 14.3 12.1 65.4 53.9 17.8 10.3 35.6 19.0 37.3 15.0 13.7 13.6 16.2 8.3 24.4 23.0 41.9 7.4 17.8 21.8 14.0 24.6 8.0 3.7 18.0 10.1 3.3 17.5 33.9 11.7 10.6 12.0 10.7 14.0 7.8 8.1 5.4 17.7 11.8 9.6 11.7 16.7 7.7 6.9 19.6 19.1 31.7 16.6 12.8 13.1 10.3 10.2 58.9 32.8 16.7 7.6 17.4 25.7 36.0 12.1 12.0 16.1 13.5 6.2 12.7 16.4 21.9 10.4 24.4 23.2 16.9 23.8 8.2 9.2 8.9 10.0 5.6 29.4 18.2 12.0 9.1 21.9 16.9 7.6 10.8 8.7 8.3 27.4 15.4 7.0 8.9 13.0 6.8 14.1 19.1 18.0 41.6 6.5 15.7 19.5 9.4 11.2 34.2 36.9 20.3 4.7 7.0 11.3 39.7 7.7 6.6 12.7 9.0 3.5 15.2 11.9 46.3 6.6 25.8 25.9 21.9 22.6 9.0 1.8 9.6 10.8 3.8 14.1 27.6 12.5 11.0 16.3 12.0 4.5 7.5 7.5 4.5 17.5 16.3 6.3 10.2 10.0 6.2 8.1 13.2 11.3 36.9 6.9 7.6 15.0 9.2 11.0 42.6 51.3 14.8 7.0 12.5 8.1 36.2 5.7 6.8 9.0 6.3 5.1 19.7 12.0 15.7 5.3 14.3 13.9 20.5 20.7 5.2 1.8 15.0 16.1 5.6 13.5 27.8 7.6 7.0 9.7 6.8 6.1 5.7 2.8 4.4 12.6 10.0 6.0 6.0 5.9 7.4 7.9 13.4 17.5 22.9 5.1 6.8 10.3 12.5 8.0 26.7 37.1 12.3 2.4 9.8 5.1 43.5 2.6 4.0 3.5 7.3 9.0 8.7 12.9 22.0 5.2 26.1 13.4 23.1 18.1 3.4 1.8 10.9 11.5 3.7 14.7 16.4 5.5 5.7 11.4 9.4 3.0 7.2 6.1 4.3 7.5 10.9 3.9 5.0 12.2 3.2 5.3 13.0 19.7 22.2 4.7 7.6 9.0 6.1 5.1 36.3 29.9 23.6 3.2 2.0 15.3 53.8 5.8 2.4 4.7 5.2 8.0 10.5 13.3 20.9 1.9 10.9 15.4 23.3 15.6 3.0 4.4 16.9 6.1 6.0 17.8 12.8 6.4 2.4 12.1 8.2 4.5 3.5 4.1 12.1 12.2 10.1 3.9 3.0 6.3 3.9 7.7 7.7 14.7 8.9 5.5 6.3 11.9 6.0 6.2 25.0 22.9 6.9 4.9 7.6 6.1 31.9 2.8 4.7 4.6 8.7 3.9 5.2 11.9 14.4 1.4 6.6 12.4 20.1 12.2 2.5 2.7 7.0 1.8 4.6 16.0 10.3 7.6 3.5 13.7 7.2 5.0 4.1 3.5 2.1 10.7 7.8 3.7 1.9 9.3 4.1 4.7 8.9 6.9 9.9 5.6 3.0 9.8 5.2 4.5 14.9 32.7 65.3 2.3 9.1 6.2 Official figures kindly furnished by Richard C. Lappin, Chief Statistician, Division of Vital Statistics, Bureau of the Census, U. S. Dept. of Commerce. fever. The curve is not only lowered, but it is also changed in char- acter. The remaining typhoid after the water-borne infection has been removed is known as residual typhoid, and the curve in such cases is spoken of as the "normal" typhoid curve. The normal curve shows a distinct summer prevalence recurring with marked uniformit}' each year, and lacks the great irregularities which characterize the curve of a com- munity drinking badly infected water. ISTormal typhoid is endemic ty- phoid; Sedgwick has proposed the name "prosodemic" {proso, through, and demos, the people) as more expressive of this type of the disease. The amount of residual typhoid varies markedly in different localities; thus, it is twice as high in the southern as in the northern part of our countr5\ Eesidual typhoid should not exceed 5 deaths per 100,000 pop- 110 DISEASES SPREAD BY THE ALVTNE DISCHARGES ulation. It is due to^carriers, milk, other food, contacts, flies, etc., and may be controlled by sanitary housecleaning. Channels of Entrance and Exit. — The typhoid bacillus probably al- ways enters by the mouth. Typhoid fever is generally regarded as primarily a gastro-intestinal infection, although the disease itself is not produced unless the blood, glands, and other structures of the body are invaded v/ith the specific microorganism. The disease is now regarded as primarily a blood infection or bacteremia. The typhoid bacillus grows and multiplies in the intestinal tract, penetrates the mu- cosa, and thus invades the body. The bacilli leave the body mainly in the feces and urine, occasionally in the sputum and other discharges. Typhoid bacilli appear in the feces early in the disease; sometimes be- fore the fever. Later in the disease they diminish in number and usu- ally disappear during convalescence, although they may continue indefi- nitely (see Bacillus Carriers) . The feces may contain only a few typhoid bacilli; usually they are present in considerable numbers; occasionally practically replacing the colon bacillus. Typhoid bacilli commonly appear in the urine about the second, third, or fourth week. They grow well in this fluid both within and without the body, and may be present in such enormous numbers that the urine resembles a 24-hour-old bouillon culture. From the standpoint of prevention, it is very important not to neglect the virus in the nrine. Hexamethylenamin in ten-grain doses or more, three times a day, di- minishes the frequency of typhoid bacilluria. This drug is eliminated as formaldehyd, provided the urine is acid, and is therefore not effective in an alkaline urine. The sputum ordinarily does not contain the bacilli unless there is a pneumonia or severe bronchitis. Gould and Quales, and also Purjesz and Perl,* have found typhoid bacilli in about 50 per cent, of the cases by rubbing the gums, tonsils, and tongue of patients suffering with ty- phoid fever. The microorganisms from the mouth were found as late as the fourth to eighth week of convalescence. These findings are im- portant from the standpoint of diagnosis and prevention. The bacilli may be eliminated with the discharges from suppurating middle ears ; from abscesses, such as periostitis, months and even years after the disease. Diagnosis. — An early diagnosis of typhoid fever is essential for the successful treatment of the patient, and is of vital importance in. con- trolling the spread of the infection. Early diagnosis can only be assured through laboratory methods. Typhoid bacilli may be readily isolated from the blood, the feces, or the urine. Blood Cultures. — Probably the easiest method, as well as the one giving the maximum information, is through blood cultures. The tak- ing of a little blood for this purpose is no more difficult or annoying *Wien. klin. Woch., 1912, XXV, 1494. TVriloll) Kl-'.VKK 111 to the patient than s\\al)l)in^f the Ihitiat I'nr diplilhcria. A few drops of blood may be obUiined by puneturini^ the lobe of tiie ear or the finger, with the \isual iireiaiitions to prevent bacterial contaniination. A much better method, however, consists in withdrawing 5 to lU e. c. of blood by means of a syringe from (inc of the veins at the bend of the elbow. The technic is very simple, and, if the needle is sharp, the patient scarcely feels the puncture. The blood may be planted in bouillon, or in bile. After 24 hours in the incul)ator, any growth that occurs is trans- planted to Endo's medium, colonics isolated, and tested for agglutina- tion. Often a pure culture is ol)taincd in the first medium, so that the diagnosis may l)c. established in 21 hours — at most, in 2 or 3 days. Typhoid iKuilli ai)pcar in tlie blood early in the disease, perhaps occasionally during the prodromal symptoms. Kayscr obtained positive results from 90 per cent, in the first week, ()5 per cent, in the second, 42 per cent, in the third, 35 per cent, in the fourth. Our results in AVashington were approximately the same. The typhoid bacilli prob- ably do not grow in the blood during life. Their presence in the blood stream represents an overflow from the spleen and lymphatic tissues. The presence of typhoid bacilli in the blood may be taken to mean ty- phoid fever. The same cannot always be said if they are found in the feces or urine. The Feces. — From the feces or urine typhoid Ijacilli are best iso- lated upon Endo's medium.'^ This consists of a 4 per cent, alkaline agar containing fuchsin, which has been decolorized with sodium sulphite. Upon the surface of this medium typhoid colonies appear in 24 hours as translucent, dewdrop-like colonies, whereas colon bacilli and other organisms that produce acid and split the fuchsin appear as red colonies. Suspicious colonies are fished and may be tested at once under the micro- scope for agglutination, or may be planted in bouillon to obtain a growth sufficient for macroscopic agglutination tests. In an}' critical case pure cultures should be obtained and studied for morphological, cultural, and other biological characters. The specimen of feces may be preserved hours or days by placing it in glycerin, ® one part of feces to 2 parts of 30 per cent, glycerin. This percentage of glycerin has the further advantage of keeping down B. coli and other associated bacteria. Technic. — Mal^e plain, nutrient, sugar-free agar as follows : Tap water (cold), one thousand cubic centimeters; powdered agar, fifteen grams; peptone ' (Witte), ten grams; meat extract (Liebig), three grams. Cook in double boiler one hour. Make the reaction just al- kaline to litmus by the cautious addition of XaOH. Cook fifteen min- utes to set the reaction, and then filter through absorbent cotton. 'Otlior useful media are: Drigalski-Cunradi, Kruiiiwiede or Russell's dou- ble sugar. "Teague and Clurman: Jour. Inf. Dis., XVIII, 6, June, 1916, p. 653. 113 DISEASES SPEEAD BY THE ALVINE DISCHAEGES The tap water should be as cold as possible and the agar should be "dusted" on the surface and allowed to settle into the medium before heat is applied and before the other ingredients are added. After filtration, the medium is stored in flasks containing known amounts, conveniently in one hundred-cubic-centimeter lots, and steri- lized in the autoclave. To use the medium: (a) Prepare a ten per cent, solution of fuch- sin in ninety-six per cent, alcohol, (b) Prepare a ten per cent, solu- tion of sodium sulphite in water. Add one cubic centimeter of (a) to ten cubic centimeters of (b) and heat in the Arnold sterilizer for twenty minutes = (c). Add one per cent, of lactose (which must be chemically pure) to the agar medium described above, and heat in the Arnold sterilizer until the medium is melted and the lactose thoroughly distributed in it. The decolorized fuchsin solution (c) is then added in the pro- portion of one cubic centimeter of the mixture to each one hundred cubic centimeters of medium; then thoroughly mixed. Plates are then poured and allowed to harden (with the covers re- moved) in the incubator for thirty minutes, after which time they are ready for inoculation. Preparation of Feces for Inoculation. — The feces are collected pref- erably in the small rectal tubes described by Kendall.'^ A small por- tion of feces (about a loopful) is thoroughly emulsified in ten cubic centimeters of sugar-free broth, and preferably incubated one hour at 37° C. prior "to the inoculation of the plates. This preliminary incu- bation does two things: the clumps of bacteria settle down, leaving a more uniform suspension of bacteria in the supernatant fluid for inocu- lation, and these bacteria undergo a slight development in a medium particularly suited for their growth. The thin suspension of the stool is noAV rubbed upon the surface of the agar plates by means of a bent, sterile, glass rod, and the plates incubated for 18 hours at 37° C. The suspicious translucent, colorless colonies are removed entire to small test tubes containing one cubic centimeter of broth and incubated for two hours at 37° C. At the end of this time there will be sufficient growth to make the customary microscopic agglutination tests. Con- firmatory cultural characters may be obtained by inoculating suitable media from the same tubes as those from which the organisms for agglu- tination were obtained. Physicians should encourage boards of health to furnish diagnostic aids of a laboratory nature. Such work should be in the hands of specialists rather than entrusted to those who make occasional anal- yses. Early and accurate diagnosis is just as important to prevent the ''Boston Med. and Surg. Jour., CLXIV, No. 1, Sept., 1911. TYPHOID FEVER 113 spread of other communicable diseases as it is with tyj>hui(l. Those facts emphasized here will not be repeated uiidcu- each disease. Bacillus Carriers.''* — About 33 per cent, of cases continue to discliarf^^e typhoid bacilli for three weeks after the onset of tlio disease, and about 11 per cent, for 8 to 10 weeks; these are known as coHvaJcscnil carriers. From 2 to 4 per cent, of all cases continno to discharji^e typlidid bacilli indefinitely; these are chronic or permanent carriers. '^ry])lioid bacilli are found in the stools of some ]iersons witliout a clinical history of hav- ing had the disease; these are pnssirr. carriers, also called healthy or normal carriers. Albert states that 25 per cent, of all chronic ty])hoid carriers have never had typhoid fever, and further estiniales tliat 1 in every 1,000 of the i^eneral population is a carrier. In our \Vashin,<^ton studies,® Ave found 0.3 per cent, of the population in 1!)0S to l)e tem- porary passive carriers. At the Strassburg Station (li)03-5) Klinger reported 11 or O.Gl per cent, of 1,700 healthy individuals to be temporary passive carriers, and 12 to be permanent carriers. In my laboratory at Harvard, specimens from over 2,000 healthy persons were examined in 1917, with only one typhoid carrier — a man who had the disease several years before. The per cent of carriers naturally varies with time, place, personnel, and prevalence of typhoid fever, Woinen outnumber men as carriers about 4 to 1, About 80 per cent, of all chronic carriers and about 60 per cent, of temporary carriers are females. Women are more subject to inflammation of the gall-bladder and to gall stones, and it is now well understood that typhoid bacilli localize and maintain themselves in the gall-bladder and bile ducts. The gall-bladder is the source of the fecal typhoid bacilli found in carriers. Children are less subject to gall-bladder disease, and therefore seldom become carriers. The significance of these facts is of importance in looking for carriers, special attention being given to women who have or have had symptoms, however slight, in connection with the gall- bladder or liver. The remarkable tendency of women to become car- riers is particularly hazardous when we bear in mind their intimate asso- ciation with the handling and preparation of food. Typhoid carriers are either fecal or urinari/, or both; the former is more frequent than the latter, and apparently also more dangerous ; that is, most outbreaks of typhoid fever traced to carriers turn out to be indi- viduals who discharge typhoid bacilli in the feces rather than in the urine. It seems that some carriers are more dangerous than others. This is due partly to personal habits, partly to opportunity to infect food and drink, and partly to the virulence of the organism. Further, carriers are quite irregular in the elimination of typhoid bacilli. See also pages 401-2. Rosenau, Lumsden and Kastle: Uyff. Lah. Bull., "No. 52, U. S. Public Health Service, p. 124. S T?^ 114 DISEASES SPREAD BY THE ALA^IXE DISCHAEGES Typhoid carriers in dairies have been responsible for many outbreaks. A carrier employed as a cook, waiter, nurse, or in a dairy is a special menace. A very large percentage (from 5 to -±U per cent.) of cases of typhoid fever have been traced to carriers. Carriers have a greater opportunity to spread the infection than bed-ridden cases. The amount of harm which a single individual can cause is amazing. The story of "Typhoid Maet" was the first of its kind to be re- ported ^ in America, and has become a classic. ]\Iary Mallon was a cook in a family for three years, and in 1901 she developed typhoid fever. About the same time a visitor to the family had the disease. One month later the laundress in this family was taken ill. In 1902, Mary obtained a new place, and two weeks after her arrival the laundress was taken ill with typhoid fever. In a Aveek, a second case developed, and soon seven members of the household were si.ck. In 1904, the cook went to a home on Long Island. There were four in the family, besides seven servants. Within three weeks after her arrival, four servants were attacked. In 1906 Mary went to another family, and six of the eleven mem- bers of this family were attacked with typhoid between August 27th and September 3rd. At this time, the cook was first suspected. She entered another family on September 21st, and on October 5th the laundress developed typhoid fever. In 1907, she entered a home in Xew York City and two months after her arrival two eases developed, one of which proved fatal. During these five years, "Typhoid Mary" is kno\\Ti to have been the cause of twenty-six cases of typhoid fever. She was virtually a prisoner by the Xew York Department of Health in a hospital from March 19, 1917. Cultures taken every few days showed bacilli on and off for three years. Sometimes the stools contained enormous numbers of typhoid bacilli, and again for days none could be foimd. "Typhoid Mary" then escaped from observation until 1914. In Oc- tober of that year, she was engaged as cook in the Sloane Hospital for "Women in Xew York. In January and February of 1915, an outbreak of typhoid occurred, principally among the doctors, nurses and help of the institution, involving twenty-five cases. The cook was suspected, but she left the premises on a few hours' leave, and did not return or leave her address. She was, however, located by the Health Department under an assumed name, and an investigation established her identity as the famous "Typhoid Mary." A subsequent study of her career showed that she had infected still other individuals beyond those already mentioned, and that she ma\ V. A. M. A., June 1.5, 1907, XLVIII, p. 2019. Military Surgeon, July, 1910, — a review of the facts by Geo. A. Soper. TYPHOID FEVER 115 have given rise to the avcU known water-borne outbreak of typhoid in Itliaca, Xew York, in 1903, involving over 1,300 cases (see page 11T7). The fact is that a person by the name of Mary Mallon had been em- ployed as a cook in the vicinity of the place where the fir.<t case appeared, and from which contamination of the water supply occurred. Sawyer ^° reports a very instructive history of a typhoid carrier (H. 0.) responsible for several outbreaks. The carrier was carefully stud- ied over a period of several years, during which time he infected thirty persons, five of whom died. Frequent examinations of feces of this car- rier gave negative results for four months after he had been treated witli autogenous typhoid vaccines; nevertheless, he infected three persons Avhen suljsequently released from quarantine on parole. The removal of the gall-bladder failed to cure II. 0., for typhoid bacilli were found in the feces several times after the operation. It is particularly noteworthy that 41 successive examinations of feces during a period of fourteen months all proved negative, yet the typhoid bacillus was finally isolated from the stomach contents containing bile. This carrier, on account of the virulence of the organism, or careless personal habits, is unusually dangerous and represents a class that should be controlled by quarantine or close supervision. He further illustrates the saying "once a carrier, always a carrier,^' which seems to be true of chronic typhoid carriers. Another instructive outbreak caused by a carrier is reported by Sawyer ^^ in which 93 cases of tA'phoid fever occurred in Hanford, Cal., as a result of infected food served at a public dinner. The vehicle of infection was a large pan of spaghetti prepared by a carrier. This dish was baked after it had been infected, but this baking was shown by laboratory experiments to have incubated the bacteria instead of disin- fecting the food. The Widal reaction is present in the blood of about 60 to 75 per cent, of typhoid bacillus carriers. It is, therefore, of value as a pre- liminary test in the epidemiological search for carriers. In blood test- ing for this purpose dilutions of 1 :50 and 1 :25, and even a titer of 1 :10, may be used. The test should be made with both B. typhosus and. B. paraiyphosus a and p. The bacilli should then be searched for in the urine and feces of those giving a positive reaction. It should be remem- bered that about 90 per cent, of persons immunized with typhoid vac- cine will give a positive agglutination reaction, and that on the other hand it may be very weak in a carrier. The question of preventing the spread of the disease through bacil- lus carriers is important and difncult. Surgical methods fail to cure carriers, for the typhoid bacillus may continue to grow in the bile ducts after removal of the gall-bladder, and perhaps also in the small intes- ^Jour. A. M. A., June 19, 1915, LXR', 25. p. 2051. "^Jour. A. M. A., Oct. 31, 1914, LXIII, IS, p. 1537. 116 DISEASES SPBEAD BY THE ALVINE DISCHAEGES tine. Nichols^ Simmons and Stimmel ^^ believe that the so-called uri- nary typhoid carriers are really kidney carriers, and can be cured by nephrectomy; that intestinal carriers are really bile passage carriers of two kinds: (a) cases in which the gall-bladder alone is infected and which can be cured by cholecystectomy, and (b) cases in which gall-bladder and bile passages are both infected, and which cannot be cured by surgical measures. Medical measures, such as hexamethylenamin, are efficient for bacil- luria, but are of no avail in the fecal carriers. Attempts have been made to relieve the condition by the use of bacterial vaccines. Petruschky ^^ and also Header have reported encouraging results, especially with the use of autogenous cultures. Hektoen suggests the use of kaolin, which acts by adsorption. Most cases resist all attempts to relieve the condi- tion. It is unnecessary to place bacillus carriers incommunicado. It is sufficient to restrict their activities so that they cannot infect food or their surroundings. With proper care and cleanliness typhoid carriers may present little danger to their fellow men. This, however, requires intelligence and conscientiousness. The problem, at present, is to detect the carriers, so as to establish a sanitary isola- tion, if not an actual quarantine. See Eecognition of Carriers, page 111. A chronic carrier should never be allowed to handle or prepare food, even though a number of consecutive examinations prove negative. The intermittent and irregular character of the carrying state should be borne in mind. Gregg reports a carrier who had typhoid fever 53 years before, and Bolduan and Noble one of 46 years standing, who then caused a large milk-borne outbreak. Compulsory control of irrespon- sible carriers is essential. The prevention and. cure of the carrying state is one of the practical and rewardful problems for research. Resistance of the "Virus. — The typhoid bacillus has no spore. It is, therefore, comparatively easy to destroy. The only difficulty present- ing itself is getting at the bacillus when imbedded in fecal masses. When dry, most typhoid bacilli die in a few hours; occasionally a few survive for months. The fact that typhoid bacilli are killed by drjdng renders infection through dust unlikely. When a moist medium, such as water, milk, or urine, is heated to 60° C, practically all the typhoid bacilli such a medium may contain are killed. An exposure at 60° C. for 20 minutes will surely kill all of these microorganisms. They are not destroyed by freezing. See Eela- tion to Ice, page 1184 et seq. In their resistance to germicides typhoid bacilli behave like the aver- age non-spore-bearing bacilli. Thus, bichlorid of mercury, 1-1,000; ^^Jour. A. M. A., Aug. 30, 1910, Vol. LXXTIT. No. 9, p. 680. "Dettt. med. Woclischr., July 11, 1912, XXXVIII, 28. TYrHOID FEVER 117 phenol 21A per cent; formalin, 10 \)vr cent, are effective upon the naked germs. In order to kill the typhoid bacilli in feces special pre- cautions or stronger solutions are necessary (see page 143'2). The viability of typhoid bacilli in feces is very variable, depending on the composition of the feces and tlio varieties of other bacteria present. Sometimes the typhoid bacilli in feces perish in a few hours, often in a day; under certain circumstances they may live for much longer periods. In the Plymouth epidemic typhoid bacilli prob- ably remained alive and virulent in the feces, exposed to the winter's cold, for several months. Levy and Kayser found that they remained alive in feces for 5 months in the Avintcr. The life of the organism in privies and in water is usually comparatively short. In nature they seldom if ever live in water beyond 7 days, and are often dead in 48 hours. They probably live longer in clean water than in contaminated water. In the outer world antibiosis plays an important part, also the presence of deleterious chemicals, temperature, light, desiccation, sun- light, and other factors known to be injurious to spore-free bacteria. As a rule, the typhoid bacillus does not survive long in the soil under the usual conditions. Typhoid Bacillus in Nature. — The typhoid bacillus should be re- garded as a pathogen, not as a saprophyte. It lives and grows prin- cipally in the human body. It has a tendency to die in water, air, soil, upon fomites, or in nature generally. The grand exception to this statement is in the case of milk, in which the typhoid bacillus grows well. The typhoid bacillus may live 12 days in crude sewage (Firth) ; 1-i days in a septic tank (Pickard) ; 4 months in butter (Bailey and Field) ; 5 days in home-made cheese (Heim) ; 12 days in pot cheese (Lemke) ; 39 days in ice cream (Mitchell). It is destroyed in 24 hours in ■milk, butter-milk, whey or butter having an acidity of 0.3 to 0.4 per cent. Krumwiede and ISToble found that with a moderate con- tamination, typhoid bacilli are killed in sour cream in about four days. In endemic centers the typhoid bacillus is much more widely dis- tributed in man than the cases indicate. Thus, in the District of Columbia, of 1,000 healthy persons examined during the typhoid season of 1908, typhoid bacilli were found in the feces in 3 instances." At least one and perhaps two of these individuals were regarded as tem- porary carriers. In each instance the organisms were found only once. The population of the District of Columbia in 1908 was 300,000, and at the ratio of 1 per 1,000 this would represent about 300 healthy persons in that community harboring and shedding typhoid bacilli for a brief period of time during the typhoid season. "Roscnau, Lumsdeii and Kastle: I^i/ff- Lab. Bull., No. 52, U. S. P. H. S. 118 DISEASES SPREAD BY THE ALVINE DISCHARGES MODES OF SPREAD Typhoid fever is spread from cases and carriers both by direct or indirect contact — indirect through water, milk, milk-products, oysters, and other foods; also flies, fingers, and fomites. Each of these modes of spread needs separate consideration. Man is the source of the infection, and the disease must be fought in the light of an infection spread directly and indirectly from man to man. Water. — Water-borne typhoid is a common occurrence. Not long ago it was regarded as the sole or usual mode of spread; now we know that this was a mistake. Most fecal matter ultimately finds its way to water; most water courses draining inhabited regions are contam- inated with human feces. Surface water is, therefore, apt to contain typhoid bacilli. The f-act that there may be no clinical case of typhoid fever in the drainage area is no guarantee that the water may not be infected — in view of the prevalence of missed cases and bacillus carriers. Fortunately, typhoid bacilli do not grow and multiply in Avater under natural conditions. They usually die in a few days, and rarely persist longer than 7 days. They succumb more quickly in some waters than others, more quickly in summer than winter. Euediger ^^ has shown, that typhoid bacilli disappear much more rapidly from polluted water during the summer months than during the winter months when the river is protected with a covering of ice and snow. Water plays a large but diminishing role in the spread of typhoid fever. The great water-borne epidemics have overshadowed the other modes of communication. We know that the larger part of the typhoid now prevalent in this country is not water-borne; Whipple in 1908 estimated it at 35 per cent.; it is now certainly much less. Typhoid fever may be excessively prevalent, even epidemic, in a city having a water supply of good sanitary quality. In the vast majority of cases water-borne typhoid is contracted from a surface supply, that is, a river, small stream, pond, or lake. Ground water becomes a source of danger only under special conditions, espe- cially in limestone regions. See chapter on Water. Water-borne epidemics present certain definite characteristics. They almost always occur in the spring, fall, or winter, when the water is cold. Most of the great water-borne epidemics have occurred in northern cities, both in this country and in Europe. They usually have a sharp onset, the curve rises to a peak, and declines rapidly. The pollution is usually nearby; that is, there is a rather direct trans- fer of fresh virulent infection. Granting that the typhoid bacillus does « Jotw. Am. Pub. Health Assn., June, 1911, Vol. I, No. 16, p. 411. TYPHOID FKVEn, 1902 TO lOlC (Doixth Rate per 100,000 of Population) ciTy Richmond boToujh.K.y. 2u«nstx)rouflh.Y.K. Cam6fli.X.J. iQiii^((,Mas5. Uncotn;t(t>r. Dayton. Ohio Mfmphfe.Ttnn Sourtj33«n6,ln6. 5anAnfomo.Taa3 ^duannfllt.fifl Nfiul-on.flass. Mcu) Orleans, La. Covington .xy. Richmond.Ua. LouisuUU,Kij. AHantfl,6fl S<attk.Wash. Euansuilk.lni. Springncli.lU. Gran6HapiAi5,Wic(i. Wllminaron. Del. Lancasftr.Pa. Mauist'ura.Pa. ii)ti«linfl ]}) \h\. flinnwpolis.Mino. ToU^o.Ohio Cincinnati. Ohio Ph»la6c(phia,Pa. AUwheny.Pa. Pi^^sburd Pa RochcsKrA'.y. Suracusf.ar.y. Fall R\v<r,<na35. Brockron.Mass. Taunton.Mass. Hav<rhUl,tiass. PorHan6,01e. Sfll^m,Mns5i MllwauKfe Wis. t)etroit,Mich. Chicago. 111. Buffalo.X.a. iTit.Pa. CUuclani.OJiio PulLith Minn Tucnburg.rtass. camtridgf , i^ass. Somcrviut .i:\as5. Worcester, tlass. BTi6flcport,Cc»nn. Marfford.Conn. ftal6cn.Mas5. Boston. eaas3. cndsea.Wass. litM) Bc6for6,Mass. •Vi)at<rbury,(!Qnn Scranton.Pa. Porllan6,Orcg. JohnstoiDn.Pa. AUoona.Pa. saltlaKcCUu.litaii KolyoKc.^lass, Bronx Porough.dt.y. ManhaUan forough.ar.Vi, PawtucKet.R.l. ^f«lyarK.^\c.J. J<rstuCUy,Jf.3. BflUi'morf.«6 St.Paut.Minn. danton.Ohio BrooKlun PoTOUjfi.A'.y. Oolumpus.otiio WcKtcsport.Pa HE N0HKi3 rETKRS CO., WASMtNCT< Fig. 11. — Influence of Public Water Supplies on the Typhoid Feveb Death Rate (Diagram prepared by Marshall 0. Leighton, U. S. Geological Survey, from figures furnished by Dr. Cressy L. Wilbur, Chief Statistician of Vital Sta- tistics, Bureau of tlie Census — from Kober.) 119 120 DISEASES SPREAD BY THE ALVINE DISCHAEGES not grow in cold water, there must have heen a very considerahle dilu- tion in most of the epidemics. The follovring examples are given of the fact that "water-borne outbreaks of t}'phoid fever occur during the winter, fall, or early- spring, when the water is cold. Thus we have the water-borne epidemic in Plymouth, Penn., in 1SS5, which began with the spring thaw and doubtless came from the frozen accumulation of t3T3hoid excrement from a single case. Yery similar to the Plymouth outbreak was that at New Haven, Conn., in 1901. The outbreak at Ithaca, X. Y., started in epidemic proportions in January. The epidemic in Sherboume, Eng- land, in 1873, likewise started in January. Four acute epidemic exacer- bations are recorded in Philadelphia in December of the years 1884, 1890, 1899, and 1903. Several similar epidemics have occurred: in the Avinter time in Chicago — one in January, 1890, another in January, 1896, and one in March, 1891. Another striking instance Is the epi- demic in JSTewark, IST. J., in February, 1899, and one in December, 1891. Abroad, epidemics are recorded in Berlin in Februar}', 1899, in Paris in February, 1894, and in Yienna in Xovember, 1888. All af thjese are generally believed to have been water-borne 'and must have taken place when the water was very cold. In fact, as previously pointed out, ex- tensive water-borne epidemics of typhoid fever rarely occur in the sum- mer time. i1~t~ It was formerly thought that a high typhoid rate necessarily meant badly infected water. "We know now that this does not necessarily fol- low, as has been proved by the experiences in Washington, Winnipeg, army camps, and many southern cities. Almost all the water-borne epidemics of typhoid fever rest upon cir- cumstantial evidence. It is difficult to isolate the typhoid bacillus from water, and the damage is usually done before suspicion points to the water.^^ It is clear that in cities which have had safe water supplies for a period of years the typhoid death rate (residual typhoid) should not be above 5 per 100,000, unless some unusual conditions exist, such as poor control of railk, or lack of control over patients and carriers, and disregard of modern sanitary knowledge. Ko single measure in reducing typhoid fever on a large scale ap- proaches the effect of substituting a safe for a polluted water supply. As an instance of this wholesale saving of human life, the reduction of typhoid fever in four American cities is shown in Fig. 13. Ice. — Ice may, under exceptional circumstances, occasionally be the vehicle by Avhieh typhoid bacilli are transferred. Freezing does not kill B. typhosus, but there is a great quantitative reduction not only in the ^* Examples of water-borne outbreaks of typhoid fever will be found in the chapter on Water. TYPHOID FE\KI{ 121 act of freezing, hut during storage; hence the danger is greatly lessened. The only suggestive outbreak of typhoid fever attributed to ice was reported by ITutchins and Wheeler in 1903 in the St. Lawrence Hospital, three miles below Ogdensburg. A few other instances in which ice is believed to have conveyed the infection have been reported, but are based upon flimsy evidence. The fact that natural ice is usually stored many weeks or months before it is used is a sanitary safeguard. Manufactured P/TTSBURGH, ?t\. - -Typh 01 D Fever. D£ATH MTE PCK 100.000 /900 TO 1910. 1900 /<joi iqoi 1903 iqott 190s /<^ob '9oy /for 1909 /9/0 /<«» \ X ^..■ /,7(7 \ I i r ^,^ \ \ ?7 r no V \ ii >< NO \/ t- 1 ii 5 1 i S » lao n •u ^ 1 90 ^ 1 •> «0 to •tie << 0^ ro ^ ii io r ^ ^ so 1 *o 1 • V »0 N V lo V ^ (0 0 Fig. 12. — IMMEDIATE AND Steikixg Effect of Purifying a Badly Infected Wateb Supply upon the Typhoid Situation. ice made from distilled water and handled with cleanly methods is above reproach. For a discussion of ice in relation to typhoid fever and other infections, see page 1188 et seq. Milk. — Trask collected 317 typhoid epidemics up to 1908 caused by infected milk. Since then . many more instances have come to light. Doubtless many milk outbreaks have escaped attention or have been attributed to water or other sources. The typhoid bacillus grows well in milk, and it is now realized that this medium is a frequent and important mode of communication. Most milk outbreaks are reported 122 DISEASES SPREAD BY THE ALVINE DISCHAEGES from England or America. On account of the almost universal custom of boiling the milk in European and tropical countries, milk outbreaks are rarely reported from these regions. During our four years' study of typhoid fever in Washington, it was found that at least 10 per cent, of the cases were milk-borne. The milk usually becomes contaminated on the farm, from a case or a carrier. It may also become infected in transportation, at the city dairy, or in the home. Milk outbreaks come abruptly, rise to a peak like a water epidemic, and subside rather sharply. There are comparatively few secondary cases. Milk-borne epidemics of typhoid fever have certain characteristics which permit ready recognition. o so AO 6 0 eo lOo lao i4o i6o iso aoo | 1903 pi 1904 ■■ 1905 VVa.UrTowft.Xr. 1906 1982 ■ 1893 w 1894 Lawrence, Miss. 1895 1996 1898 m mmmlgg^^i^^ 1899 w 1900 1 AlbaiiiiXr 1901 I90& H BB^^i 1 ■ 1908 Cincinnati. Onio. Fig. 1.3. — Abrupt Reduction in Death Rates from Typhoid Fever Incident TO Water Purification in Four American Cities. Column X. — The Black Squares Indicate Raw Water and the Clear Squares Filtered Water. (a) There is a special incidence of the disease on the track of the implicated milk supply. The disease follows the route of the milk wagon. The outbreak is localized to such areas. (b) The better class of houses are invaded, and persons in better cir- cumstances generally suffer most. (c) Those who drink milk are chiefly affected and those suffer most who are large consumers of raw milk. (d) The incidence is high among women and children. (e) The incubation period may be shortened perhaps on account of the large amount of infection taken. (f) More than one case occurs simultaneously in a house. This is a very suspicious circumstance to the epidemiologists. The .first indication of a milk outbreak in a city with a good water supply is usually the fact TYIMIOII) FKVEl? 123 that two or more persons in a liouscliold come down witli lyiilioid fever within a few days of each other. (g) Clinically the disease often runs a mild course, owing to the fact, no doubt, that the virus becomes attenuated in the process of mul- tiplication in iho milk. In water-borne typhoid the same germs are ingested that were passed ; in milk-borne typhoid it may be the succeed- ing generations tliat are ingested. Milk-borne outbreaks are sometimes very extensive. One of the largest epidemics occurred in Boston (Jamaica Plain) in March and April, 1908. Four hundred and ten cases were reported; 348 of them drank the suspected milk. Among the first victims of the disease was the milkman, wlio was believed to have infected the milk through tasting it. The number of persons involved in a milk-borne epidemic varies greatly, depending upon the amount of milk infected and other factors. It must not be uncommon for a single bottle of milk or a small quantity to become infected, and thus transmit the disease to one or two persons. Such instances are exceedingly difficult to trace. Ofttimes the milk becomes infected from a carrier. An instance of this occurred in "Wash- ington (Georgetown) in 1908. In this case the milkmaid had typhoid fever 18 years previously. Examinations showed almost pure culture of B. typJiosus in her feces. Fifty-five persons who drank the infected milk contracted the disease. Milk Products. — Fresh milk products, such as cream, ice cream, butter, and buttermilk, and fresh cheese, may contain the typhoid bacil- lus, and are occasionally media of communication. Cream contains more bacteria than the milk from which it is taken. The use of infected cream in coffee, on cereals, etc., is sufficient to cause the disease. Several instances in the Washington studies were traced ■ to such use of cream. As a rule, coffee in the cup is not hot enough to kill the typhoid bacillus, if present in the cream added. In "Washington several cases of the disease were traced to ice cream. Mitchell working in my laboratory found that B. typhosus survives in ice cream for from 12 to 39 days. Lumsden^' traced the Birmingham, Alabama, outbreak in 1916, and another in Chattanooga, Tennessee, in 1917, to ice cream. An outbreak at Helm, California, in 1916, was found by Cumming to be due to ice cream.^® Bruck has sho-«Ti that the typhoid bacillus will live in butter for 27 days. BuitermUk may be quite as dangerous as the cream from which it is derived. The acidity and overgrowth of other organisms is said to kill the typhoid bacillus in 24 hours. In clieese the time of fer- mentation, antibiosis, etc., lessens the likelihood of survival of the "Am. Jour. Public Health, December, 1917, "J. A. M. A., April 21, 1917, LXVIII, 16. 124 DISEASES SPEEAD BY THE ALVINE DISCHARGES typhoid bacillus. Fresh cream cheese, such as cottage cheese, may be responsible for an occasional case. Oysters, Mussels, and Shellfish. — The first outbreak of typhoid fever attributed to this source was investigated by Conn at Wesleyan University, Middletown, October, 1894. Twenty-five cases were attrib- uted to eating infected oysters; 4 died. Not all of those who took sick had clinical typhoid fever. Some had gastro-intestinal disturbances with illness lasting but a few days. About one-quarter of those attending the dinners at which the oysters were served were made ill. A similar instance occurred at the Mayors' banquets at South Hamp- ton and Winchester, in 1903. Dr. L. W. Darra Mair^^ showed that much of the typhoid fever in Belfast, Ireland, from 1897 to 1901, was due to eating cockles and mus- sels taken from sewage polluted water. The amount of the fever dimin- ished markedly and its seasonal prevalence was changed by "betterment of the shellfish situation. In Brighton, England, Dr. J. T. C. Nash^" proved that much of the typhoid fever in the Borough of Southhead-on-Sea prior to 1899 was due to infected oysters. There was a sharp reduction in the amount of fever when the fore shore fisheries were stopped, and almost a cessation of all cases when attention was given to all shellfish, including the improved laying and cooking of cockles. In the Washington studies it seems that oysters and shellfish play a minor role in the spread of the disease, which occurs mostly in the sum- mer time, while oysters and similar sea food are relished mainly in winter. Comparatively few of the cases studied gave a history of having eaten oysters within 30 days prior to the onset of the disease. Oysters become dangerous when consumed soon after taking them from a pol- luted bed, or when floated or bloated in infected water. For further discussion of this topic, see page 840. Fruits and Vegetables. — Vegetables, such as celery, lettuce, water cress, and radishes, partaken raw, and grown on land fertilized with fresh night soil, may be infected, and this probably accounts for an occasional case.^^ Vegetables so contaminated are not made safe by the ordinary methods used in preparation of such food for table use. In large cities it is practically impossible to trace this source of infection. It therefore remains more a suspicion than a conviction. An outbreak which occurred in the summer of 1905, in Springfield, Mass., was attrib- uted to infected fruits and vegetables. At a wedding breakfast in Philadelphia June 24th, with 43 guests in "Proc. Roy. Soc, Epidemiology Sec, April, 1909, Vol. II. Part 2. ^ Idem. ^'Melick, J., Infcts. Dis., Vol. XXI, No. 1, July, 1917, p. 38. TYrilOII) FEVER 125 attendance, 19 persons ate watercress sandwiches.'^ Eighteen of these were ill July 2'2nd with typhoid fever, only 2 of them beiiiii; in Thilu- delphia at the time, while the other K! were scattered in suburban terri- tory and in summer resorts along the Atlantic Coast as far north as Maine. The watercress had been secured from a farm on which the sanitary conditions were quite unsatisfactory. A similar outbreak oc- curred in Hackney, London, in 1903, although the evidence in that out- break was not so convincing. ]\Iorse -^ reports an outbreak presumably due to celery. Creel -* found typhoid bacilli upon the tips of leaves of plants culti- vated in contaminated soil. Under conditions most unfavorable to the B. typhosus the infection lasted at least 31 days — a period sufficiently long for some varieties of lettuce and radishes to mature. Vegetable salads are sometimes accused of conveying typhoid and other infections, but in these instances it is more apt to be the salad dressing than the salad itself. See an outbreak reported by Leake due to mayonnaise dressing prepared by a person in the early stage of the disease.^^ Flies. — The evidence is now complete that the common house fly (Musca domestica) may convey the infection of typhoid. It is not inap- propriately called the typhoid fly. The typhoid bacilli may be smeared upon the feet or other parts of the insect, or may live in the intestinal tract and pass in the dejecta in almost pure culture. Flies live, feed, and breed in fecal matter and decomposing organic substances of all kinds. It is easy to see how they may convey infections from this source to our food, lips, or fingers. Alice Hamilton isolated typhoid bacilli from 5 out of 18 house flies captured in Chicago in the privy and on a fence near a sick room during a local water-borne epidemic. It has been shown experimentally that living typhoid bacilli may remain upon the bodies of flies for as long as 23 days. Special attention to the role played by the fly was given by Eeed, Vaughan, and Shakespeare in their studies of the prevalence of typhoid fever in our army camps in 1898. They concluded that flies undoubtedly served as carriers of the infection and attributed about 15 per cent, of the cases to this mode of communica- tion. They found that "flies swarm over infected fecal matter in the pits and then deposit it and feed upon the food prepared for the soldiers at the mess tents. In some instances, where lime had recently been sprinkled over the contents of the pits, flies with their feet whitened with lime were seen walking over the food." The danger from fly trans- mission varies very much, and depends upon circumstances. In a camp it is considerable; in a well sewered city the risk is diminished. In our ^Engineering I^^eics, Aug. 14, 1913. '^Report State Board of Health of Mass., 1899, p. 751. "^ Public Health Reports, Feb. 9. 1912. p. 187. XXVIl. 6. ^Public Health Reports, Sept. 17, 1920, Vol. XXXV, No. 38, p. 2197. 126 DISEASES SPEEAD BY THE ALVINE DISCHAEGES Washington studies we could find no relation between fly abundance in the summer of 1908 and typhoid prevalence. It is not possible to express mathematically the percentage of cases caused by flies — the figures would vary greatly, depending upon circumstances. The danger of typhoid from flies in cities has doubtless been overstated. However, if only one per cent, of the cases were thus transmitted, the suppression of flies would still be quite worth while (page 312). Dust. — Typhoid bacilli soon die when dried, especially when exposed to the sun and air. Dust-borne infection in this disease must be rare. In the South African War there were frequent dust storms in some local- ities, so that the food was covered with dust and sand. Some of the infection was believed to have been conveyed in this way. Fomites. — The infection may be conveyed upon soiled linen, blankets, and other objects. It was believed by Eeed, Yaughan, and Shakespeare that the clothing, blankets, and tents in the Spanish- American War became infected and were a prime factor in spreading the disease. After the South African War some of the blankets used by the troops were sent back to England and used on a training ship, on which typhoid fever appeared. The blankets were found to be dirty and soiled with fecal matter, from which Klein is reported to have obtained living typhoid bacilli. The danger of fomites contaminated with fresh infec- tion is real, and emphasizes the importance of disinfecting bedding, towels, handkerchiefs, body linen, and other fabrics. Soil. — The soil, long regarded as the most important factor in the spread of typhoid fever, and by Pettenkofer and others considered an essential element, is now given scant consideration. Pollution of the soil, however, cannot be disregarded. The typhoid bacillus may live fcr a long time in sewage-soaked earth, A polluted soil may endanger the water, milk, and other foods, or infect indirectly through flies and other means. For more extended information on this subject, see Section VII. Contact Infection. — "Contact" is a convenient term to indicate the spread of infection directly or indirectly as a result of close associa- tion between the sick and the sound. Actual contact is not necessarily implied. The term is used to indicate the transfer of the infection through a short intervening space in a brief period of time (see page 461). Thus the infection may be passed from one to another through kissing, soiled hands, remnants of food, infected thermometers, or tongue depressors, contaminated towels or other fabrics; cups, spoons, glasses, etc. If the nurse infects a cup of milk or glass of water that carries the infection to another member of the household, such cases are included under "contacts." The infection may also be spread in the household by flies, fingers, and various other means, usually difficult to trace, and which are, therefore, all included under this group. Eegarded in this light, contacts play a large role in the spread of the disease. TYPHOID FEVER 127 Extensive nuini(ii)al out breaks have been repoiifd as largely or en- tirely due to contact infection. Winslow in 1901 studied such an out- break in Newport. Others have been reported from Knoxville, Winni- peg, Springfield, and from Germany and England. Jvoch regarded the spread of typhoid in Triur in the light of contact infection. Freeman says that the majority of outbreaks in the smaller towns of Virginia are due to this cause. Extensive outbreaks in institutions are often due to contact with mild t'ases or carriers. *'Flies. fingers, and lood" (Sedg- wick), and "dirt, diarrhea, and dinner" (Chapin), which too often get sadly confused, explain the occurrence of many a case of contact infec- tion in typhoid fever as well as other diseases. In army camps with clean water and good milk, contact infection may rise to epidemic proportions. In the Spanish-American War, of 107,361 of our troops in camp, 20,738 contracted typhoid, mostly by "contact"; 1,580 died. Similar conditions prevail in rapidly growing cities, in crowded apartments, and in congested regions with a susceptible population and other favoring conditions. The danger of contact is well shown by the frequency with which nurses, ward attendants, house physicians, and others similarly exposed take typhoid fever. Studies of the incidence of the disease in the Massachusetts General Hospital, Bos- ton, in the Presbyterian Hospital, Philadelphia, and in the Johns Hop- kins Hospital, Baltimore, show that typhoid fever was at least twice and may be eight times as prevalent among those who came in close and fre- quent association with the patient as among the population at large. Further, the disease contracted under such conditions seems to run a course of more than ordinary severity, with a greater number of compli- cations and with a high mortality. This is doubtless due largely to the fact that the contactors receive fresh virulent virus. In our studies of typhoid fever in Washington we were impressed with the importance and frequency of contact infection in that endemic center. In 1907 we attributed 6 per cent, of the cases to contacts; in 1908, 15 per cent._, and in 1909, 17 per cent. This included only contact with cases during the febrile stage of the disease. In Strassburg, Kayser attributed 16.8 per cent, of the cases occurring during 3 years in that city to contact infection. Little groups of cases following a primary cia.se in a suburban focus, in my experience, frequently fall in the cate- gory of contacts. Typhoid fever, in view of all the facts, must now be regarded as a "contagious" disease. We will never have an end of it until it is so regarded and managed accordingly. 128 DISEASES SPEEAD BY THE ALVINE DISCHAEGES TYPHOID VACCINES Preventive Typhoid Inoculations. — An active immunity to typhoid fever may be induced by introducing dead typhoid bacilli into the subcutaneous tissue. The procedure is harmless, rational, and effective. Our knowledge of inoculations against typhoid fever began with the work of Pfeiffer and Kolle,^'' who inoculated two volunteers in 1896. About the same time Almroth Wright ^^ inoculated several persons, and in 1898 continued the work upon an extensive scale in India upon 4,000 British soldiers. In 1900, during the Boer War, Wright, together with Leishman, prepared a vaccine ^^ and supervised the inoculation of 100,000 British troops. The results in India were quite encouraging, but for various reasons the same procedure in South Africa was not as satisfac- tory as had been anticipated. Prophylactic inoculation on the advice of Koch was used by the .Germans in the Herero campaign in southern West Africa in 1904. The prophylactic was voluntary and only about half of the command (7,287 men) availed themselves of it. The results, while good, fell short of expectations. In this country Eichardson was the first to advocate and practice inoculations as a means of protection against typhoid fever. The best results have been obtained in the United States Army where typhoid inoculations were recommended as a voluntary pro- tection in 1909, but were made compulsory in 1911. Leishman ^^ in his Harben lecture (1910) explains the lack of success in early years by saying that the vaccine may have been made less efficient by the use of too great heat in killing the bacilli. Further, it should be noted that smaller doses and fewer injections were given then than now. It is well to know that it took about ten years to establish the efficiency of typhoid prophylactic inoculations. The typhoid vaccines may be prepared in a number of different ways. Usually dead bacilli are used, although live bacilli have been inoculated. The bacilli may be killed either with the aid of heat or germicidal sub- stances ; the dead or live bacilli may be sensitized by the addition of anti- typhoid serum; the vaccines may be prepared with pulverized bacilli, from bacillary extracts, or by the use of various chemical methods. Lipovaccines are made by suspending the bacilli in a fluid fatty substance of suitable consistency. The vegetable oils are better for this purpose than the animal fats. Lipovaccines are absorbed slowly and therefore the entire amount can be inoculated at one time. Experi- ^'Pfeiflfer and Kolle: Deutsche med. Woohnschr., 1896, XXII, 735. *' Wright: Lancet, London, Sept. 19, 1896, 807; Brit. Med. Jour., Jan. 30, 1897, 16. ="The material injected is called a vaccine and the process is spoken of as vaccination. The term in this connection is a little confusing. ^Leishman, W. B.: Jour. Roy. Inst. Pub. Health, London, 1910, XVIII, 394. TYPHOID FEVER 129 ments indicate that liiiovaccim's have only about one-half the protective power of saline .^suspensions. See Lipovaccincs, [)aj;e ol^li. T"'^sually the vaccine is made from a twenty-four-hour-old culture killed by heatinfj to 53° C. for thirty minutes, depending upon phenol (0.5 per I'ciit.) to kill any bacilli thai may have survived. Overheating impairs the immunizing j^ower of the vaccine. IMost typhoid bacilli die before the temperature reaches 60° C. Some of the strains have a lower thermal death point. Cultures killed without heat have perhaps greater protective properties. The killed cultures are suspended in saline solu- tion,— isotonic salt solution. Certain strains seem to cause the production of more antibodies than others. In the earlier work it was believed that the more virulent strains produce a greater protection. This is doubtful, for it appears that the protection afforded is not in proportion to the local or febrile reaction, but to the amount and variety of antibodies stimulated. The Rawlins strain is now greatly used in this country for experience has proved its protective power. The injections are given subcutaneously at intervals of from five to ten days. From 500,000,000 to 1,000,000,000 dead typhoid bacilli are in- jected at each inoculation. The number of inoculations varies with different authorities. At least 3, preferably 4, should be given; the greater the number of injections the greater the immunity induced. The reactions are usually moderate and never serious. They consist of local manifestations; irritation, and inflammation about the site of inoculation, such as pain, redness, swelling, edema; also general symp- toms, such as malaise, pains in the back and limbs, and fever. The num- ber and character of the reactions in the experience of the United States Army ^° are shown in the following table : Number of doses Reaction, Absent Reaction, Mild Reaction, Moderate Reaction, Severe First dose 45,680 44,321 38,902 68.2% 71.3% 78.0% 28.9% 25.7% 20.3% 2.4% 2.6% 1.5% 0.3% 0.2% Third dose 0.1% Children, as a rule, react less than adults. Of 1,101 persons inocu- lated by Hartsock, 11 per cent, showed no reaction, 83 per cent, mild reaction, 5 per cent, a moderate reaction, and 1 per cent, a severe reac- tion. There is always some local tenderness and redness at the point of inoculation. The systemic symptoms usually pass in 24 hours. The best time to give the treatment is late in the afternoon, for then the severest part of the reaction is over by the morning. The injections Russell, F. F.: Jour. A. M. A., LVIII, No. 18, May 4, 1912. 130 DISEASES SPREAD BY THE ALVINE DISCHARGES are usually given into the subcutaneous tissue of the outer side of the arm or into the abdominal wall; sometimes the interscapular space. There is no laboratory index of the degree or duration of the immu- nity produced as a result of the inoculations. The following antibodies appear in the blood : agglutinins, precipitins, opsonins, lysins, stimulins ; agglutinins persist for 2 years and even longer. There are factors in- volved in the immunity not understood, and therefore, the subsequent freedom of typhoid fever among individuals protected in this manner is the only index of value. The negative phase advanced by Wright and denied by Leishman and others does not occur. At least there appears to be no increased sus- ceptibility to the disease during the so-called negative phase. There is, therefore, no known objection to giving the prophylactic to those exposed to the disease or during an epidemic. In fact, the typhoid vac- cines have been used as a therapeutic agent during the fever. The immunity varies in degree and also in duration ; at least one year (Pfeiffer and Kolle's vaccine) ; four years (Wright's vaccine). On the average, the immunity may probably be depended upon for about 3 years when produced by 4 injections of dead bacilli. In the United States Army typhoid immunization is repeated every three years. In case, however, two or more cases occur in the same com- mand within two weeks, then the entire command is again inoculated. The experience of the American Expeditionary Forces showed that the immunity is not sufficiently strong or durable to protect against mass infections. The immunity may be prolonged or renewed by recourse to reinoculation. One attack of typhoid fever, however mild, produces, as a rule, a lasting immunity. Second attacks, however, occur. Draschfeld's fig- ures, based on 2,000 persons in the Antwerp Hospital, show that only 0.7 per cent, of that number were affected twice. This percentage is doubtless too high, for the figures were collected before our knowledge of paratyphoid infections. The typhoid vaccines do not protect against paratyphoid infections, and contrariwise paratyphoid does not protect against typhoid. In the United States Army, where the vaccinations are done under the supervision of Major Russell, we have the following results : During 1913 the army had only two cases of typhoid in the enlisted force of over 80,000 men. One of these occurred in a man who had not been vaccinated ; the other was among the troops in China, who had been immunized in 1911 and the history of the case is in doubt. In six years, 1909 to 1914, there was only one death from typhoid in the U. S. Army, while the rate in the country at large averaged over 16.5 per hun- dred thousand. The health record established by the Maneuver Division of the TYPHOID FEVER 131 TABLE 3. — ^TYPHOID, 1901-1012, FOR THE WHOLE ARMY. AT HOME AND ADROAD— OFFICERS AND ENLISTED MEN (Not Including native organizations, as Porto Rican Infantry and Philippine Scouts.) Year 1901. 1902. 1903. 1904. 1905. 1906. 1907. 1908. 1909* 1910* 1911* 1912. 1913. 1914. 1915. 1916. 1917. 1918. Mean Cases Deaths Strengtli Ratios Ratios Number 1,000 of Number 1,000 of Case Mean of Mean Fatality Strength Strength 81,885 552 6.74 74 .88 13.0 80,778 565 6.99 69 .85 12.2 67.643 34 T 5.14 30 .44 8.6 67,311 293 4.35 23 .33 7.8 65,688 206 3.14 20 .30 9.7 65,159 373 5.72 18 .27 4.8 62,523 237 3.79 19 .30 8.0 74.692 239 3.20 24 .31 lO.O 84,077 282 3.35 22 .26 7.8 81.434 198 2.43 14 .17 7.1 82,802 70 .85 8 .10 11.4 88,478 27 .31 4 .044 14.8 80,766 4 .04 87,228 7 .07 3 .03 42.8 97.656 8 .08 0 . . • 110.454 25 .24 3 .03 12.0 671,156 297 .44 23 .03 7.7 W'ld War 768 .30 133 .05 Occurring Among Those Who Were Vaccinated Deaths Cases 1 7 11 * Typhoid vaccination was voluntary during 1909 and 1910, and until Sept. 30, 1911, when It was made compulsory for officers and men. United States Army at San Antonio, Texas, during the summer of 1911, is a triumph in preventive medicine. The division had a mean strength of 12,801 men. All were treated with the typhoid vaccines. The result was that from March 10th to July 10th only two cases of typhoid fever developed; no deaths. One patient was a private of the hospital corps who had not completed his immunization, having taken only two doses. His case was very mild and probably would have been overlooked but for the rule that blood cultures were made in all cases of fever of over 48 hours' duration. The other case was a teamster who had not been inocu- lated. Among the 12,801 men there were only 11 deaths from all dis- eases. Typhoid fever prevailed at the time in the neighborhood. Thus, there were 49 cases of typhoid fever with 19 deaths in the city of San Antonio during this period. This contrasts markedly with the t}^hoid record of the United States Army during the Spanish-American War, when the typhoid record of a division of volunteer troops camped at Jacksonville, Florida, in 1898, under conditions similar to those at San Antonio, was as follows: The division at Jacksonville had 2,693 cases with 248 deaths, which was about the average typhoid incidence of the camps. The U. S. Navy had only seven cases among 50,000 men during the year ending June, 1913. Four of these occurred among men treated at a tropical station, where the vaccine had deteriorated. All the cases were mild. The results in recent years are still better. By contrast, in 1911 the rate was 3.61 per 1,000. 132 DISEASES SPREAD BY THE ALVINE DISCHARGES Spooner reports that in the Massachusetts General Hospital/^ among the nurses and others exposed to typhoid fever, 80 per cent, of whom had been inoculated during the previous three years, not a case was con- tracted, and for the first year in the history of the institution (1912) there were no cases among the nurses or attendants. The morbidity rate in training schools for nurses in Massachusetts during three years was nearly nine times greater in the uninoculated than among the inocu- lated. Metchnikoff and Besredka ^^ failed to protect chimpanzees against typhoid infection by means of killed bacilli, but obtained immunity apparently as definite as that produced by an attack of the disease by the use of living cultures.^^ Polyvalent Vaccines, — It is now customary to use a vaccine con- sisting of a mixture of B. typhosus, B. paratyphosus a, and B. para- typhosus P as a routine, because the typhoid vaccines do not protect against paratyphoid infections, and vice versa. During the World War, it was customary to add other cultures such as cholera, dysentery or plague to the mixture for troops serving in localities where these infec- tions prevailed. These various mixtures apparently produce no greater reaction than the single typhoid vaccine and induce a specific active immunity against each virus represented in the mixture. Dose nad num- ber of injections remain approximately the same as for single vaccines. Summary. — The results of typhoid inoculations can no longer be questioned. The morbidity is lowered in those who have been properly "vaccinated." The most striking effect is in the lowering of the mor- tality. Preventive typhoid inoculations involve no risk whatever, and •are especially applicable to those unduly exposed to the infection, such as nurses, hospital attendants, physicians, travelers, soldiers in camps, persons in epidemic localities, and individuals in the family of a bacillus carrier. Typhoid vaccination should be mandatory in asylums and other custodial institutions. The method is serviceable for general use among the public in endemic foci, but it is a question whether this artificial method of acquiring immunity would serve as good a purpose in the end as fighting the disease along the lines of general sanitation — which has been so successfully done in many European centers. It