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In Human Beings.
The disease of hydrophobia has been known from early times, and is alluded to in the works of Aristotle, Xenophon, Plutarch, Virgil, Horace, Ovid and many others, as well as in those of the early writers on medicine. Celsus gives detailed instructions respecting the treatment of men who have been bitten by rabid clogs, and dwells on the dangers attending such wounds. After recomlnendmg suction of the bitten pnt~t by means of a dry cupping glass, and thereafter the application of the actual cautery or of strong caustics, and the employment of baths and various internal remedies, he says: Idque cum ita per triduum factum est, tutus esse honio a periculo videtur. Solet autem ex eo vulnere, ubi parum occursum est, aquae timor nasci, ~po4iof3~aJ Gracci appellant. Miserrimum genus morbi; in quo simul aeger et siti et aquae metu cruciatur; quo oppressis in angusto spes est. Subsequently Galen described minutely the phenomena of hydrophobia, and recommended the excision of the wounded part as a protection against the disease. Throughout many succeeding centuries little or nothing was added to the facts which the early physicians had made known upon the subject. The malady was regarded with universal horror and dread, and the unfortunate sufferers were generally abandoned by all around them and left to their terrible fate. In later times the investigations of Boerhaave, Gerard van Swieten (1700-1772), John Hunter, Francois Magendie (1783-1855), Gilbert Breschet (1784-1845), Virchow, Albert Reder, as also of William Youatt (1776-1847), George Fleming, Meynell, Karl Flertwig (1798-1881), and others, have furnished important information; but all these were put into the shade by the researches of Pasteur.
The disease is communicated by the secretions of the mouth of the affected animal entering a wound or abrasion of the human skin or mucous membrane. In the great majority of cases (90%) this is due to the bite of a rabid dog, but bites of rabid cats, wolves, foxes, jackals, &c.. are occasionally the means of conveying the disease. Numerous popular fallacies still prevail on the subject of hydrophobia. Thus it is supposed that the bite of an angry (log may protluce the disease, and all the more if the animal should subsequently develop symptoms of rabies. The ground for this erroneous notion is the fact, which is unquestionable, that animals in whom rabies is in the stage of incubation, during which there are few if any symptoms, may by their bites convey the disease, though fortunately during this early stage they are little disposed to bite. The bite of a non-rabid animal, however enraged, cannot give rise to hydrophobia.
The period of incubation of the disease, or that time which elapses between the introduction of the virus and the developinent of the symptoms, appears to vary in a remarkable degree, being in some cases as short as a fortnight, and in others as long as several months or even years. On an average it seems to be from about six weeks to three months, but it mainly depends on the part bitten; bites on the head are the most dangerous. The incubation period is also said to he shorter in children. The rare instances of the appearance of hydrophobia many years after the introduction of the poison are always more or less open to question as to subsequent inoculation.
When the disease is about to declare itself it not unfrequently happens that the wound, which had quickly and entirely healed after the bite, begins to exhibit evidence of irritation or inflammatory action, or at least to be the seat of morbid sensations such as numbness, tingling or itching. The symptoms characterizing the premonitory stage arc great mental depression and disquietude, together with restlessness and a kind of indefinite fear. There is an unusual tendency to talk. and the articulation is abrupt and rapid. Although in some instances the patients ~vill not acknowledge that they have been previously bitten, and deny it with great obstinacy, yet generally they are well aware of the nature of their malady, and speak despairingly of its consequences. There is in this early stage a certain amount of constitutional disturbance showing itself by feverishness, loss of appetite. sleeplessness, headache, great nervous excitability, respiration of a peculiar sighing or sobbing character, and even occasionally a noticeable aversion to liquids. These symptoms constituting what is termed the melancholic stagecontinue in general for one or two days, when they are succeeded by the stage of excitement in which all the characteristic phenomena of the malady are fully developed. Sometimes the disease first shows itself in this stage, without antecedent symptoms.
The agitation of the sufferer now becomes greatly increased, and the countenance exhibits anxiety and terror. There is noticed a marked embarrassment of the breathing, but the most striking and terrible features of this stage are the effects produced by attempts to swallow fluids. The patient suffers from thirst and desires eagerly to drink, hut on making the effort is seized with a most violent suffocative paroxysm produced by spasm of the muscles of swallowing and breathing, which continues for several seconds, and is succ~ded by a feeling of intense alarm and distress. With great caution and determination the attempt is renewed, but only to be followed with a repetition of the seizure, until the unhappy sufferer ceases from sheer dread to try to quench the thirst which torments him. Indeed the very thought of doing so suffices to bring on a choking paroxysm, as does also the sound of the running of water. The patient is extremely sensitive to any kind of external impression; a bright light, a loud noise, a breath of cool air, contact with any one, are all apt to bring on one of these seizures. But besides these suffocative attacks there also occur general convulsions affecting the whole muscular system of the body, and occasionally a condition of tetanic spasm. These various paroxysms increase in frequency and severity with the advance of the disease, but alternate with intervals of comparative quiet, in which, however, there is intense anxiety and more or less constant difficulty of breathing, accompanied with a peculiar sonorous expiration, which has suggested the notion that the patient barks like a dog. In many instances there is great mental disturbance, with fits of maniacal excitement, in which he strikes at every one about him, and accuses them of being the cause of his sufferingsthese attacks being succeeded by caIrn intervals in which he expresses great regret for his violent behaviour. During all this stage of the disease the patient is tormented with a viscid secretion accumulating in his mouth, which from dread of swallowing he is constantly spitting about him. There may also be noticed snapping movements of the jaws as if he were attempting to bite, but these are in reality a manifestation of the spasmodic action which affects the muscles generally. There is no great amount of fever, but there is constipation, diminished flow of urine, and often sexual excitement. - -
After two or three days of sufferifig of the most terrible description the patient succumbs, death taking place either in a paroxysm of choking, or on the other hand in a tranquil manner from exhaustion, all the symptoms having abated, and the power of swallowing returned before the end. The duration of the disease from the first declaration of the symptoms is generally from three to five days.
Apart from the inoculation method (see below), the treatment of most avail is that which is directed towards preventing the absorption of the poison into the system. This may be accomplished by excision of the part involved in the bite of the rabid animal, or, where this from its locality is impracticable, in the application to the wound of some chemical agent which will destroy the activity of the virus, such as potassa fusa, lunar caustic (nitrate of silver), or the actual cautery in the form of a red-hot wire. The part should be thproughly acted on by these agents, no matter what amount of temporary suffering this may occasion. Such applications should be resorted to immediately after the bite has been inflicted, or as soon thereafter as possible. Further, even though many hours or days should elapse, these local remedies should still be applied; for if, as appears probable, some at least of the virus remains for long at the injured part, the removal or effectual destruction of this may prevent the dread consequences of its absorption. Every effort should be made to tranquillize and reassure the patient.
Two special points of interest have arisen in recent years in connection with this disease. One is the Pasteur treatment by inoculation with rabic virus (see also PARASITIC DISEASES), and the other was the attempt of the government to exterminate rabies in the British Isles by muzzling dogs.
The Pasteur treatment was first applied to human beings in 1885 after prolonged investigation and experimental trial on animals. It is based on the fact that a virus, capable of giving rabies by inoculation, can be extracted ~ from the tissues of a rabid animal and then intensified or attenuated at pleasure. It appears that the strength of the rabic virus, as determined by inoculation, is constant in the same species of animal, but is modified by passing through another species. For instance, the natural virus of dogs is always of the same strengt.h, but when inoculated,into monkeys it becomes weakened, and the process of attenuation can be carried on b3 passing the virus through a succession of monkeys, until ii loses the power of causing death. If this weakened virus is then passed back through guinea-pigs, dogs or rabbits, it regaim HYDROPHOBIA
its former strength. Again, if it be passed through a succession of dogs it becomes intensified up to a maximum of strength which is called the virus fixe. Pasteur further discovered that the strength can be modified by temperature and by keeping the dried tissues of a rabid animal containing the virus. Thus, if the spinal cord of a rabid dog be preserved in a dry state, the virus loses strength day by day. The system of treatment consists in making an emulsion of the cord and graduating the strength of the dose by using a succession of cords, which have been kept for a progressively diminishing length of time. Those which have been kept for fourteen days are used as a starting-point, yielding virus of a minimum strength. They are followed by preparations of diminishing age and increasing strength, day by day, up to the maximum, which is three days old. These are successively injected into the circulatory system. The principle is the artificial acquisition by the patient of resistance to the rabic virus, which is presumed to be already in the system but has not yet become active, by accustoming him gradually to its toxic effect, beginning with a weak form and progressively increasing the dose. It is not exactly treatment of the disease, because it is useless or nearly so when the disease has commenced, nor is it exactly preventive, for the patient has already been bitten. It must be regarded as a kind of anticipatory cure. The cords are cut into sections and preserved dry in sterilized flasks plugged with cotton-wool. Another method of preparing the inoculatory virus, which has been devised by Guido Tizzoni and Eugenic Centanni, consists in subjecting the virus fixe to peptic digestion by diluted gastric juice for varying periods of time.
The first patient was treated by Pasteur's system in July 1885. He was successively inoculated with emulsions made from cords that had been kept fourteen and ten days, then eleven and eight days, then eight, seven, six days, and so on. Two forms of treatment are now used(i) the " simple," in which the course from weak to strong virus is extended over nine days; (2) the " intensive," in which the maximum is reached in seven days. The latter is used in cases of very bad bites and those of some standing, in which it is desirable to lose no time. Two days are compressed into one at the commencement by making injections morning and evening instead of once a day, so that the fifth-day cord is reached in four days instead of six, as in the " simple " treatment. When the maximumthe third-day cordis reached the injections are continued with fifth-, fourth-, and third-day cords. The whole course is fifteen days in the simple treatment and twenty-one in the intensive. The doses injected range from i to 3 cubic centimetres. Injections are made alternately into the right and left flanks. The following table shows the number treated from 1886 to 1905, with the mortality.