CHAPTER XXXI SOME MICROBIC DISEASES AND THEIR PREVENTION. (Part 1)

CHAPTER XXXI SOME MICROBIC DISEASES AND THEIR PREVENTION. VACCINATION AND ANTITOXIC SERUMS 1. Tuberculosis.— One of the first diseases of which microbes were conclusively proved to be the cause was’ tuberculosis, a disease to which more deaths are annually attributed than to any other. For the latter reason it has Fie. 123. THe microbe of tuberculosis (Bacillus tuberculosis). (Very highly magnified) A minute amount of the spit (sputwm) of a consumptive has been spread out thin and photographed. The tubercle bacilli are the little sticks or small rods scattered all about among larger irregular epithelial cells, mucus, etc. been called the “ great white plague,” and under the com- mon name of “consumption” one form of it is only too familiar. The name “tuberculosis ’”’ was given to the disease because of certain characteristic cheesy nodules or tuber- cles (little tubers) found in the lungs and other tissues of 477 478 THE HUMAN MECHANISM persons affected with it, and until 1882 it was generally regarded as a constitutional disease, readily inherited and often “running in families.” In that year, however, Koch announced the great discovery that in the tubercles could be found peculiar and apparently characteristic microbes belonging among the bacteria; also, that by special meth- ods he had cultivated these microbes pure, or free from all others; and, finally, that with them he had inoculated healthy guinea pigs and actually produced tuberculosis in the infected animals. Intense interest was everywhere felt in Koch’s splendid discovery, which was quickly confirmed, and soon became an established and universally accepted fact. It is now known that tuberculosis is not ordinarily an inherited or constitutional, but an acquired, disease, infectious, conta- gious, and environmental in origin, and due to the ray- ages of a special microparasite, a bacterial microbe named ~ Bacillus tuberculosis. It is true that the disease often runs in families, but infectious diseases frequently do this; and the reason why it affects some families so much more than others is believed to be simply that some families are more susceptible to it, more adapted to its growth, than others; precisely as some soils are better suited than others for growing wheat or grass or corn. 2. How Tuberculosis is spread. — As this disease is caused by the invasion of a specific microbe, ¢¢ can only be caused by the entrance of that microbe into susceptible bodies. Sanitarians generally believe that the principal ways in which tuberculosis is conveyed from one patient to another are the following: (a) by contagion, that is, by personal contact of tuberculous with non-tuberculous per- sons, and especially by kissing. A consumptive mother or sister or friend, fondling a baby and “smothering it with kisses,” may thus transmit the germs of the disease to the child; (6) by objects handled or mouthed (such as food, MICROBIC DISEASES. PREVENTION 479 forks, drinking cups, pencils, or towels) first by consump- tives and then by susceptible non-consumptives ; (c) by dust containing sputum expectorated upon streets or floors, and then dried and carried in the air; (d) by milk or meat of tuberculous animals; and (e) by the moisture of the breath thrown off not as vapor but as fine droplets or spray, in coughing or even while talking. It is not certain just what part any or all of these play in the dissemination of the disease. At one time it was thought that the principal vehicle of tuberculosis was the spit, or sputwm, of tuber- culous patients expectorated upon floors, sidewalks, or streets and afterwards dried, pulverized, and driven about as dust particles, which might readily find access to healthy throats and lungs. There is no doubt that the spit of con- sumptives may, and often does, contain the germs of the disease, and for this reason “spit cups” and destructible handkerchiefs (e.g. of paper) should always be used by them; but further investigations have shown that drying and exposure to sunlight both tend to weaken and to de- stroy microbes, so that to-day, while dust is still regarded by all as a vehicle of very great importance in the spread of tuberculosis, more significance than formerly is attrib- uted to other factors. It is an open question how far milk is a carrier of tuber- culosis. Cows undoubtedly often suffer from a form of the disease not readily distinguishable from that which occurs in man, and the frequency of tuberculosis in children certainly suggests that infected milk may have been the cause of it. But, on the other hand, it is far from certain that bovine tuberculosis is readily transferable to man; and at present, while it may be that milk is an important vehicle of the disease, the whole question is much in doubt. The same thing is true of meat from tuberculous animals, although in this case thorough cooking must destroy most, if not all, of the germs. The safest plan is to use for food 480 THE HUMAN MECHANISM no milk or meat which is in the least doubtful in quality, at least not without first subjecting it to thorough cooking. At present the dissemination of the bacilli through the air by means of finely divided droplets of mucous or moisture, as suggested above, is regarded as of special importance. 3. The Prevention of Tuberculosis. — No successful steps have yet been taken toward the prevention of tuberculosis by vaccination, or in any other ways than by warding off the microbe and by helping the patient in his struggle with it by giving him good air, good food, rest, and all other favorable conditions which shall aid the body in resisting infection and the ravages of the disease. It has been proposed to isolate eases of tuberculosis and in general to deal with them very much as the more con- tagious diseases are ordinarily dealt with. There is some- thing to be said in favor of this plan, but the general opinion is that such isolation is a hardship to the patient and not often necessary for the safety of the community. Consumptives should, however, be expected, and even required, to be especially cleanly in their habits, and to collect and destroy their sputum in cheap paper cups or in paper handkerchiefs, which can readily be burned. They should never spit upon floors or streets, or cough into the faces of friends or attendants, and they should wash their hands and mouths frequently and thoroughly. Milk or meat derived from tuberculous animals should not be used, and dust, which may at any time contain the germs of tuberculosis, should be kept down as far as possible, both in houses and in streets. Above all, every means of direct conveyance of the fresh virulent microbes from persons having the disease to new victims should be carefully avoided. Some of these means are kissing and coughing, by which latter minute infectious particles may be thrown to a distance and caught upon the face or hands of friends, or upon food, tableware, or linen; and MICROBIC DISEASES. PREVENTION A81 any lack of absolute cleanliness in washing dishes, cups, spoons, napkins, etc., recently used by consumptives, is to be scrupulously avoided. Those, also, who do the washing need to be on their guard against infection, by exercising extreme care and cleanliness. There are many other forms of tuberculosis besides con- sumption, but this is the form of principal interest to students beginning the study of hygiene and sanitation. 4. Hygiene in the Treatment of Tuberculosis. — While consumption is the cause of so many deaths, it is not neces- sarily a fatal disease. The Bacillus tuberculosis is usually of very slow growth and low virulence; it does not, like some microbes, produce large quantities of poisonous tox- ins which, upon entering the blood, cause rapid and exten- sive injuries to most organs. On the contrary, its action is at first largely confined to the spot in the lungs where it has gained a lodgment, and at the outset the constitu- tional disturbances are slight. So insidious is the attack and growth of the germ that the patient does not at first even suspect its presence, and merely feels “out of sorts” or “run down.” Only later, when the pathological processes have spread over a considerable area of tissue, are the symp- toms serious; and frequently the disease is not recognized until irreparable damage is done. It is chiefly for this reason that consumption claims so many victims; for the inroads of the disease are by no means unresisted by the living cells of the body. From the outset a struggle between these cells and the invading microbes takes place; and it should be better known than it is that in the majority of cases the human mechanism is the victor in the struggle. This is shown by the fact that autopsies on persons who have died of other diseases dis- close in a surprisingly large percentage of cases healed tuberculous lesions, where the presence of the disease had not been suspected. In other words, the disease moves on 482 THE HUMAN MECHANISM to a fatal issue only when the vital resistance proves une- qual to the defense, and the mortality from consumption would undoubtedly be exceedingly low were sufficient attention paid to the hygienic care of the body and the sanitation of its surroundings, by both of which the vital resistance is powerfully reénforced. This is in itself a powerful argument for attention to general hygiene, and it points out unmistakably the hygi- enic treatment of the disease when once recognized. No reliance whatever should be placed in drugs. On the con- trary, the patient, his family, and friends should recognize that the one hope lies in the hygienic conduct of life. The patient should live and sleep out of doors, if possible; he should fearlessly breathe cold air, but should protect the skin from chilling by warm clothing ; if he cannot live out of doors, the windows of the living and sleeping room should be kept wide open, even in winter weather; the sleeping ~ room should have light walls, and all curtains and draper- ies which limit the amount of sunlight should be dispensed with; the furniture of the room should be reduced to a minimum and should be such as can be easily cleaned; rest from anything but very moderate muscular activity, and from nervous strain, is absolutely essential; and all these measures should be reénforced by abundant feeding with appetizing and easily digested food; the feeding, indeed, should be pushed to the extreme, should even be forced feeding, but only with easily digestible foods. In brief, rest, fresh and cool air, sunshine, and abundant food are the cures for tuberculosis, and, unless the disease has gone too far before it is recognized, they are almost certain cures. While some climates are more favorable for the treat- ment of tuberculosis than others,—a cold, dry climate being preferable, — it should be understood that the treat- ment we have outlined has been used with excellent results MICROBIC DISEASES. PREVENTION 483 even in the patient’s own home, wherever that may be; and this hygienic treatment should be employed whether or not it is possible to go away from home. Continuous high temperature and high humidity, or dampness, are the main conditions which make change of climate desirable; and where these are not present it is generally better to treat the patient at his own home, where family and friends may not only minister to his needs but may also maintain those cheerful surroundings which count for so much both in sickness and in health. 5. Typhoid Fever. — This disease is now believed to be due to the bacterial microbe known to bacteriologists as Fic. 124. Typhoid fever germs (Bacillus typhi). (Highly magnified) Above, swimming free in normal blood serum ; below, ‘‘ clumped ”’ or “‘agglu- tinated ’’ in the serum of a typhoid fever patient Bacillus typhi. The latter was observed by Koch, Eberth, and others about 1879, but first thoroughly worked out by a pupil of Koch, Dr. Gaffky, in 1884. Typhoid fever has been well known since about 1840, previous to which time it was confused with typhus (jail, spotted, or ship) fever, —a disease now not often met with. It is one of the worst maladies that afflicts mankind, for 484 THE HUMAN MECHANISM although not generally fatal in more than about ten per cent of the cases, it is a slow fever, disabling the patient even when it does not kill, and requiring weeks and often months for its course and for convalescence. It is widely distributed, probably all over the world ; and, although less widespread than tuberculosis, it is still one of the chief causes of death. It is a disease which seriously damages the intestine and is one form of what is sometimes called «inflammation of the bowels.” The microbe finds its way into the alimentary canal with food or drink, and is believed to multiply in the intestine and to invade the body proper, producing a poisonous substance (typhotoxin) which causes the fever and otherwise injures the whole organism. The germs are probably cast off in abundance with the various excreta, and as diarrhea is a frequent (though not invari- able) accompaniment of the disease, typhoid fever is called a diarrheal disease. At its beginning and, in mild attacks, - throughout the whole disease, the victim may not be con- fined to his bed, but may “keep about.’ Such cases are known as “ walking” typhoid. 6. How Typhoid Fever is spread. — Since the germs of this disease are present in the excreta, — both urine and feces, and even in the saliva, —it has been well called a “filth” disease. The old idea of a filth disease, however, was that filth bred disease, and that almost any heap of dirt or rotting material might generate disease, especially typhoid fever, and inflict it on persons in the vicinity. This idea is now abandoned, for it is held that the germs of any one kind or species of disease can come only from other germs of the same kind; that is to say, typhoid fever can come only from a person or persons now having, or having recently had, that disease. The excreta of such persons may, nevertheless, readily convey it; and if food or drink are polluted in any way by such excreta, then the germs readily find access to fresh victims. MICROBIC DISEASES. PREVENTION 485 Unfortunately, food and drink are oftener polluted than most persons realize. Water may be contaminated by sew- age; milk, by the dirty hands of careless or unclean milkers ; oysters growing in harbors or estuaries, by city sewers discharging therein ; vegetables, by manure; and fruits or berries, by filthy hands. When we stop to think that filth may readily find access to food and drink in these and many other ways, it is clear that typhoid fever may still be called a filth disease, even if we understand by the term that it is a disease conveyed by infected filth, but not bred or generated by filth alone. : . 7. The Prevention of Typhoid Fever. — This disease can be vastly reduced in amount and destructiveness in any community in which it abounds, by careful attention to the avoidance and destruction of its microbes, and by main- taining high vital resistance through hygienic and whole- some living. No means are yet known of vaccinating against its attacks, as is done for smallpox, nor has any antitoxic serum yet been discovered effective for its cure, as is antitoxin for diphtheria. The microbes of typhoid fever may generally be avoided by the use of pure drinking water, pure milk, clean vege- tables and fruits, raw oysters derived only from harbors and estuaries free from sewage, and, in general, by the use of pure foods and drinks. Microbes are readily destroyed by cooking at a high temperature and, in the case of the excreta of patients suffering from typhoid, by disenfection, which, under the direction of an attending physician, should always be thoroughly carried out. It should never be forgotten that, contrary to the gen- eral impression, typhoid fever is really contagious, i.e. may ‘be “taken” by contact, not necessarily with the patient, but very readily with his excreta, or with his linen, or with any of his belongings soiled with his excreta. Hven trained nurses sometimes seem to forget this fact, for not HS 486 THE HUMAN MECHANISM infrequently a trained nurse contracts the disease from her patient. Similar secondary cases of typhoid fever, espe- cially in families in which the mother or sister attends the patient and at the same time prepares food for the rest of the family, are painfully common. It has been proved again and again that persons over- worked or otherwise in poor condition are those most sus- ceptible to this disease, and we could hardly have a better instance than typhoid fever affords of the double duty which a sound hygiene imposes upon us, namely, (a) the duty of avoiding infection and (6) the duty of keeping the mechanism in such good condition that if by accident infection occurs, the microbes shall not be able to over- come its vital resistance. 8. Diphtheria. —This disease has long been known under the name of “membranous croup” and “malignant sore throat,” but it was not until 1884 that Loeffler, one of the - pupils of Koch, detected the microbe now generally agreed to be its sole and only cause (Fig. 125). It is believed that this microbe, Bacillus diphtheria, finding lodgment in the throat of a susceptible person, grows and multiplies there, secreting meanwhile a poison- ous substance, or toxin, which injures the tissues of the throat and causes the formation of the white spots and false membrane so characteristic of the disease, and also damages the rest of the body after its