Treatment.—The wound or swelling should be cauterized and a solution of carbolic acid or bichloride of mercury injected around it and applied to its surface. Stimulants and feeding are important.
LOCKJAW. (Tetanus).—Tetanus or lockjaw, as it is commonly called, is an infectious disease and is characterized by painful and violent contractions of the voluntary muscles; it may be of the jaw alone or of a considerable part of the body.
Causes.—The intelligence and mental faculties are not impaired. In most cases it follows a wound or injury, although in others there seems to be no exciting causes. Fourth of July celebrations furnish a great many of our lockjaw cases. Ten to fifteen days usually elapse after the wound before lockjaw really sets in.
Symptoms.—It comes on occasionally with a chill or chilly feelings; usually by rigidity (stiffness) of the neck, jaw and face. On arising in the morning there is sometimes a stiffness of the muscles at the back of the head. It is not unusual on taking a slight cold to have a stiff neck and often the patient's attention is not attracted by this symptom. Sometimes this stiffness begins or soon extends to the muscles of the lower jaw; the throat becomes dry and is painful and gradually the stiffness increases to a continuous contraction, spasm, and extends to the muscles of the trunk and extremities. The body becomes rigid in a straight line or bent backward, forward or sidewise. This spasm occurs after any slight irritation and is extremely painful. Temperature is usually low. During the first spasms the patient may attempt to open his mouth as he may naturally be suspicious of the trouble that is coming; he succeeds with difficulty and even finds it hard to swallow; soon the jaws may be firmly closed, and it is from this feature of the disease that it gained the name of lockjaw. The contractions in some cases do not extend beyond the neck and face muscles. During the contractions the face may be drawn into frightful contortions. Food can be given only through such spaces as may exist between the teeth, as often the patient cannot open his mouth himself, nor can it be pried open by any force that would be allowable. When the muscles of the trunk are affected the abdomen may be drawn inward, become very hard and stiff, chest movements are affected, making it difficult to breathe, sometimes almost to suffocation. Sometimes the body becomes bent like a bow, as in some cases of spinal meningitis, so that only the head and heels support the weight of the body. The body may become so rigid that it can be lifted by a single limb as you would a statue. It is fortunate that there are few cases, comparatively, of lockjaw as the distorted face and general contractions of the body are painful to witness.
Recovery.—The mortality in lockjaw cases runs about eight per cent. Sometimes death is caused by exhaustion from the muscular exertions; the patient is seldom able to sleep and sometimes wears out in a few days. Sometimes suffocation brings a sudden end to his sufferings and usually one or two days to ten or twelve days is the limit. Among the lower classes where sanitary science is seldom observed, and even among the better classes, lockjaw has been known to occur in infants. It usually comes on, in ten to fifteen days after birth, and the child seldom lives more than a few days, It is hard to account for such cases which may come on suddenly from the slightest excitement such as sudden noises, etc.
MOTHERS' REMEDIES.—l. Lockjaw, Successful Remedy for.—"A very good and successful remedy for this disease, is to apply a warm poultice of flaxseed meal, saturated with laudanum and sugar of lead water, to the jaws and neck."
2. Lockjaw, Smoke as a Cure for.—"Smoke the wound for twenty minutes in the smoke of burnt woolen cloths. This is considered a never failing remedy."
PHYSICIANS' TREATMENT.—If from a wound cut open and use antiseptics. Isolate the patient and have absolute quiet. Antitoxin is used with success in some cases of lockjaw, but this and other remedies or measures must be handled by a physician, Opium is sometimes given and stimulants such as brandy, whisky, etc. As it is a case of life or death in a very short time, we cannot advise depending upon home treatment. A preventive caution that must always be observed is the use of antiseptics and the strictest care of all injuries and wounds that might result in lockjaw. This is a disease where an ounce of prevention is worth a thousand pounds of cure, because by the time the disease is recognized as lockjaw and has really made an appearance, it may be too late for medical skill. While you are waiting for the doctor you may apply cold cloths or even an ice bag to the spine. If the spasms are severe let the patient inhale chloroform to kill the pain and quiet him. In the meantime secure the best physician within your reach, and follow his directions carefully, be calm and self- possessed when in the presence of the patient, for you must remember that he has full possession of his mental faculties and will notice every evidence of fear or worry in the faces of those who are nursing him. This will only add to his sufferings, affect his nervous system and undermine his general vitality. Read carefully the nursing department in this book and you will gain some valuable hints and knowledge regarding the sick room.
GLANDERS.—This is an acute disease of the horse and occasionally of man. It is called "glanders" when the affection appears in the nostrils, and is called "farcy" when in the skin.
Causes.—The bacilli is usually introduced from infected horses through the nose, mouth and cheek, mucous membranes or skin abrasions (rubbing off of the skin). There are large or small lumps in the skin, mucous membrane of the nose and mouth.
Symptoms. Acute Glanders.—1. Incubation lasts from three to four days. There are signs of inflammation at the site of infection and general symptoms. In two or three days, small lumps appear on the mucous membrane of the nose, and ulcerate, with a discharge of mucus and pus. Sometimes these nodules die locally, and their discharge is then foul. The glands around the neck are enlarged. An eruption appears over the face and joints. Inflammation of the lungs may occur. Death may take place in eight to ten days.
2. Chronic Glanders.—This may last for months. It acts like chronic cold with ulcer in the nose. Some recover.
3. Acute Farcy.—The local and general signs are those of an infection, with necrosis (local death) at the site (in the skin) of inoculation; nodules, (lumps) known as "farcy buds" form along the lymphatics (glands) and form pus. There may be pus collections in the joints and muscles. Death often occurs in one to five days.
Chronic Farcy.—Tumors in the skin of the extremities, containing pus. The process is local, the inflammatory symptoms light, and the duration may be months or years.
Treatment of Glanders.—This disease does not often occur in man; it is an awful affliction. All infected horses must be killed, it is dangerous for man to be around one. If seen early, the wound should be cut out or burned out with caustics, and afterwards dressed like any wound. The "farcy buds" should be opened early. There is very little hope in acute cases of glanders. In chronic cases recovery is possible, but it will be after a long tedious time. There must be proper nourishing food and tonic medicines. Each case should be treated according to the indications. It is safe to say the parts should be thoroughly cut or scraped out and then treated with antiseptics and the general system built up, by tonics and stimulating remedies, if needed. As stated before, acute glanders and acute farcy are almost always fatal.
BIG-JAW OR LUMP-JAW. (Actinomycosis).—This is an infectious disease of cattle, less frequently of man, and it is caused by what is called the "ray fungus." This grows in the tissues and develops a mass with a secondary chronic inflammation.
This disease is widespread among cattle, and also occurs in the pig. In the ox it is called the "big jaw." The infection may be taken in with the food, and it locates itself often in the mouth or surroundings. Oats, barley, and rye may carry the germ to the animals. The fungus may be found even in decayed teeth.
Alimentary Canal Type.—The jaw has been affected in man. One side of the face is swollen or there may be a chronic enlargement of the jaw, which may look like a sarcoma (tumor). The tongue also is sometimes affected and shows small growths. It may also occur in the intestines and liver. There is at first a tumor (lump), and this finally suppurates.
In the Lungs.—They also can be affected. It is chronic here and there is cough, fever, wasting and an expectoration of mucus and pus, sometimes of a very bad odor (fetid). It sometimes acts like miliary tuberculosis of the lungs, and this is quite frequent in oxen. Other diseases of the lungs and bronchial affections occur and abscesses and cavities are formed that may be diagnosed during life.
Symptoms.—If in the jaw there may be toothache, difficulty of swallowing and of opening the jaw. The adjacent muscles may be hardened (indurated). A swelling appears at the angle of the jaw and this quickly passes into suppuration; later it opens first outside, then inside—into the mouth and discharges pus containing little yellow masses. It will extend down even into the bowels unless it is properly treated. Then there will be stomach disturbances and diarrhea. It may ulcerate through the bowels and cause peritonitis. The liver, spleen and ovaries may also become affected.
The Skin.—There may be chronic suppurating ulcers of the skin and the "ray fungus" can be found in them.
Diagnosis.—The "ray fungus" can be found. There is a wooden hardness of the tissues beyond the borders of the ulcers; there are the little yellow granules in the pus. The course is chronic. Mild cases recover in six to nine months or earlier, the mouth form being the most favorable.
Treatment.—Surgical. Remove the parts involved. Internally, iodide of potash in large doses is recommended. The food should be plenty and nourishing. In this case we must recommend you to a physician instead of the home treatments.
GONORRHEA (Urethritis).—This can be called an infectious inflammation of the urethra, caused by the gonococcus, a microbe or germ, causing a specific inflammation of the mucous membrane of the urethra or vagina.
Incubation.—The time that elapses between the exposure and development of the symptoms in the urethra is variable, extending from a few hours to twelve or fourteen days. In the great majority of cases, however, the disease appears during the first week. The patient notices a drop of milk-like fluid at the opening of the urethra, which is slight, red and puffed or turned out; a tickling sensation is often felt in this locality, and the next time urine is passed it is attended with a feeling of warmth at the end of the canal, or with actual scalding. After this the symptoms increase rapidly in number and severity, so that within forty-eight hours, or even sooner, the disease may be described as having passed its first or increasing stage, the characteristic phenomena of which are as follows:
Changes in the meatus (opening). There are redness, eversion (turning out), ulceration and eating away and often erosion of the lips of the opening of urethra. Sometimes, but rarely, so much swelling that the person can hardly pass the urine, which drops away. The other symptoms are too well-known by those who have had this disease to need a description.
Prognosis.—It is now considered more than a cold, and it is the cause of terrible sickness in both sexes, among the innocent as well as the guilty.
Treatment.—It may be cured perhaps in a short time, and yet no one can be certain of its absolute cure. This disease is better understood now, and the treatment is entirely different from formerly. The strong injections are now considered not only useless but dangerous to the future health of the patient. The best treatment is mild antiseptic injections, irrigation carefully done by an expert person; remaining quietly in bed, being careful to use food and drink that are not stimulating, keeping the bowels open by proper diet and mild laxatives and the urine mild by soothing diuretic remedies. Unfortunately those affected want quick work and they get it, frequently to their future sorrow. The following are good injections. Before each injection the urine should be passed and an injection of an antiseptic like listerine, etc., one dram to an ounce of boiled water, to cleanse the canal. You can use twice a day the following:
Fluid Extract Hydrastis (colored) 1 dramWater 1 ounce
Use one dram of this for each injection. It stains the clothes so you must be careful. This is good and healing.
GONORRHEAL ARTHITIS. (Gonorrheal Rheumatism, Inflammation of the Joints).—This is more common in men than women. Occurring during, and at the end of or after inflammation of the urethra. It usually involves many joints, such as the temporal, maxillary and collar bone. The effusion in the joints is usually serious.
Symptoms.—Variable joint pains may be the only one. The attack may resemble an acute articular rheumatism of one joint, or a subacute rheumatism of one or more.
Sometimes there is a chronic one-jointed inflammation usually of the knee.The tendon sheaths and bursae may be involved alone, or with the joints.Gonorrheal septicemia may result from arthritis. This is protracted.Iritis is a most frequent complication. The urethra source of theinfection must be cured.
Treatment.—Keep the joint quiet and you can use an ice cap for the pain. Tonic treatment with quinine, iron, and arsenic in chronic cases is needed. The joints should be kept at rest in acute cases. In chronic cases massage and slight motion. The tonics must be chosen for each individual case. One afflicted with this must be under treatment for a long time.
HIP JOINT DISEASE. (Morbus Coxarius).—This is more common in children than in adults.
Cause.—It is usually tubercular.
Symptoms. First stage.—It may be overlooked; slight lameness, a little stiffness is noticed at times. The muscles begin to dwindle.
Second stage.—Child limps very perceptibly, dwindling is more apparent.Pain appears.
Treatment.—Absolute rest. Lying down treatment if begun early arrests this disease often. Build up the system. Splints and brace are needed sometimes.
KNEE JOINT DISEASE. (White Swelling).—This is simply a tuberculous knee.
Treatment.—Rest. Stop motion of the joint by some form of splint or plaster of Paris cast. Get a good physician at the beginning in these cases and you will save lots of after worry and blame for yourself. It does not pay to wait. These joint diseases will progress, and often treatment is begun months after trouble is seated. It ought to be criminal negligence and dealt with accordingly to neglect such diseases. Parents should never forget that they have endowed their children with such a constitution, and they should be glad and willing to correct it as far as they can.
LEPROSY. Definition.—Leprosy is a chronic infectious disease, caused by what is called the "Bacillus Leprae," and is characterized by the presence of tubercular nodules in the skin and mucous membranes (tubercular leprosy), or by changes in the nerves (anaesthetic leprosy). These forms are separate at first, but ultimately they are combined and there are disturbances of sensation in the characteristic tubercular form.
History.—Leprosy is supposed to have originated in the Orient, and to be as old as the records of history. It appears to have prevailed in Egypt even so far back as three or four thousand years before Christ. The Hebrew writers make many references to it, and it is no doubt described in Leviticus. The affection was also known both in India and China many centuries before the Christian era. The old Greek and Roman physicians were familiar with its manifestations, ancient Peruvian pottery represent on their pieces deformities suggestive of this disease. The disease prevailed extensively in Europe throughout the middle ages and the number of leper asylums has been estimated at, at least, 20,000. Its prevalence is now restricted in the lands where it still occurs while once it was prominent in the list of scourges of the old world.
It is now found in Norway and to a less extent in Sweden, in Bulgaria, Greece, Russia, Austro-Hungary and Italy, with much reduced percentage in middle Europe; it is the rarest of diseases in England where once it existed. In India, Java, and China, in Egypt, Algiers, and Southern Africa, in Australia and in both North and South America, including particularly Central America, Cuba, and the Antilles, it exists to a less extent. It has been recognized in the United States chiefly in New Orleans, San Francisco, (predominantly among the Chinese population of that city). The disease has steadily decreased among the latter colonists in Minnesota, Wisconsin and Iowa. Isolated cases have been recognized in almost every state, and leprous cases are presented at the public charities of New York, Philadelphia, Boston, etc. The estimated number of lepers a few years ago in the United States varied between two hundred and five hundred. It is represented as diminishing in frequency in the Hawaiian Islands, Porto Rico and the Philippines. In the Hawaiian Islands it spread rapidly after 1860, and strenuous attempts have been made to stamp it out by segregating all lepers on the island of Molokai. There were 1,152 lepers in that settlement in 1894. In British India, according to the leprosy commission, there were 100,000 lepers in 1900.
Cause.—The bacillus, discovered by Hansen, of Bergen, in 1874, is universally recognized as the cause of leprosy. It has many points of resemblance to the tubercle bacillus. These bacilli have been found in the dwellings and clothing of lepers as well as in the dust of apartments occupied by the victims.
The usual vehicle by which the disease is transmitted is the secretions of a leprous patient containing bacilli or spores. The question of inheritance of leprosy is regarded now as standing in the same position as that relating to the inheritance of tuberculosis; no foetus, no new-born living child, has been known to exhibit the symptoms of either disease. Several cases have been cited where infants but a few weeks old exhibited symptoms of leprosy. It affects men more than women. Infection is more common after the second decade, though children are occasionally among its victims. When it occurs in countries where it had not previously existed, its appearance is invariably due to the infection of sound individuals by lepers first exhibiting symptoms where the disease is prevalent.
Neisser states this: "The number of lepers in any country bears an inverse ratio to the laws executed for the care and isolation of infected persons. The disease appears to spread more rapidly in damp and cold, or warm and moist, climates than in temperate countries. It is not now regarded as contagious. The leprosy of the book of Leviticus not only includes lepra, as that term is understood today, but also psoriasis, scabies and other skin affections," The leper, in the eye of the Mosaic law, was ceremoniously unclean, and capable of communicating a ceremonial uncleanness. Several of the narratives contained in the Bible bear witness to the fact that the Oriental leper was seen occasionally doing service in the courts of kings, and even in personal communication and contact with officers of high rank.
Symptoms.—Previous symptoms: Want of appetite, headache, chills, alternating with mild or severe feverish attacks, depression, nosebleed, stomach and bowel disturbances, sleeplessness. The durations of these symptoms is variable. Some patients will remember that these symptoms preceded for years the earliest outbreak of lepra (leprosy). In other cases only a few weeks elapsed. These earlier skin lesions are tubercular, macular (patches), or bullous elevations of the horny layer of the skin. It may then be divided into three varieties tuberculous, macular and anaesthetic.
LEPRA TUBEROSA. (Tuberculated, Nodulated or Tegumentary (skin) Leprosy).— This nodular type comprises from ten to fifty per cent of cases. After the occurring of the symptoms just mentioned spotted lesions appear, which are bean to tomato in size, reddish brown or bronze-hued patches, roundish, oval or irregular in contour, well defined, and they occur upon the face, trunk and extremities. The skin covering them is either smooth and shining, as if oiled, or is infiltrated, nodulated and elevated. The surface of the reddened spots is often oversensitive.
After a period ranging from weeks to years, tubercles rise from the spots described, varying in size from a pea to that of a nut, and they may be as large as a tomato. They are in color, yellowish, reddish-brown, or bronzed, often shining as if varnished or oiled, are covered with a soft, natural, or slightly scaling outer skin, roundish or irregular in shape and are isolated or grouped numbers of very small and ill-determined nodules may often be seen by careful examination of the skin in the vicinity of those that are developed. They may run together and cause broad infiltrations and from this surface new nodules spring. They may be in the skin or under the skin and feel soft or firm. The eruption of these tubercles is usually preceded at the onset by fever, as well as by puffy swelling of the involved region, eyelids, ears, etc. These leprous tubercles choose the face as their favored site. They mass here in great numbers, and thus produce the characteristic deformity of the countenance that has given to the disease one of its names, Leontiasis (lion face).
In such faces the tubercles arrange themselves in parallel series above the brows down to the nose, over the cheeks, lips and chin, and as a result of the infiltration and development of the conditions the brows deeply over-hang; the globes of the eyes, and the ears, are so studded with tubercular masses as to stand out from the side of the head. The trunk and extremities, including the palms of the hands and soles of the feet, are then usually involved to a less degree. The arm-pit, genital and mammary regions, and more rarely the neck and the palms of the hands and soles of the feet, may be invaded. In occasional cases when the development of tubercles upon the face and ears is extensive, there may not be more than from five to fifty upon the rest of the body, and these either widely scattered and isolated or agglomerated in a single hard, flat, elevated plaque of infiltration upon the elbow or thigh. When the tubercles run together (become confluent) large plaques of infiltration may form, which are elevated and brownish or blackish in color.
The soft palate and larynx are often involved when the skin lesions are present. The voice may sound gruff and hoarse, and the tongue, the larynx and soft palate have been found studded with small sized, ashen-hued tubercles. These tumors or tubercles may degenerate and form into irregularly outlined, sharply cut, glazed ulcers, with a bloody or sloughing floor, or they may disappear and leave behind pigmented, shrunken depressions, or they lose their shapes from partial resorption. A large plaque may flatten in the center until an annular disk is left to show its former location. Coincident symptoms are disturbance in the functions of the sweat and sebaceous secretion, thinning and loss of hair in the regions involved, especially the eyebrows, and disorders of sensibility. Later results, are a nasal catarrh, atrophy of the sexual organs in both sexes, with impairment or loss of procreative power, hopeless blindness. However the course of the disease is very slow, and years may elapse before these several changes are accomplished. Often the disease appears quiescent for months at a time, after which fever occurs and with it acute or sub-acute manifestations appear, including gland disease, orchitis, ulcerative processes, slow or rapid, followed by gangrene and a relatively rapid progress is made toward a fatal conclusion.
Toward the last the mutilations effected by the disease may result. Parts of the fingers or toes, whole fingers or toes, and entire hand or foot may become wholly or partially detached by the ulcerative and other degenerations. This stage of this type of the disease may extend through ten or more years. After it has fully developed the dejected countenance of the leper, with his leonine expression and general appearance is highly characteristic.
LEPRA MACULOSA.—This form is more common in tropical countries and is distinguished chiefly by its macular (spotty) lesions. In size they vary from a small coin to areas as large as a platter. They are diffused or circumscribed, roundish or shaped irregularly, yellowish, brownish or bronzed in color, often shiny or glazed. They may be infiltrated and may be elevated, or on a level with the adjacent tissues. The patches are usually at first very sensitive, but they finally become insensitive, so that a knife can be thrust deeply into them without being felt. The regions chiefly affected by this type are the back, exposed parts, the backs of the hands and wrists, the forehead, the cheeks, ears, back of the feet, and ankles. The eruptions may be scanty or general; conspicuous or insignificant. The eruptive symptoms are associated commonly, early or late, with the serious phenomena described below.
LEPRA ANAESTHETICA. (Nerve Leprosy. Atrophic Leprosy. Lepra Trophoneurotica).—Before the development of this form of leprosy there may be one or two years of ill-health. Usually the skin at this time becomes in localized patches over-sensitive, sometimes there is over-sensitiveness and special nerves, because of their enlargement, become accessible to the touch. Those named later become tender, and the seat of lancinating or shooting pains. This clinical variety may be commingled in its symptoms with each of the other types. With or without such commingling, however, there commonly is noted, after exposure to cold or after being subject to chills first an eruption, red (erythematous) patches, or of "bullae," size of a bean on cheeks, ears, back of the feet, and ankles. The eruption may be outer skin covering (epidermis) and filled with a clear tinted or blood-mixed serum, and usually occurring upon the extremities. The scars that follow are shrunken (atrophic) patches, each often greater in extent than the base of the original trouble, color whitish, shiny, glazed, or better described as a tint suggesting the hue of mica; their outline is circular and form also the dumb-bell figure by running (coalescing) together, or juxtaposition. These scars are always without sensitiveness (anaesthetic), and they may exist together with spotted and non-sensitive patches upon the trunk or other parts such as the face, hands, feet, ankles, thighs, but rarely on the palms and soles. Neither those of the one class nor of the other, however, are disposed over the surface of the body in lines, bands or curves, corresponding with the distribution of the skin (cutaneous) nerves. Sometimes the ulnar and other nerves (median, posterior tibial, peroneal, facial and radial) that are accessible to the touch are swollen, tender, insensitive or as rigid as hardened cords. Reddish-gray swellings may be recognized by the eye along the nerve tract. General shrinking skin symptoms follow. The skin becomes dry and harsh; there is little or no sebaceous product and the skin of the face seems tightly drawn over the bones. As a consequence of deforming shrinking (atrophy) of the eyelids, a persistent overflow of tears, consequent eye changes follow, and a constant flow of saliva escapes from the parted lips. The fingers are half drawn into the palm of the hands; the nails are distorted and ulceration occurs later. These ulcers are irregular, oval, roundish or linear in form covered with thin blackish, flattened, tenacious crusts with soft bases, and their floors covered with a soft debris mixed with blood, the whole insensitive to every foreign body, and external application. At last the symptoms of mutilating lepra (leprosy) may occur, digits or portions of the wrist, part of hand (meta carpus) or corresponding portions of the foot may be detached from the body. Death may occur at any time during the course of the disease. In this form it is said to last from eighteen to twenty years and is thus not so rapidly fatal as the tubercular variety.
Treatment.—The main treatment is the isolation and segregation of all lepers from contact with the well; wholesome laws are enforced in some countries where leprosy prevails, and provision is made not only for the isolation and segregation, but also for their care. On account of its relative variety America has not yet awakened and legislation only forbids the entry of infected persons. At Molokai, in the Hawaiian Islands, provision is made for the care of lepers. Many of the public hospitals for the care of the sick poor refuse to receive lepers. The child of a leprous woman should be removed from the mother after birth and not nursed by another woman. No medicines are known to have any curative effect. An immediate change of residence and climate should be made if the patient happens to live in a district where the disease prevails. A highly nutritious diet should be taken.
The outlook.—The future is in general dark for the leper. It is often of a malignant character, and a fatal result is the rule. A change of climate and conditions may help. Scandinavian lepers who have removed to the United States have been greatly benefited by the change, but there is no known cure. The isolation should be as effective as that for tuberculosis. It is not contagious but infectious.
HYDROPHOBIA.—Rabies and hydrophobia are two different terms, meaning the same disease, the former meaning to rage or become mad. This term applies more especially to the disease as it exists in the maniacal form in the lower animals, while hydrophobia comes from the Greek, meaning "dread of water." As we occasionally find this dread of water only in the human subject, the term is properly used in such a case. The lower animals frequently attempt to drink water even though the act brings on a spasmodic contraction of the swallowing (deglutitory) muscles. Hydrophobia is an acute infectious disease communicated to man by the bite of an animal suffering from rabies. It is due to a definite specific virus which is transmitted through the saliva by the bite of a rabid animal. Its natural habitat (location) is the nervous system, and it does not retain its virulence when introduced into any other system of organs. It is essentially a nervous disease and transmitted by the saliva of rabid animals. When inoculated into a wound this virus must come in contact with a broken nerve trunk in order to survive and reproduce itself. If by accident it attacks the end of the broken nerve trunk, it slowly and gradually extends to the higher nerve centers and eventually produces the disease.
The incubation, or the time it takes for the disease to develop, varies, but usually is from three to six months. There is a recorded case where the person began to show symptoms of the disease thirteen days after having received a severe wound on the head. The incubation period is seldom longer than six months. The symptoms of the disease in the human being vary within narrow limits. There are three classic symptoms usually encountered, and these are fear, apprehension or excitement, together with deglutitory (swallowing) spasms, terminating in general paralysis. The patient remains conscious of his agony to the end, but the period of illness is of short duration, lasting from one to three days.
The bites of rabid dogs cause ninety per cent of the cases in man and animals. The cat is the next important factor in spreading the disease and about six per cent of the cases are caused by this animal. For other cases four per cent come from bites of horses, wolves, foxes, etc. The wolf in Russia, or other animals like it, may be the chief cause there; but dogs cause ninety per cent, taking all the cases found. Man, dog, cat, horse, cattle, sheep, goat, hog, deer, etc., are subject to the disease either naturally or experimentally. The disease is confined commonly to dogs, because the dog naturally attacks animals of his own species and thus keeps the disease limited mainly to his own kind. Naturally the dog follows this rule, but on the other hand, in the latter stages of the disease he usually goes to the other extreme and even attacks his own master, etc. The dogs that are the most dangerous and do the greatest damage are of the vicious breeds.
The rabbit or guinea pig is used for demonstration in the laboratory. Guinea pigs respond to the virus more rapidly than do other animals and therefore they are especially useful in diagnostic work. Rabbits, however, on account of the convenient size and ease with which they are operated upon, are usually the choice in the production of material used in treating patients.
The director of one Pasteur Institute says, "We have two classes of patients to deal with in the Pasteur institute. The larger class, of course, are those inoculated by the bite of rabid animals, but we also have a few who are infected by the rabid saliva accidentally coming in contact with wounds already produced. In these accidental eases the disease is almost as likely to result as in those to whom the virus is directly communicated by the bite." The wounds considered most dangerous are the recent fresh wounds. The possibility of infection decreases with the formation of the new connective tissue which protects the ends of the broken nerve fibres. One must remember, however, that wounds over joints, especially on the hands, are likely to remain open for some time. A dog ill of this disease can give the disease to man through licking a wound. Such a case has been recorded. This dog licked the child's hands before it was known to be mad. The child died from the disease. As stated before ninety per cent of the cases are inoculated by the bites of rabid animals.
The wounds are considered according to their severity and location. Lacerating, tearing wounds upon uncovered surfaces, especially the head, are the most dangerous. This is due to the fact of the closeness of the brain and the large amount of infection in such a wound, and for this reason treatment should be immediately given. But smaller wounds should also be treated for the smallness of the wound furnishes no sure criterion as to the future outcome of the disease. All possible infections should be regarded as dangerous when considering the advisability of taking the Pasteur Treatment. The small wound has usually a longer period of incubation, because of the small amount of infection, still it may cause a fatal termination. A dog never develops rabies from a lack of water or from being confined or overheated during the summer months. A spontaneous case of rabies has never been known. It must be transmitted from animal to animal and the history of the case will point to a previous infection by a diseased animal.
Where rigid quarantine rules exist the disease does not occur. In Australia they quarantine every dog, that comes to that country, for six months, and in consequence they have never had a case of rabies. In Russia they have had many cases. In Constantinople the disease frequently "runs riot." France has lost as many as 2,500 dogs in one year. Before the Pasteur Treatment was instituted (in 1885) there was an average of sixty deaths in human beings in the Paris hospitals.
Belgium and Austria average one thousand dogs annually. There was a yearly average in Germany of four hundred dogs, dying of rabies, until the law requiring the muzzling of dogs was strictly enforced and since that time the disease is practically unknown. We do not have strict quarantine laws against dogs, and the result is death from hydrophobia in many states annually. It was formerly believed that rabies was a hot weather disease. The number of cases during the winter months of late years has disproved that belief, for the records of the institute for treatment of hydrophobia at Ann Arbor have shown a decrease of cases during the summer months. This was before 1908. This shows that rabies is not a hot weather disease.
Ordinarily cases of rabies occur here and there (sporadic), but if the conditions are favorable epidemics break out. One dog may bite several dogs and these dogs bite others and thus spread the disease to many. Not every animal bitten by a mad dog develops the disease. The disease does not always follow the bite. Only about forty per cent of all animals bitten by a mad dog contract the disease. This is given by a noted authority. Statistics also show that in man the disease develops in only about twenty per cent of the cases in those who have been bitten by rabid dogs. But in dealing with those who have been bitten such measures should be taken as would be if they were certain of developing the disease; one cannot tell how much poison enters the system in such cases and preventive procedures should be taken. There are reasons why everyone who is bitten does not contract the disease.
The location and character of the bite must be considered. Bites on the head, neck and hands have been recognized as more dangerous, from early times, and such bites produce fatal results quicker than do bites on other parts of the body, and the reason is largely due to the fact that the other parts of the body are more or less protected by the clothing, and this clothing prevents the entrance of so much poison into the system. Bites on the head give a high mortality rate and are rapidly fatal. The close proximity to the brain is one reason.
The part the clothing plays in protection is clearly shown by the following quotation from an eminent authority: "In India where the natives dress very scantily, the mortality was exceedingly high up to a few years ago, at which time the British introduced the Pasteur laboratories. The clothing protects the body and it holds back the saliva and can be looked upon as a means of filtering the saliva of the rabid animal, most of the saliva is held back as the teeth pierce the clothing, so that upon entering the flesh the teeth are practically dry, and only a portion of the virus is introduced. Upon entering the wound this small amount of virus is further diluted by the tissue juices to the non-infectious point. We know from actual experimental work in the laboratory that the higher dilution will not kill."
If a portion of the brain of an animal dead from street virus is taken and made up in a dilution of one to five hundred, and this is injected, we find that it does not produce death. But a dilution of one to three hundred will invariably kill. This is practically what very often happens when one is bitten through the clothing. The saliva may be filtered and held back so that a small amount is introduced; perhaps a dilution of one to five hundred of the virus may get into the wound, but this is usually not enough to cause the disease. There is no possible way of estimating the amount of the inoculation. In such cases one's chances of never contracting the disease are only decreased; that is all we can say.
The treating of individuals, bitten by rabid animals, in the Pasteur Institutes, is simply the practical application of results obtained by Pasteur from his original work on rabies virus. Pasteur was a French chemist living in Paris, and he began his search for the cause and cure of rabies in 1880. He hoped to find a sure method of preventing the development of the dread disease, even if he could not find a cure for it after it had developed. While he was pursuing this research Pasteur had access to the cases of rabies in the Paris hospitals, and these numbered sixty each year. He had practically an unlimited supply, for France could furnish him with twenty-five hundred more mad dogs, and a large number of other animals each year.
Pasteur devoted the remainder of his life to the study of this subject. He collected some saliva from the mouth of a child, on December 11, 1880, who had died at the Hospital Trousseau four hours before. This saliva he diluted with distilled water, and this mixture he injected into rabbits, and they all died, and the saliva taken from these rabbits when injected into other rabbits caused their death with rabies. He found also that saliva from rabid dogs almost always caused the disease. The incubation period varied within wide limits, and very often the animals lived. He then used the blood of rabid dogs for inoculation, but these blood inoculations always failed to produce the disease. Pasteur was convinced after careful study of rabid animals during the many months necessary to complete his experiments, that rabies was a disease of the nervous system, and that the poison (virus) was transmitted from the wound to the brain by the way of the nerve trunks. Then to prove his theory Pasteur removed a portion of the brain of a dog that had died of rabies. A part of this was rubbed up in sterile water and used to inoculate other animals; and subcutaneous inoculations with this material almost always produced death.
After this Pasteur tried a new method and injected directly into the nervous system, either into the nerve trunk or directly into the brain, after trephining, and all such injections produced rabies in the injected animal and death. He also found that rabbits inoculated in the brain always died in the same length of time. When he injected into the nerve trunk the inoculation period was longer, depending upon the distance from the brain. Two problems now remained for Pasteur to solve, and these were, how could he obtain the definite virulence and how could he reduce the virulence regularly and gradually, so that it could be used by inoculation safely as a vaccine to produce immunity to rabies in healthy animals, and also to prevent the development of rabies in animals bitten by rabid animals. He first tried successive inoculations. These inoculations were made, after trephining, directly to the brain, and he used a portion of the brain as a virus each time. He inoculated rabbit number one with a portion of brain taken from a rabid dog, and this rabbit died on the fifteenth day. He then inoculated rabbit number two with a portion of the brain of rabbit number one; from the brain of rabbit number two the virus was supplied for inoculating rabbit number three, and thus the brain of each inoculated rabbit was taken, after its death, for material to inoculate the next rabbit in the series. This experimentation showed him that each rabbit in the series died a little sooner, showing that the virus was becoming more virulent, till no increase in activity of the poison was shown after the fiftieth successive inoculation. "Rabbits inoculated with a brain suspension of rabbit number fifty all died in seven days." This caused Pasteur to name the virus of number fifty "virus fixe," a virus of definite length. He now had obtained a virus of definite strength and the next question was, how could the virulence be gradually and definitely reduced.
This he accomplished after many experiments. He proved that pieces of the "medulla oblongata" suspended in sterile tubes which contained fragments of caustic potash, steadily and gradually reduced their virulence as they dried, till the fourteenth day, when they were practically inert. New specimens were prepared each day and cords which had dried in one day Pasteur called "one-day virus;" cords which had dried in two days, "two day's virus," and so on up to the fourteenth day. With this graduated virus he now experimented on dogs, and the injection he used on the first day consisted of an emulsion of fourteen-day virus; for the second day, the thirteen-day virus, thus using a stronger virus each day, until on the fourteenth day he used the full strength virus. This treatment produced what is called immunity in the dog, and even the direct inoculation into the brain of the strong virus would not produce death.
After Pasteur had thoroughly satisfied himself by repeated trials, he announced his wonderful discovery, and it was in 1886 that Pasteur considered the preventive inoculation in human beings as resting upon a satisfactory experimental basis. During these five years this eminent man proved that it was possible to protect or immunize the lower animals, rabbits and dogs, against inoculation with the virulent virus.
The efficiency of this immunity was given trials by different methods of inoculation. It was found that sixty per cent of dogs inoculated under the "dura" (a membrane of the brain) were saved if treatment was given the second day. This test is more severe than is required to meet the ordinary infection of rabies. Pasteur, after a series of these final tests were so convincing, prescribed the preventive inoculations in human beings and on July 6th, 1886, the first human patient received the first treatment of his series of inoculations.
The method of obtaining the attenuated virus used in the treatment is as follows: A rabbit is inoculated by the brain method before described, each day, with suspension of the fresh, fixed virus. These rabbits die in six days after the inoculation. In this way a rabbit dies each day; the spinal cord is removed, divided into sections, and suspended in a flask containing potassium hydrate. The action of potassium hydrate is drying (desiccating). A series of these cords, which have been hung on fourteen successive days, are always kept in stock for the treatment of patients. The virus becomes less active with each successive day of exposure to drying (desiccation) and finally the virulence is altogether lost.
When the patient comes for treatment the fourteenth and thirteenth-day cords are used for the first inoculation, and on each successive day the patient receives inoculation, the strength of which has been regulated by the number of days the cord has been hanging. During the first four days patients receive injections of six cubic centimeters of emulsions made from cords aging from fourteen to seven days, and from the fifth day until the completion of the course of treatment patients receive emulsions from cords of higher immunizing properties, but no cords desiccated for less than four days are used.
Death rate from 1878-1883 before Pasteur treatment was instituted taken from documents in the department of the Seine:
1878 143 bitten. 24 deaths. 1879 76 " 12 " 1880 68 " 5 " 1881 156 " 22 " 1882 67 " 11 " 1883 45 " 6 "
Average of one death to every six bitten, or seventeen per cent mortality.
Incubation period from eleven days to thirteen months, average one hundred and twenty days, depending upon location of bite. Pasteur Institute records during the years 1886-1887 and first half of 1888, show that Pasteur had under his supervision 5,374 persons bitten by animals either proven or thought to have been mad. Mortality for 1886 was 1-34 per cent, during 1887 it was 1-12 per cent, during 1888 it was 77/100 per cent. With the later treatment the mortality has decreased to 3-10 per cent in 1908. The Pasteur method of treatment is a process of immunization which must be completed before the development of the disease. It is of no value after the symptoms have appeared.
Those who have not been affected can be immunized the same as those who have been bitten. The individual who has been bitten by a mad dog realizes when and how severely he has been bitten, and were it not for the so-called period of latent development of the virus, it would not be possible to carry out the Pasteur treatment. The patient may, if he will, take advantage of this fact and be immunized by treatment before the disease has developed. Deep and severe bites are most dangerous, but the disease may develop simply from a rabid dog licking a scratch of the skin. As before stated bites on exposed or uncovered surfaces, are more dangerous than those through clothing. There is a very easy access of the saliva to the wound in the unprotected part, while in the protected parts the teeth in passing through the protection, clothing, are freed of their saliva at least partially. The virus is conveyed from the bitten part or inoculation to the central nervous system through the nerve trunk, and the rapidity of extension depends upon the resistant powers of the patient, the virulence and the amount of virus deposited in the bitten part at the time the person was bitten. This disease develops only in nerve tissues. Virus can be found in the nerves of the side bitten, while the corresponding nerves on the opposite side are free from it. It can be ascertained that the virus is present in the medulla oblongata before the lower portion of the cord.
Comparative danger.—A wound of the hand after a delay of three weeks is as dangerous as a bite on the head exposed only a few days. There is always a possibility of an accumulative action and extension of the virus along the nerve trunk to the central nervous system during the interval of exposure, and this should be always borne in mind. It is stated by authority that the virus is not transmitted by the bite of a rabid animal until two days previous to the appearance of the first symptoms. It is with some difficulty that a decision is reached in advising patients who are bitten to take treatment early in the course of the disease. The symptoms are often so very obscure and slight that they are not recognized. If a dog which is not naturally vicious suddenly bites without any cause it should be tied securely and watched for seven days; and should it develop symptoms of the disease during this period the bite should be considered dangerous.
Immediate treatment of the wound.—A temporary measure is the cauterization of the wound; do not neglect this because a few hours have passed since the person was bitten, for wounds may be cauterized with advantage even after two or three days have elapsed. Of course the earlier it is done the better. If they are thoroughly laid open and scrubbed it is more effective. Nitric acid used freely is the best method to use. Wash the wound freely with boiled water after the acid has been applied; ninety-five per cent carbolic acid may be used if nitric acid cannot be obtained.
If carbolic acid is used it is necessary that it be washed from the wound by the free use of absolute alcohol, followed by boiled water and a dressing of bichloride of 1-7000. This prevents the ulceration of the wound by the carbolic acid. Cauterization thoroughly done destroys a part of the inoculated virus. Thorough cauterization is especially necessary with large wounds in which large quantities of the virus is inoculated.
When to send patients to an Institute.—Send them immediately, if there is good reason to believe the animal had rabies. It is not wise to wait until the animal dies; it is very important that treatment is begun as soon as possible, especially in severe bites.
What to send for examination.—The entire head may be sent by express, or better, the health officer should bring it in person. This saves time and relieves anxiety; or a portion of the brain may be removed under thoroughly clean conditions and placed in a sterilized twenty per cent solution of glycerin and water. In this way the virus retains its virulence and putrefaction is diminished. The first method is the best, taking the head directly. The head after it reaches the laboratory is examined microscopically for "negri bodies," and if there is no contamination the microscopic findings are verified by animal inoculations. The presence of negri bodies in a specimen is of great value owing to the rapidity with which a diagnosis can be made. In one case a positive diagnosis was reported within twenty minutes after the specimen entered the laboratory and within the next hour and a half the patient bitten by the dog the same day had begun her course of protective injections and was saved.
Protection.—To stamp out this disease city authorities, etc., can enact laws. All ownerless dogs should be killed, and the keeping of useless dogs should be discouraged by taxation. All dogs should be thoroughly muzzled where the disease prevails. This article is made up from an article written by an acknowledged authority on this disease, a man in charge of a Pasteur Institute.
Cities where Pasteur Institutes are located:Ann Arbor, Michigan. Baltimore, Maryland.Chicago, Illinois. Austin, Texas.Minnesota. Toronto, Ont.New York City.
Anaemia, or Anemia.—This may be defined as a reduction of the amount of blood as a whole or of its corpuscles, or of certain of its more important constituents, such as albumin and haemoglobin. Primary or essential anemia includes chlorosis and pernicious anemia; secondary anemia results from hemorrhages, poor nourishment or intoxications, poisons. Chlorosis, a primary anemia chiefly of young girls, characterized by marked relative decrease of haemoglobin.
Causes.—It usually occurs in blondes of from twelve to twenty years of age and most often from fourteen to seventeen years of age, when the menstrual function is being established and during which time they are rushed with their school work. There may be a family history of chlorosis or tuberculosis. Poor food, hard, unhealthy work, confinement in close unventilated rooms are other causes.
Symptoms.—Rounded fleshy appearance may continue. There is some difficulty of breathing, palpitation of the heart on slight exertion, from a fright or from excitement, tendency to faint feeling or even fainting, headache, a tired feeling, hard to stir or do anything, irritable temper, poor or changeable appetite, the digestion is disturbed, there is constipation, coldness of the hands and feet, difficult menstruation, irregular menstruation, leucorrhea, amenorrhea, and sometimes there is a slight fever. The color is often of a yellowish-green tinge, and this is more noticeable in the brunette type, though the cheeks may be flushed; the whites of the eyes bluish white in color. The heart sounds are not right. The blood is pale in color. The red cells are diminished, but usually are not below eighty per cent of the normal; the haemoglobin is greatly reduced, sometimes to thirty-five or forty per cent. The age, greenish tint of pallor, bluish whites of the eyes, poor nutrition, etc., aid in making the diagnosis.
Treatment.—Fresh air, good food, care of the bowels and rest if the symptoms are severe. When it is not so severe, plenty of outdoor exercise is necessary and beneficial. That takes them away from their cramped sedentary life and gives the sunshine, good pure air, and change of the scene. Horseback riding is a very good form of exercise, but it should be slow riding. "Tending" the horse is also good, and sleeping in the open air is excellent. Automobile riding is too straining and should not be indulged in.
1. Blaud's pills are very much used. The formula follows:
Dried Sulphate of Iron 2 dramsCarbonate of Potash 2 dramsSyrup Sufficient
Mix thoroughly, and make forty-eight pills. Take one to three pills, three times a day after meals.
2. Fowler's solution of arsenic is also very good remedy; three to four drops three times a day. It must be watched for bad symptoms and should only be taken under a physician's supervision.
Diet.—This should be good and varied to suit the special taste, and as the stomach and bowels are usually disordered such food should be chosen as will best agree. Diet plays a very important part.
PERNICIOUS ANAEMIA.—This is characterized by great decrease of the red cells of the blood with a relatively high color index and the presence of large number of germs. The causes are unknown.
Condition.—The body is not emaciated. A lemon color of the skin is usually present. The muscles are a dark red, but all the other organs are pale and fatty. The heart is large and fatty. The liver and spleen are normal in size, or only slightly enlarged with an excess of iron in the pigment. The red cells may fall to one-fifth or less of the normal number. The rich properties of the blood are fearfully decreased.
Symptoms.—Stomach and bowels, dyspepsia, nausea and vomiting, or constipation, may precede other symptoms or they may last throughout the case. The onset is gradual and unknown, with gradually increasing weary feeling, paleness and some difficulty in breathing and palpitation of the heart on exertion. There is paleness of the skin and the mucous membranes, the lips look pale, no color. The paleness becomes extreme, the skin often having a lemon yellow tint. The muscles are flabby; the ankles are swollen, you can see the arteries beat. Hemorrhages may occur into the skin, mucous membrane and retina of the eye. Nervous symptoms are not common. The pallor and weakness become extreme, sometimes with intervals of improvement and death usually occurs. The following is Addison's description given by Dr. Osler:
It makes its approach in so slow and insidious a manner that the patient can hardly fix a date to the earliest feeling of that languor which is shortly to become extreme. The countenance gets pale, and white of the eyes become pearly, the general frame flabby rather than wasted. The pulse perhaps larger, but remarkably soft and compressible, and occasionally with a slight jerk, especially under the slightest excitement. There is an increasing indisposition to exertion, with an uncomfortable feeling of faintness or breathlessness in attempting it; the heart is readily made to palpitate; the whole surface of the body presents a blanched, smooth and waxy appearance; the lips, gums and tongue seem bloodless, the flabbiness of the solid increases, the appetite fails, extreme languor and faintness supervene, breathlessness and palpitation are produced by the most trifling exertion, or emotion; some slight oedema (swelling) is probably perceived about the ankles; the debility becomes extreme. The patient can no longer rise from the bed; the mind occasionally wanders; he falls into a prostrate and half torpid state and at length expires; nevertheless, to the very last, and after a sickness of several months' duration, the bulkiness of the general frame and the obesity (fat) often present a most striking contrast to the failure and exhaustion observable in every other respect. The disease is usually fatal.
Treatment.—The patient should remain in bed and should use a light nourishing diet, taking food in small amounts and at stated intervals. Rest in bed is essential. Dr. Osler treated a case in the following way: I usually begin with three minims (drops) of Fowler's solution of arsenic three times a day and increase the dose to five drops at the end of the first week; to ten at the end of the second week; to fifteen at the end of the third week, and if necessary go up to twenty or twenty-five. Symptoms of an overdose are rare; vomiting and diarrhea occur. Then the medicine must be discontinued for a few days.
SECONDARY ANEMIA. Causes.—Hemorrhage form (bleeding). (a) Rapid bleeding from the rupture of an aneurism, from a blow, or eating into the blood vessels by an ulcer. (b) Slow bleeding as from nose-bleed, flow from the womb, piles or in "bleeders" people who bleed readily.
2. Inanition form.—Not nourished because of interference in taking food or assimilating food, from cancer of the gullet, or disease of the stomach.
3. Toxic poison cases; from acute and chronic diseases, such as typhoid fever, tuberculosis, rheumatism, syphilis, malaria, nephritis; or chronic lead poisoning, mercury, arsenic, and copper poisoning.
Symptoms.—There is pallor, dizziness, headache, palpitation and dyspnoea, difficult breathing on exertion; there is weakness, tendency to fainting, poor appetite, dyspepsia and constipation. The red blood cells are diminished, also the haemoglobin. Death may occur from a single hemorrhage.
Treatment.—Remove the cause and rest. Good fresh air, good easily digested food. The bowels must be kept regular. Iron and arsenic are good remedies if necessary. It is not possible to give special directions. A person in this condition needs a good physician. There is no time to waste. Iron and arsenic are good remedies, but they must be used intelligently and in proper doses. Blaud's pill is good in some cases. It contains iron. Also Fowler's solution of arsenic.
LEUKAEMIA.—An affection characterized by persistent increase in the white blood corpuscles, associated with changes, either alone or together, in the spleen, lymphatic glands and bone-marrow.
1. Spleen and Bone-Marrow, (Spleen-Medullary) type.—The changes are especially localized in the spleen and in the bone-marrow while the blood shows a great increase in elements which are derived especially from the latter tissue.
2. Lymphatic Type.—The changes in this type are chiefly localized in the lymphatic apparatus, the blood showing an especial increase in those elements derived from the lymph glands.
Causes—Unknown. It is most common before middle age.
Symptoms.—Either type may be acute or chronic. The invasion may be gradual, sometimes with disturbance of the stomach and bowels, or nose-bleed. (a) The first type is the common one. The spleen generally becomes enlarged; it is sometimes tender and painful, it may occupy over half of the abdominal cavity and varies in size after a hemorrhage, diarrhea or after a meal. There may be paleness of the face, etc., early and late nausea, vomiting, diarrhea, and dysentery are common, as is also ascites (dropsy in the abdomen). The pulse is rapid, full and soft. Fever is usual. Hemorrhages occur in the skin, retina, pleura, peritoneum, etc. Headache, dizziness, short breathing, and fainting may occur from the anemia. The liver may be enlarged. The blood shows a great increase in the white cells. Sometimes they are more numerous than the red blood cells. (b) Lymphatic type is rare, various groups of the lymph glands are enlarged, usually separate, but sometimes matted together; others, such as the tonsils may become large. The blood shows an increase of the white cells, but less than in the other form. The spleen is usually somewhat enlarged. Recovery is rare; the lymphatic cases may last only six or eight weeks. The course is usually progressive for two or three years.
Treatment.—The same as for Pernicious Anaemia.
FALSE LEUKAEMIA. (Pseudo-Leukaemia).—Also called Hodgkin's disease, malignant lymphoma, and general lymphadenoma. This is a progressive anemia and enlargement of the lymph glands and the skin, with secondary lymphoid growth in the liver, spleen and other organs.
Causes.—Males are more affected than females, and usually young persons. Continual local irritation causes a local enlargement of the gland, but the actual cause is unknown.
Symptoms.—The lymph glands of the neck, arm-pit or groin are enlarged and without any pain, followed by anemia, loss of strength and slight fever. The glands enlarge slowly or rapidly, forming large masses, while the growth extends to other regions. The spleen may be felt; the skin may be bronzed. In cases with involvement of deep seated nodes the first symptoms may be those of pressure on blood vessels, nerves, trachea, bronchial tubes or other structures.
Treatment.—Cut them out if they are small and localized. Arsenic, quinine, cod-liver oil are good medicines.
PURPURA.—This is not strictly a disease, but a symptom. This includes a group of affections characterized by hemorrhages into the skin.
Symptoms.—There are hemorrhages into the skin, and this takes the form of small blood spots underneath the skin, (petechia) and spots like the bursting of a blood vessel shows vibices or ecchymoses. The first are in small minute points and appear, as a rule, in the hair follicles and unlike the erythemas (redness) do not disappear upon pressure. Another kind occurs as streaks, while the ecchymoses are larger, but similar in nature to the first kind. They may be larger than a split pea, and they range from a deep red to a livid bluish tint. They assume a yellowish brown, then a yellow color, as they fade away and finally disappear. This eruption appears in a series of crops and the legs are the usual seat.
1. Symptomatic Purpura. (a) Infectious. Occurs in typhus fever, endocarditis, cerebro-spinal meningitis, typhoid fever, etc. (b) Toxic; from snake bites, iodide of potash, quinine, copaiba, bella donna, ergot, etc., and with jaundice. (c) Cachectic; with cancer, tuberculosis, leukaemia, false leukaemia, scurvy, etc. (d) Neurotic; with hysteria, neuralgia, and some organic disease. (e) Mechanical; due to violent effort and poor venous circulation.
2. Type arthritic purpura. (a) Simple Purpura. A mild form usually occurring in children, sometimes with pains in the joints, rarely any fever. There is anemia, disturbance of the stomach and purpuric spots on the legs, often on the arms and trunks. (b) Rheumatic purpura; this usually occurs in men from twenty to forty years old. There is usually pain and swelling of several joints, temperature 101 to 103 degrees, purpuric eruption chiefly on the legs and about the affected joints, often with hives and digestive disturbances: (c) Henoch's purpura; usually in children and is sometimes fatal. There are recurrent joint pains and swelling, disturbances of the stomach and bowels, skin troubles resembling it, and hemorrhage from mucous membrane.
PURPURA HAEMORRHAGIC.—This is a severe form, usually seen in delicate girls. The cause is unknown.
Symptoms.—Weakness, extensive purpuric spots (small blood spots in the skin), eruption, hemorrhages from the mucous membranes which may cause secondary anemia, slight fever, slow clotting of the blood. The duration is from ten to fourteen days. Death may occur within a day in cases marked by profuse bleedings into the skin and prostration.
Treatment.—Remove the causes. Fresh air, food and tonics, etc. This disease is serious and needs careful treatment from a physician.
HAEMOPHILIA. "Bleeders."—This is a hereditary disorder characterized by a tendency to persistent bleeding, spontaneously or even after a slight injury.
Causes.—Usually hereditary through many generations. It is transmitted through daughters, themselves usually not "bleeders," to their male children. It is found most often in the Anglo-German races.
Condition.—The blood vessel walls are thin; the skin is delicate, clotting of the blood is usually retarded.
Symptoms.—It comes spontaneously or after only slight wounds; the person is extremely delicate. The bleedings occur from the skin, or mucous membrane, or from wounds, but rarely during menstruation or confinement. They vary from small spots to bleeding which may end fatally, or in recovery with marked anemia. There may be pain and swelling of the joints, etc., and this may leave deformities resembling deformed arthritis. The result is worse the earlier the disease shows itself. They may live to old age.
Treatment.—Avoid, as much as possible, wounds and operations in "bleeding" families. Marriage of the women should be discouraged. For bleeding: rest, ice, tannic or gallic acid or adrenalin locally if the bleeding points can be reached. Plug the nostrils for nose-bleed both behind and in front.
SCURVY. (Scorbutus).—A constitutional disease characterized by weakness, anemia, sponginess of the gums and tendencies to bleeding.
Causes.—This disease has been called "The calamity of sailors." It has been known from the earliest times, and has prevailed particularly in armies in the field and among sailors on long voyages. It has become a very rare disease in the United States.
Predisposing Causes.—Overcrowding; dark unhealthy rooms; prolonged fatigue; mental depression.
Exciting Cause.—The lack of fresh vegetables, poisoning from slightly tainted food, or an infection. The gums are swollen, sometimes ulcerated, skin is spotted, bluish, etc,
Symptoms.—It comes on gradually (insidiously). There is loss of weight, progressively developing weakness and pallor, very soon the gums are swollen and look spongy and bleed easily. The teeth may become loose and fall out. The breath is very foul. The tongue is swollen, but it may be red and not coated. The skin becomes dry and rough and (ecchymoses) dark spots soon appear, first on the legs, and then on the arm and trunk and particularly about the hair follicles. These are spontaneous or follow a slight injury. In severe cases hemorrhages under the periosteum (the covering of the bones) may cause irregular swelling, especially in the legs, and these may break down and form ulcers. The slightest bruise or injury causes hemorrhages into the injured part. Extravasion under the skin, especially in the lower extremities may be followed by permanent hardness (induration) and stiffness due to connective tissue infiltration (scurvy sclerosis). There may be pains in the joints and often watery swelling (oedema) of the ankles. Bleeding from internal mucous membranes is less common than from the skin. The appetite is poor, palpitation of the heart and feebleness and irregularity of the pulse are prominent symptoms. Owing to the sore gums the patient is unable to chew the food. The urine often contains albumin and is scanty and concentrated. There are weariness, depression, headache and finally delirium or coma, or symptoms due to hemorrhages within the brain; or day and night blindness may be present.
Recovery.—The patient will recover if the cause can be removed, unless it is far advanced. Death may result from complications.
Treatment. Preventive.—Fresh or canned vegetables or fruit must be eaten.
Treatment for the attack.—Dr. Osler, of England, says: "I think the juice of two or three lemons daily and a diet of plenty of meat and fresh vegetables will cure all cases unless they are far advanced. For the stomach small quantities of scraped meat and milk should be given at short intervals, and the lemon juice in gradually increasing quantities. As the patient gains in strength you can give a more liberal diet, and he may eat freely of potatoes, cabbage, water cresses, and lettuce. A bitter tonic may be given. Permanganate of potash or dilute carbolic acid forms the best mouth-wash. Penciling the swollen gums with a tolerably strong solution of nitrate of silver is very useful. Relieve the constipation by enemas."